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The Pelvic Radiotherapy Clinic Nuala Lee Abstract: A description of communication about sexual issues with men and women undergoing pelvic radiotherapy. Introduction. Return to Nursing Progress contents list The sexual well being of a person with cancer is an aspect of care that is often neglected. This may be due to the mistaken belief that such matters are of a low priority to patients with a life threatening disease or it may reflect the difficulty that many health care professionals. have in communicating about sexual issues with patients. The continuing need for close relationships with others remains following a cancer diagnosis and its treatment, even if expression of sexuality has to be altered due to physical changes, libido or opportunity. Recognising this issue was the first step in setting up the pelvic radiotherapy clinic. The clinic aims to see both male and female patients weekly during the course of their treatment to discuss issues surrounding the side effects of their therapy. These side effects include:
It was noted by the nursing staff that whilst taking blood tests prior to the set up of the clinic that patients often made a casual reference to sexual matters. Were they dropping hints in the hope that someone might hear? On questioning the patients few felt that sexuality issues had been fully discussed. Many felt that they were unable to ask their doctors about sexual matters. What was being told to patients prior to treatment and by whom? Did patients feel their sex life was the price they had to pay for survival? Many of the patients receiving treatment are being treated with curative intent and may live for several years with the treatment side effects. Clearly they need to be adequately informed and educated as to what they can and cannot expect to achieve. With the support of the Senior Nurse Manager, Departmental Manager and Consultants within the department it was decided that it was a role that could be carried out in a Nurse Led clinic setting and so in February 1996 the clinic began to see patients who were seen by either one of the Senior Sisters or a male Senior Radiographer. The male radiographer was in fact the information radiographer and it was thought that male patients may prefer to see someone of their own sex rather than a female. This became evident when men who could not be seen by the radiographer would feel embarrassed discussing this issue with someone "young enough to be my granddaughter." However after the initial consultation patients often broach the subject again themselves as they realise this is often their best route to further information. It took six months for the clinic to be set up and in this time information sheets on sexuality issues were written, rewritten and agreed upon by the multidisciplinary team within the department. Information sheets on the other main side effects were already available. The radiographer and nurses received further teaching on aspects of sexuality in order to prepare them for dealing with this issue. A day of the week had to be agreed upon to run the clinic which allowed the nurses and radiographer to be relieved of other duties and when there was a doctor in the department to prescribe medication as needed. It was also felt that there was a need for the nurses and radiographer to meet after each clinic to discuss issues which were relevant and to offer support and advice to one another. Their were no initial cost implications in setting up the clinic apart from the cost of relieving the nurses/radiographer of other duties. The patients being treated for pelvic tumours were generally treated on one specific machine so with the help of the radiographers on this machine details of all patients receiving treatment to this area was compiled and given to the nurse in charge of the clinic to ensure all patients were seen and monitored throughout treatment. These details were in the form of a list and therapy cards were signed by the clinic to say that the patient had been seen so that few patients were missed. A list of names was also given to the reception staff who alerted the patients on their arrival that they were to be seen in the clinic prior to going home. It was hoped that patients would see the same person weekly in order to build up a rapport. However if patients or indeed the radiographer/nurse felt uncomfortable with a certain individual then that patient would be seen by someone else when possible. In the first few weeks of the clinic the first cost implications were encountered. Firstly it was felt that sexual matters were indeed very private and the general nursing kardex which was accessible by all the team was deemed an inappropriate method on which to record sexual issues unless there was some medical reason for this to be known. It was decided to incorporate a separate kardex for the clinic which would be kept locked in the Sisters office and used as necessary. The second cost implication was that of pads for incontinence. It became apparent that many of the patients particularly the males were suffering with dribbling incontinence and were finding life difficult particularly if they were trying to go to work or travelling on public transport. Pads were supplied to these patients, and then referred onto District Nurses post treatment if the incontinence continued so that further pads could be supplied. Before the set up of the clinic only patients who were being incontinent whilst lying on the treatment couch or who actually mentioned the problem were being referred for help and advice The third cost implication was that of vaginal dilators. Prior to the set up of the clinic, few patients were receiving dilators or being told about their use and their benefits. It was also felt that there was a need for the nurses and radiographer to meet after each clinic to discuss issues which were relevant and to offer support and advice to one another. Many professionals feel ill equipped to deal with the sensitive often embarrassing subject of sexuality with patients. This may be due to the fact that education within our disciplines is scant on how to deal with sexual problems or because they feel there are others specially trained to deal with this issue. Often our own beliefs and values stand in the way of these discussions, as can age. Our society tends to associate sex with youth and beauty and to misunderstand or ignore the sexual needs of people who are older and/or have physical or learning difficulties. In realising that a persons sexuality is an important and normal part of his/her identity we must include it as a normal part of our care.(1 ) There are several techniques that can be used to incorporate sexuality into our nursing care and for the clinic it was agreed that the PLISSIT model by Jack Annon could be used.(2) P = Permission - this gives the patient permission to discuss sexual concerns. LI = Limited Information - about the effects of treatment or disease on sexual function. SS = Specific Suggestions - giving different ways to express their sexuality. IT = Intensive Therapy - the patient may need to be referred for surgical intervention or psychosexual counselling. Annon believes that 70% of sexual problems can be dealt with at the permission level but that the health care professional should take the patient to whichever level they are able to. It is vital, though, to know one's own limitations and therefore it is important to know who to refer onto when further help is needed. For the clinic to function it was felt that problems that could not be dealt with at our level would be referred to the Consultant in charge of the patients treatment and that the Consultant would make the ongoing referral. Pelvic Radiotherapy Diarrhoea, Cystitis, skin break down, tiredness and nausea are common side effects of treatment to this area. It was fealt that before initiating a discussion about sexual problems, raising these more common issues first may help to relax the patient, and for them to gain confidence in the person leading the discussion Most patients treated with pelvic radiotherapy suffer major vaginal changes such as pelvic fibrosis, shortening and narrowing of the vagina, complete loss of natural lubrication and reduced elasticity of the vaginal wall. (2) This may then lead to pain during intercourse, lack of sexual desire, complete or almost complete lack of orgasm and fear of the cancer returning. Partners often feel that they can cause much harm by engaging in sexual activity or may indeed catch the cancer themselves. This in turn can lead to communication breakdown and physical withdrawal. The clinic plays an important role in encouraging communication between patient and partner, dispelling myths and educating about altered methods of love-making. The clinic actively encourages patients to discuss sexuality with their doctors and patients have found it an easier subject to broach when they can say "the nurse asked me to tell you..." However, many women feel much more comfortable talking to female nurses rather than male doctors as they often feel women can identify with the problems more fully. Also patients are often seen in very busy clinics and feel they cannot waste the doctor's time talking about sex. Fertility is a major and very sensitive issue that needs to be discussed. Often the treatment will involve the patients ovaries being included and an early menopause will follow. Patients need to be advised to use adequate contraception during treatment and for 4-6 months after treatment to ensure that the menopause has occurred. The aim of the clinic when discussing sexual issues with these women is to give hope that it is possible to feel feminine and sexually whole again despite physical changes that have occurred. Women are encouraged to use dilators or to have regular sexual intercourse to minimise narrowing and shortening of the vagina. If patients feel that they are unable to use dilators then they are encouraged to use clean fingers and to gently dilate themselves. There was no age limit on giving out dilators. There is research to suggest that women who do not follow advice regarding the use of dilators and do not resume their pre treatment level of sex were more likely to develop physical and sexual changes (4). Therefore there is a need for sexual information concerning the effect of treatment on relationships with partners. It was hoped that patients would see the same person weekly in order to build up a rapport. However if patients or indeed the radiographerinurse felt uncomfortable with a certain individual then the patient would be seen by someone else when possible. Recommendations:
An important issue which is discussed with the men is that of erectile dysfunction. This is defined as the failure of the penis to achieve rigid erection. Impotence is often used to describe this condition. Erectile dysfunction is not a disease but a secondary condition brought on by another cause. Surgery, radiotherapy or the very presence of prostate, bladder or bowel disease may cause erectile dysfunction. There are many other causes such as diabetes, hormone insufficiency, certain drug therapies, smoking, heavy drinking and the use of recreational drugs. Psychological problems may cause erectile dysfunction such as money worries or relationship worries. Tiredness and fatigue as well as anxiety are enough to cause problems. It is important to discuss this issue with patients as male sexual function is closely linked to psychological well being and often very personal questions must be asked. (5) A history of ability to have an erection needs to be ascertained. Humour, when used appropriately may help the patient to relax and assist the nurse/radiographer to ascertain problems. Often other physical causes may have resulted in erectile dysfunction and it is therefore important not to make unrealistic goals. If patients are able to achieve erection before the start of treatment then they are more likely to be able to achieve erection after the cessation of treatment. However, those whose disease has caused erectile dysfunction may not regain erections after the treatment has finished. It is important to discuss the tact that radiotherapy itself may result in impotence and patients should be aware of this prior to treatment. There are patients who may wish to trade their survival chances with that of sexual functioning and this needs to be recognised and patients given support as necessary. 1. Post treatment we advise men that orgasm can be painful and that the semen may be colourless. 2. Anxiety itself can cause erectile dysfunction and we encourage men to try to relax before engaging in sexual activity. 3. Erections may improve with time so we encourage patients to keep trying, and to still use the penis to stroke and caress (masturbation) as it is still sensitive and orgasm is possible without erection. 4. Patients who have not managed to have an erection after one year following treatment are unlikely to see any improvements. 5. Communication with partners is essential and discussion of feelings and altered roles in the relationship should be encouraged. 6. Fertility may depend on the dose of treatment given and whether other treatments such as chemotherapy are being used. For the clinic to function it is essential that the nurses, radiographers and doctors give the same advice. It has become an important part of the patients total care and has proved to be very successful in answering patients queries, initiating sexual discussions and improving the quality of life for these patients. An audit is necessary to carry out a full evaluation of the clinic. The clinic has provided an ideal place to discuss sexuality issues as it offers privacy and confidentiality and a route by which more difficult problems can be referred on. It also allows for patients to be monitored more closely throughout treatment. The clinic is still in its infancy and changes will need to be made as staff changes are inevitable. Therefore it is vital that all health care staff are knowledgeable in the side effects of their treatment modalities and more importantly are able to inform patients of these side effects appropriately. 1. Els Van Ooijen. Learning to approach patients sexuality as part of holistic care. Nursing Times 1996. Sept 4 (92) p 36. 2. Annon JS. Behavioural treatment of sexual problems; brief therapy. New York: Harper and Row 1976. 3. Abitbol MM, Davenport JH. Sexual dysfunction after therapy for cervical cancer. American Journal Obste/Gynae 1974. May 15 ;119;181-9 4. Wabrek AJ, Gunn JL. Sexual and psychological implications of gynae malignancy. JOGN Nursing 1984. Nov/Dec 13:371-6 5. Helgason AR, Fredrikson M, Adolfsson J, Steineck G. Decreased sexual capacity after external radiation therapy for prostate cancer impairs quality of life. Int. J Radiation Oncology Biological Physics 1995:32:33-9. Nursing Progress: Issue 2: July 1997. Copyright: Nursing Progress, Royal Hospitals NHS Trust Return to Nursing Progress contents list Back to Issue 2 contents list Page last updated by DEB on 7/03/04 |
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