Abstract

Background

Following pelvic radiotherapy (RT), a proportion of women experience problems related to sexual function, which are multifactorial in origin. The physical components relate to distortion of the perineum and vagina, which may occur as a result of surgery and/or radiotherapy and compromise sexual activity resulting in considerable distress.

Objectives

The aim of this review was to evaluate the evidence for treatment options addressing the physical components of sexual dysfunction arising from pelvic radiotherapy as prevention or treatment of acute or late complications.

Search methods

The concepts used included synonyms for radiation therapy and brachytherapy and synonyms for the spectrum of physical aspects of sexual dysfunction in women. randomized. We searched the Cochrane Controlled Trials Register (CENTRAL), Issue 1, 2002, MEDLINE 1966 to 2002, EMBASE 1980 to 2002, CANCERCD 1980 to 2002, Science Citation Index 1991 to 2002, CINAHL 1982 to 2002, as well as sources of grey literature. We also hand searched relevant textbooks and contacted experts in the field.

Selection criteria

Any study describing the therapeutic trial of a treatment to relieve the physical aspects of female sexual dysfunction which had developed following pelvic radiotherapy was considered. The quality of each study was then assessed by two reviewers independently to determine its suitability for inclusion in statistical analysis.

Data collection and analysis

Thirty‐two references met the inclusion criteria for the search but of these only four were suitable to be included for statistical analysis.

Main results

The strongest evidence for benefit is the grade IC data in the topical oestrogens and benzydamine sections which describes the treatment of acute radiation vaginal changes. The use of vaginal dilators to prevent the development of vaginal stenosis is supported by grade IIC evidence. The value of hyperbaric oxygen therapy and surgical reconstruction is supported by the much weaker grade IIIC evidence in the form of case series.

Authors' conclusions

These findings reflect the quality of published data regarding interventions for this aspect of the management of radiation induced complications. Although there is grade IC evidence, these studies are not recent, the allocation concealment is unclear in the text, and overall there is a variable level of assessment of the response, emphasising the need for more studies to be conducted with improved designs to clarify the investigative process and support the final result.

Author(s)

Arshi S Denton, Jane Maher

Abstract

Plain language summary

Vaginal dilators and intercourse are useful for alleviating post‐radiotherapy vaginal problems, but more evidence is required to assess oestrogens and benzydamine

The physical side effects of radiotherapy to the female pelvis may lead to difficulty and/or pain during intercourse. Studies of treatments (vaginal oestrogens, benzydamine douches, dilators, and intercourse) were neither recent nor good quality. This review endorses the current recommendation of using dilators and/or intercourse to prevent vaginal narrowing, however although some studies recommend the use of vaginal oestrogen or benzydamine douches, they are not statistically significant and large randomized trials are required to assess their effectiveness.

Author(s)

Arshi S Denton, Jane Maher

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

The success of vaginal stents in the prevention of vaginal stenosis following pelvic radiotherapy endorses the recommendations currently being made by oncology departments, to maintain vaginal patency by some form of vaginal dilatation and supports their reinforcement. Other reported interventions, in particular the use of benzydamine douches and vaginal oestrogens, may look promising and appear to be effective in the prevention and treatment of radiation complications affecting the vagina and vulva. However one or two small studies (even if well conducted) are statistically underpowered and provide insufficient evidence. The variable nature of this spectrum of acute and late radiation complications requires large placebo controlled studies to establish whether particular treatments are effective before they can be recommended for general use in this setting.

Implications for research 

Radiation complications in the pelvis affecting the physical aspects of sexual function in women are infrequently reported by patients to the clinicians who deliver the pelvic radiotherapy, and a number of fundamental issues remain to be clarified. First, the true incidence of these complications is not clear. Therefore, physicians caring for patients who have undergone pelvic radiotherapy need to be more aware that these patients may develop problematic symptoms which may need detailed questioning to elicit and which may require specialist assessment to characterize in detail. Secondly, there is an urgent need to define clearly the diagnostic criteria and a unified grading system by which these problems may be categorised. Without such a system, it is unlikely that meaningful randomized studies can be designed for application in a multi‐centre setting. To aid physicians and patients and to promote research, we propose that cases should be enrolled into regional or centralised registers of radiation toxicity or that all such patients should be referred to regional centres with an interest in radiation‐induced toxicity. In this way baseline assessments may be standardised, perhaps using validated check‐lists or questionnaires, therapeutic interventions may be randomized and outcome data could be pooled to assess the response to treatment objectively. This approach would provide an evidence base of results of different treatments to develop a standardised integrated care pathway for this difficult condition.

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