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SESSUALITA E STOMIA
Dott. A. Zucchi Clinica Urologica ed
Andrologica Università di Perugia
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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 .

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La sessualita nel pz stomizzato

• Problematiche sessuali nello stomizzato
• Cause organiche
• Psicologiche
• Ormonali
• Coesistenza di tutte le problematiche

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Vescica 16,000 (10)
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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 200618(1)1-18
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ANATOMIA PELVICA
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CHIRURGIA DEMOLITIVA ADDOMINO PELVICA E
DISFUNZIONE ERETTILE
LE ALTERAZIONI DELLA SESSUALITA CORRELATE AL
DANNO NERVOSO PERIFERICO ORTO E PARASIMPATICO
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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

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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.

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• 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 allinsulto meccanico e termico
• perdita di funzione per periodo lungo

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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
  dellintestino crasso
• ANEIACULAZIONE

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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)
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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

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Exeresi colorettale nelle malattie neoplastiche

• Il trattamento standard negli stadi A e B di
  Dukes (T1-gtT4, no MTS) è lexeresi mesorettale
  totale (TME). Se la lesione è a meno di 3-5 cm
  dalla linea dentata -gt 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

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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 letà 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
Oct26(10)665-68.
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La sessualita nel pz stomizzato
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• 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.
  kkyo_at_vega.ocn.ne.jp
• 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.

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ANZ J Surg. 2004 Apr74(4)189. Sexual function
after rectal excision. Keating JP. Departments of
Surgery and Anaesthesia, Wellington School of
Medicine and Health Sciences, Wellington, New
Zealand. surgjk_at_wnmeds.ac.nz 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 (gt40) 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.
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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 gt 50y
• 21 pz (13,5) di DE lieve
• Nessun disturbo delleiaculazione

Lindsay I et al. Dis. Clon Rectum. 2001
Jun44(6)831-35
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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.
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Chirurgia colorettale nelle malattie infiammatorie

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Prevenzione della disfunzione erettile

• PROBABILI KEY FACTORS
• 1 . Bilaterale Nerve Sparing Technique
• 2. Young patient age
• 3. Surgeons experience
• (Patient number 1 - 1000 vs 1001 3477)

Kundu S.D. et al. J Urol.,1722227-2231,2004
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• 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)

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Le soluzioni possibili !

• Inibitori delle PDE5
• Farmacoterapia intracavernosa
• MUSE
• Vacuum device
• CHIRURGIA PROTESICA

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La sessualita dopo la stomia
Gli aspetti psicologici
RUOLO DEL/LA PARTNER
IL counselling psicosessuologico
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Sessualita e stomia aspetti psicologici

• Il confezionamento di una stomia
• modifica la propria immagine corporea
• Riduce lautostima e lautonomia 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 unidea di disgusto correlato
  alla stomia

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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.