Can Colon Cancer Cause Erectile Dysfunction?
Treatments of colorectal diseases tend to prioritize addressing the affected areas, as do the surgeons who perform operations to remove infected tissue.
That prioritization, however, can come at the expense of overlooking serious complications. Despite its documented prevalence in survivors of colorectal cancer, sexual dysfunction remains a frequently neglected topic among many providers and patients.
For men, the complications can include erectile dysfunction (ED) after surgery.
ED risks associated with rectal vs. colon surgery
Erectile dysfunction sometimes results from rectal surgery, said Giovanni Taffurelli, M.D., a member of the internal medicine and surgery department at Sant'Orsola-Malpighi Hospital in Bologna, Italy, in an email conversation. Younger patients appear to present with the complication most frequently.
"Overall, I think that ED-related complications after rectal surgery are underestimated," Taffurelli said.
ED caused by physical issues appears to affect about 10 percent of patients who undergo the surgery, according to Taffurelli. In his experience, severe, treatment-resistant cases amount to about 1 percent to 2 percent.
"It is certainly more related to surgery for cancer than for other ailments, since in oncologic surgery the need for an accurate and complete lymphadenectomy could damage the autonomic nerve structures," he said.
In contrast to rectal operations, he noted, colon cancer surgery poses little postoperative ED risk, with one exception. With sigmoid colon surgery, resection might involve the removal of the upper rectum and lymph node dissection, which risks damaging parts of an area called the inferior mesenteric plexus.
ED caused by physical issues appears to affect about 10 percent of patients who undergo the surgery.
Additionally, the surgery comes with the risk of potential harm to nerves essential for erectile function located in the hypogastric nerve plexus. Nerve fibers from the hypogastric plexus travel with the arteries that supply the urethra, prostate, seminal vesicles, penis, the base of the bladder and more.
It makes sense then that doctors break colorectal operations down into colon versus rectal surgery, said Matthew Giglia, M.D., the chief of surgery at Ochsner Cancer Center in Baton Rouge, Louisiana.
"The large intestine is your colon and rectum," Giglia said. "And so the rectal portion that we do is definitely more high risk. And that is one of the reasons most people do extra training and fellowship in colorectal surgery, is because operating in the pelvis, it's a much more narrow space and around much more vasculature, as well as nerves. [It's] a little bit more risky and comes with more complications than just colon surgery in the abdomen."
Types of colorectal surgery
Common colorectal operations include abdominoperineal resection (APR), anterior resection (AR) and total mesorectal excision (TME).
Authors Kamal Nagpal and Nelson E. Bennett Jr., M.D., a professor of urology at the Northwestern University Feinberg School of Medicine in Evanston, Illinois, discussed those surgeries and how they affect erectile function in a 2013 review for Current Urology Reports.
Bennett said APR implies removal of the rectum and anus.
"You can't remove the anus from the top," he said. "So you [must] go to the bottom. That's what's called abdominal and perineal."
AR entails removal of some or all of the rectum, he explained.
"So for that, you just go from the abdominal side," Bennett said.
He described TME as a derivation of the AR operation.
"When you're dissecting, you hug the rectum really closely on the front," Bennett said. "But on the back, you take a lot of extra tissue to make sure to get a good cancer control, and you're hugging the front of the rectum so you don't mess up any blood vessels or nerves, because they run in that area."
Nerve damage and ED
The parts of the body responsible for erections mostly reside in the pelvic region. They supply blood to the upper rectum, where many nerves run along that blood supply to the rectum itself, according to Giglia.
"When you're doing surgery down in the pelvis, you're just at very high risk for not only injuring the nerves by cutting them or burning them during surgery, but even just retracting the rectum in certain ways, you can stretch the nerves and cause a stretch injury to the nerves where you didn't actually physically touch it. But just by being associated with those tissues, it stretches it," he explained.
The potential for that sort of nerve damage is why rectal surgery comes with a greater risk for post-op ED. Colon cancer surgery can cause erectile dysfunction.
"The nerve damage is simply manipulation," Bennett explained. "So, basically, exposing the nerve, touching it or moving it can cause damage. And, actually, the nerve inside will die all the way back to the spinal cord, but it eventually will regrow."
Bennett said colorectal surgeons use scalpels, scissors and electrocauterization. The sharpness of the first two can threaten nerves. The latter is capable of producing potentially nerve-damaging electrical energy.
Surgeons can inadvertently damage a "difficult-to-access area" of nerves, Bennett explained. Nerves exist on the side of the rectum and fan out to the bladder, prostate and penis.
"If you're resecting the rectum, all those nerves on top, at some point, connect to the penis," he said, noting that surrounding blood vessels and muscles make it difficult to access the desired tissue and give surgeons little room to work. "A surgeon might have to peel the rectum off the sidewall of muscle to remove it, which isn't easy."
Someone struggling with ED after rectal surgery may have suffered disruption of nerves in that "difficult-to-access area" during the operation.
Minimizing the chances of surgically induced ED
Seeking a surgeon with experience operating in the pelvic area and around the aforementioned nerves helps reduce the likelihood of postoperative complications such as ED, Giglia said.
"If you're in the proper plane, if you're in the proper area to dissect and you don't get into areas that you're not supposed to be in, you're a lot less likely to injure those things," he explained.
He suggests people who require risky colorectal operations find surgeons who can specifically identify the nerves that can be damaged and the structures in need of protection. This step can help increase the chances of positive outcomes for sexual function after surgical procedures.
If possible, opt for total mesorectal excision, which takes a little tissue from the front of the rectum and a more significant amount from the back while hugging the sides and avoiding incisions into difficult-to-access nerves. This approach can minimize the risk of postsurgical erectile issues, Bennett explained.
Using a laparoscopic tool for the procedure similarly results in less dissection, trauma and risk. Bennett said a laparoscope, magnifying camera and fine instruments can make it easier to access the right spot. Laparoscopy, he said, reduces the likelihood of recurrence and preserves sexual function at greater rates than other approaches.
The use of newer robotic technology for low anterior resection and APR affords magnification and enhanced visualization, Bennett continued.
"And also, you can see things in three dimensions," he said, adding that patients spend less time in the hospital, recover faster, resume regular activities quicker and have better outcomes pertaining to sexual function with robotic TME surgery.
Preparing patients for possible ED
Surgeons typically explain possible ED complications to patients before surgery, Taffurelli said.
"We routinely investigate already-existent ED prior to rectal surgery to explain to the patient a possible worsening of the symptoms," he explained. "In such patients, we also advise a urologist evaluation because they routinely deal with it after prostate surgery. Surely, this part could be improved, for example, by routinely [referring a] patient to a [psycho-oncologist] who can evaluate if preoperative ED can be related to the psychological stress of dealing with a cancer diagnosis."
Treating ED after colorectal surgery
Taffurelli said transient ED after rectal surgery remains common but usually resolves within four to six months. Phosphodiesterase inhibitors usually work for persistent ED, and the need for other treatments like injection therapy and vacuum devices is rare.
Colorectal cancer can cause depression related to the frequency and urgency of bowel movements, constipation and discomfort, all of which can negatively affect bedroom activity, Bennett pointed out.
"And then after the surgery is another problem because many of these people who have the surgery have an ostomy at the end," he said.
Having an ostomy bag that contains bodily waste isn't always ideal for libido and sexual arousal. Candid conversations about sex and intimacy with partners—sometimes aided by sex therapy or sex coaching—can make it easier to overcome obstacles created by colorectal disease and the surgery it can warrant.
Surgery for colon cancer can cause erectile dysfunction—but it doesn't mean it's long-term. It's not always easy for couples to seek help, especially for something as personal and sensitive as sex and erection troubles. Plus, if a couple hasn't sought therapy previously, they likely don't have a therapist they see regularly. Taking that first step isn't always easy.
Video visits have become a viable option for most people, and more therapists have added them as a service. Giddy telehealth makes it easy to connect with a qualified healthcare professional who can help in a variety of ways, including counseling.