Sexual Function After Surgery for Prostate or Bladder Cancer

Alejandro J. Miranda-Sousa, MD; Hugo H. Davila, MD; Jorge L. Lockhart, MD; Raul C. Ordorica, MD; Rafael E. Carrion, MD


Cancer Control. 2006;13(3):179-187. 

In This Article

Local Surgical Treatment of Bladder Cancer


There is a paucity of research devoted to evaluating female sexual function after major urologic surgery for bladder cancer. However, a recent report indicates that during radical cystectomy in women,the neurovascular bundles (located on the lateral walls of the vagina) are usually removed or damaged by removal of the bladder, urethra, and anterior vaginal wall.[44,45,46] In addition, significant devascularization of the clitoris often occurs with removal of the distal urethra, thus affecting subsequent sexual arousal and desire.[44,46] Acute surgical menopause after formal radical cystectomy can also compound the problem. Hence, postoperative sexual dysfunction is common in women. Using the validated questionnaire, Female Sexual Function Index to evaluate changes in sexual function after surgery, Zippe et al[47] assessed the effects of radical cystectomy, the type of urinary diversion, and particular surgical modifications on female sexual functioning. Among 27 patients, only 13 (48%) were able to have successful vaginal intercourse, and 14 (52%) reported decreased satisfaction in overall sexual life after radical cystectomy. The authors concluded that the type of continent diversion performed does not affect sexual function. Furthermore, they recommend several surgical modifications that may improve female sexual function, including routine preservation of the distal urethra in selected diversions in an effort to preserve the clitoral neurovasculature, preservation of the anterior vaginal wall (as much as possible) to maintain vaginal lubrication and neurovascular innervations, and tubular reconstruction of the vagina (vs posterior flap rotation) to preserve vaginal depth and maintain pain-free intercourse. These surgical modifications apply only if cancer control is not compromised. An earlier study by Horenblas et al[48] evaluated the effectiveness of sparing all internal genitalia in women in addition to the urethra in appropriate candidates. The authors concluded that such surgical modifications to the radical cystectomy procedure help preserve sexual function.

Physical and emotional factors, such as a decrease in sexual attractiveness, can influence sexual life after radical cystectomy and bladder reconstruction surgery.[49,50,51] Bjerre et al[52] evaluated the sexual profile after urinary diversion and found that almost one third of the women indicated physical problems or decreased desire and 30% felt less sexually attractive after cystectomy. This shows that sexual function is sensitive to both physical and mental effects from the treatment of bladder cancer. These psychologic and biogenic factors after radical cystectomy can make it difficult to evaluate female sexual dysfunction.[3,45,49,50,51,53] Further studies with particular emphasis on postoperative management strategies are needed to allow the surgeon to optimize postoperative sexual functioning.

Embryologically, the clitoris is the female analogous structure to the penis. Hence, it is not surprising that there are similar physiologic mechanisms involved within the corpora cavernosa of the clitoris. Nitric oxide-mediated stimulation of clitoral cavernosal smooth muscle increases blood flow and results in genital engorgement, which is important in female sexual arousal.[15,54,55] Thus, by improving clitoral sensation and blood flow, sildenafil citrate may improve vaginal lubrication and sexual satisfaction.[54,55] Reports in the literature regarding the use of sildenafil citrate for female sexual dysfunction are conflicting, and a clear consensus on its effectiveness has not yet been established.


The efficacy of nerve-sparing techniques to preserve potency in men following cystoprostatectomy is approximately 50%, but modifications to the standard radical cystectomy procedure have been developed. Muto et al[56] reported a seminal-sparing cystectomy modification involving a posterior bladder dissection during radical cystectomy that is anterior to the seminal vesicle plane to preserve the vasa deferens, seminal vesicles, prostatic capsule, and neurovascular bundles. The authors found that normal erectile function was preserved in 95% of patients with a mean follow-up of 68 months. Their procedure was performed in patients without pathology in the bladder neck or prostate. This technique can also help preserve ejaculatory function. In a similar study by Colombo et al,[57] nerve- and seminal- sparing cystectomy offered satisfactory clinical and functional outcomes. The authors stressed this option should be considered only for young, fully potent, and socially active patients with organ-confined bladder cancer. Burday et al[58] reported good potency preservation with their prostate-sparing cystectomy series, which included patients who underwent partial or complete preservation of the prostate and neobladder formation. Their results have paralleled that of other series showing good functional outcomes after performing partial or complete preservation of the prostate during cystectomy.[59,60,61,62,63] These studies reemphasize that the risk of erectile dysfunction in cystectomy patients is related specifically to the pathology involved with surgical removal of the prostate gland.


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