SESSUALITA’
E STOMIA
Dott. A. Zucchi
Clinica Urologica ed Andrologica
Università di Perugia
La sessualita’ nel paziente stomizzato
• La qualita’ di vita nel pz sottoposto a
confezionamento di una stomia intestinale si
modifica sotto il profilo sociale e psicologico.Si
assiste a un cambiamento del proprio ruolo
nella famiglia,nelle relazioni con gli amici e non
dal ultimo rilevanti sono solo alterazioni della
sessualita’ .
La sessualita’ nel pz stomizzato
• Problematiche sessuali nello stomizzato:
1. Cause organiche
2. Psicologiche
3. Ormonali
4. Coesistenza di tutte le problematiche
Vescica
16,000 (10%)
Pelvic surgery are among the most common
causes of organic sexual dysfunction in men
and women
Sexual dysfunction is highly prevalent even
after multiple technical advances in the field of
oncological surgeries in which prevalences
varies from 8 to 82%
Pathophisiology of sexual dysfunction after
pelvic surgery is unique because it can be either
vascular or neurogenic factors alone, or a
combination of both
Zippe C et al. Int J Impot Res 2006;18(1):1-18
ANATOMIA PELVICA
CHIRURGIA DEMOLITIVA ADDOMINO
PELVICA E DISFUNZIONE ERETTILE
LE ALTERAZIONI DELLA
SESSUALITA’ CORRELATE AL
DANNO NERVOSO
PERIFERICO:
ORTO E
PARASIMPATICO
MECCANISMO DEL DANNO
NEUROLOGICO
• Insulto meccanico o termico delle
strutture nervose, parziale o totale
• Neuroaprassia: lesione lieve (blocco di conduzione)
senza degeneraz. Walleriana (durata: settimane)
• Assonotmesi: assone e mielina sono interrotti, ma le
strutture circostanti (cellule di Schwann, perinervio
ed epinervio) rimangono integre. La ricrescita
assonale può procedere lungo il tubo endoneurale
intatto (durata: mesi)
• Neurotmesi: completa distruzione del tronco
nervoso: impossibilità di ricrescita
Autonomic Innervation to Corpora
Cavernosa
Pudendal Nerve
• Dorsal nerve of penis (autonomic to
corpora and sensory to skin).
Pelvic Plexus
• Visceral Branches
– Bladder, seminal vesicles, prostate, urethra,
corpora cavernosa.
• Muscular Branches
– Levator ani, coccygeus, striated sphincter.
NERVI SOMATICI
Fibre di tipo o gruppo A, sono le tipiche fibre mieliniche dei nervi
spinali (velocità di conduzione da 120 a circa 6 m/s, diametro da
20 a 1 µm);
NERVI CAVERNOSI
Fibre di tipo o gruppo C, fibre amieliniche di piccolo diametro e
quindi a bassa velocità di conduzione, che costituiscono la
totalità delle fibre postgangliari del sistema nervoso autonomo
(velocità di conduzione da 2 a 0,5 m/s, diametro inferiore a 1,2
µm).
La delicata struttura di queste fibre spiega:
•difficoltà di identificazione
•sensibilità all’insulto meccanico e termico
•perdita di funzione per periodo lungo
Quando e come si determina il danno
neurogeno?
• Lesione alta a livello del plesso ipogastrico superiore:
PER LEGATURA DELLA ARTERIA
MESENTERICA INFERIORE che vascolarizza la
parte terminale dell’intestino crasso :
ANEIACULAZIONE
Quando e come si determina il danno
neurogeno?
• Lesione del PLESSO PELVICO allorquando si isola il
retto dalla parete laterale del piccolo bacino o si esegue
la linfoadenectomia
• Lesione DEI NERVI CAVERNOSI quando si asporta
la parte terminale del retto o lo sfintere anale
DISFUNZIONE ERETTILE
AR (anastomosi bassa) - APR (Miles)
Alterazioni della sessualita’ nel sesso
femminile
• Nella donna colostomizzata o ileostomizzata il
danno prevalente e’ : la compromissione del
processo di lubrificazione
• Eccitazione ed orgasmo conservati
• Nelle pz irradiate dopo chirurgia possibile
compromissione anche di questi aspetti della
sessualita’
Exeresi colorettale nelle malattie
neoplastiche
• Il trattamento standard negli stadi A e B di
Dukes (T1->T4, no MTS) è l’exeresi
mesorettale totale (TME). Se la lesione è a
meno di 3-5 cm dalla linea dentata ->
Resezione addominoperineale (APR) o
intervento di Miles
• Nella terapia del cancro del retto hanno un
ruolo importante : RDT neo-adiuvante, RDT
adiuvante, con effetto negativo sulla funzione
sessuale
Exeresi colorettale nelle malattie
neoplastiche
• DE di vario grado riportata nel 10 fino al 60%
delle TME NS (risultati oggi migliori con VLS)
• DE fino al 92% nelle APR
• Potency rate correla con l’età ma non con lo
stadio della malattia
Keating JP ANZ J Surg 2004 Apr; 74(4): 189
Danzi M et al. Dis Colon Rectum. 1983 Oct;26(10):665-68.
La sessualita’ nel pz stomizzato
– Impact of autonomic nerve preservation and lateral node dissection on male urogenital
function after total mesorectal excision for lower rectal cancer.
– Kyo K, Sameshima S, Takahashi M, Furugori T, Sawada T.
– Department of Surgery, Colorectal Division, Gunma Prefectural Cancer Center, 617-1
Takabayashi Nishimachi, Ota-shi, Gunma, 373-8550, Japan. [email protected]
– INTRODUCTION: Urogenital dysfunction is a well recognized complication of rectal cancer
surgery. The aim of this study was to assess the impact of autonomic nerve preservation
(ANP) and lateral node dissection (LND) on male urogenital function after total mesorectal
excision for lower rectal cancer. METHODS: We studied, using a questionnaire, preoperative
and current urogenital function in 47 male patients who underwent total mesorectal excision
with the ANP technique for lower rectal cancer. Patients with and without LND were
analyzed separately. RESULTS: A total of 37 patients (78.7%) (22 patients without LND, 15
with LND) returned the questionnaire. Among the 15 patients with LND, 2 underwent
unilateral ANP. One patient without LND had urinary dysfunction preoperatively, and among
the other 21 patients only 2 (9.5%) reported minor urinary complications postoperatively.
After LND, 5 patients (33%) reported minor complications; there were no severe
complications. Among patients who were sexually active prior to the operation, 90% and
70% of patients without LND and 50% and 10% of those with LND maintained sexual
activity and ejaculation, respectively. However, 50% of patients who underwent low anterior
resection or Hartmann resection without LND and all patients with abdominoperineal
resection or LND reported reduced overall sexual satisfaction. CONCLUSIONS: The ANP
technique offers the great advantage of maintaining urogenital function after rectal cancer
surgery. After LND, although the ANP technique minimized urinary dysfunction, sexual
function, particularly ejaculation, was often damaged. Careful follow-up is important even
after ANP to improve postoperative sexual satisfaction.
ANZ J Surg. 2004 Apr;74(4):189.
Sexual function after rectal excision.
Keating JP.
Departments of Surgery and Anaesthesia, Wellington School of Medicine and Health Sciences,
Wellington, New Zealand. [email protected]
BACKGROUND: Rectal excision is associated with a risk of autonomic nerve damage and
associated sexual dysfunction (SD). The evolution of our understanding of the anatomy and
physiology of sexual function together with continual refinement of surgery for both benign and
malignant disease has led to a decrease in the incidence of SD after rectal surgery. A knowledge
of the degree of risk of postoperative SD is important both for the patient and as a benchmark for
audit of individual colorectal practice. METHODS: The available literature on the anatomy,
physiology and surgical aspects of this topic has been researched through the Medline database.
The more recently available data are reviewed in the context of the historical evolution of surgery
for benign and malignant rectal disease. RESULTS AND CONCLUSIONS: In the best hands,
permanent impotence occurs in less than 2% of patients following restorative proctocolectomy
and at a similarly low rate after proctocolectomy and ileostomy. Isolated ejaculatory dysfunction is
also numerically a minor problem post operation for benign disease. Patient age is the most
important predictor of SD after surgery for rectal cancer. The incidence of permanent impotence
remains high (>40%) after abdomino-perineal excision of the rectum (APE) but the continued
decline in the use of this operation in favour of low anterior resection (LAR), which carries about
half the risk of impotence compared to sphincter ablating surgery, is likely to have resulted in a
fall in the absolute number of patients rendered impotent as a result of rectal cancer surgery.
Anatomical dissection of the pelvis with preservation of the named autonomic fibres results in a
low and predictable rate of sexual morbidity. Surgeons could profitably spend more time with their
patients discussing the possible effects of surgery on sexual function. Further research is required
to determine the effects of adjuvant therapy for rectal cancer on sexual function.
Proctocolectomia nelle malattie
infiammatorie
• Stahlgren e Ferguson riportano 25% di DE di vario
grado nel 1959
• Lindsay nel 2001 somministra IIEF in 156 pz con FU
medio di 74 mesi: solo 6 (3,8%) con DE grave tutti >
50y
21 pz (13,5%) di DE lieve
Nessun disturbo dell’eiaculazione
Lindsay I et al. Dis. Clon Rectum. 2001 Jun;44(6):831-35
Impotence after mesorectal and close rectal dissection for inflammatory bowel disease.
Lindsey I, George BD, Kettlewell MG, Mortensen NJ.
Department of Colorectal Surgery, John Radcliffe Hospital, Oxford, United Kingdom.
PURPOSE: Close rectal dissection is a surgical technique used by some surgeons in
inflammatory bowel disease. It is performed within the mesorectum, close to the rectal
muscle wall, with the aim of minimizing damage to the pelvic sexual nerves. Other surgeons
dissect in the more anatomical mesorectal plane. Our aim was to determine whether close
rectal dissection is more protective of the pelvic sexual nerves than mesorectal dissection.
METHOD: Patients undergoing surgery for inflammatory bowel disease were entered
prospectively into a database. Male patients were mailed a standardized, validated, urologic
impotence questionnaire: the International Index of Erectile Function. RESULTS: There was
an 81 percent response rate. Six of 156 assessable patients were totally impotent (3.8
percent). They were all in the 50-year-old to 70-year-old age group, with no impotence in
patients younger than 50 years old. Twenty-one patients complained of minor diminution of
erectile function (13.5 percent), where sexual activity was still possible. There was no
statistical difference in the rate of complete (2.2 percent vs. 4.5 percent, P = 0.67) or partial
(13.5 percent vs. 13.3 percent, P = 0.99) impotence between close rectal and mesorectal
dissection (Fisher's exact test). There were no ejaculatory difficulties. The time elapsed
since surgery ranged from 2.7 months to 192.7 months, with a median of 74.5 months.
CONCLUSION: Rectal excision for inflammatory bowel disease can be conducted with low
rates of impotence. Minor degrees of erectile dysfunction may be more common than
currently recognized. We could not demonstrate that close rectal dissection significantly
protects the patient from impotence compared with operating in the anatomical mesorectal
plane. Age appears to be the most important risk factor for postoperative impotence.
Chirurgia colorettale
nelle malattie infiammatorie
Prevenzione della disfunzione erettile
PROBABILI “KEY FACTORS”
1 . Bilaterale Nerve Sparing Technique
2. Young patient age
3. Surgeon’s experience
(Patient number 1 - 1000 vs 1001 – 3477)
Kundu S.D. et al. J Urol.,172:2227-2231,2004
Principi generali nella chirurgia
“potency sparing”
•
Valutazione Potency pre-op (e post!): questionari?
•
Età pz
•
Rispetto della sicurezza oncologica
•
Esperienza del chirurgo
•
(eventuale) RDT terapia adiuvante
•
(Riabilitazione post-op)
Le soluzioni possibili !
I. Inibitori delle PDE5
II. Farmacoterapia intracavernosa
III.MUSE
IV. Vacuum device
CHIRURGIA PROTESICA
La sessualita’ dopo la stomia
Gli aspetti psicologici
RUOLO DEL/LA PARTNER
IL counselling psicosessuologico
Sessualita’ e stomia aspetti psicologici
Il confezionamento di una stomia:
 modifica la propria immagine corporea
Riduce l’autostima e l’autonomia di alcune funzioni
Altera le relazioni interpersonali:
lavorative,amicizie,affetti
Viene compromesso il delicato equilibrio della vita
sessuale:
Diminuiscono il numero dei rapporti
Minore piacere
Tendenza ad evitare il contatto fisico per atteggiamenti
difensivi di assoluta chiusura,legati ad un’idea di
disgusto correlato alla stomia
Sessualita’ e stomia aspetti psicologici
Il ruolo del couselling pre e post intervento
CHIRURGO, ANDROLOGO
PSICOSESSUOLOGO
STOMATERAPISTA
SVILUPPARE LA RESILIENZA
Aiutare il pz ad aprirsi e manifestare i propri sentimenti, il bisogno
di aiuto, rassicurazione,di vicinanza fisica, evitando pericolosi
atteggiamenti isolamento autoprotettivo sentimentale e sociale.