The document discusses sexual and urinary dysfunction that can occur after rectal resection surgery due to damage to the autonomic nervous system. It provides background on the autonomic nervous system and its role in controlling internal organs and bodily functions. It then reviews several studies that have examined the effects of rectal cancer surgery, particularly total mesorectal excision, on subsequent urinary and sexual dysfunction in patients. The studies found that such dysfunctions were more common after procedures like abdominoperineal resection compared to lower anterior resection, and were associated with damage to nerves like the hypogastric plexus and pelvic splanchnic nerves during surgery. Careful dissection around the rectum was important to preserve auton

1. ‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬

2. Sexual and urinary
dysfunction after rectal
resection

3. Hint about Autonomic Nervous
System(ANS)
 The Autonomic Nervous System (ANS) Controls the
Body's Internal Environment in a Coordinated Manner
 The ANS helps control the heart rate, blood pressure, digestion,
respiration, blood pH and other bodily functions through a series
of complex reflex actions.
 Below the conscious level.
 In the ANS there are 2 nerves between the central nervous
system (CNS) and the organ. The nerve cell bodies for the
second nerve are organized into ganglia:
 CNS -> Preganglionic nerve -> Ganglion
-> Postganglionic nerve -> Organ
 At each junction neurotransmitters are released and carry the
signal to the next nerve or organ.

4. The ANS has 2 Divisions, Sympathetic
and Parasympathetic, Which Differ in
Anatomy and Function

6. Comparison of the Actions if the Sympathetic &
Parasympathetic Systems.
 Usually (but not always) both sympathetic and parasympathetic nerves go to an
organ and have opposite effects
 You can predict about 90% of the sympathetic and parasympathetic responses
using the 2 phrases: "Fight or Flight" and "Rest and Digest".
 Special cases:
 Occasionally the 2 systems work together: in sexual intercourse the
parasympathetic promotes erection and the sympathetic produces
ejaculation
 Eye: the sympathetic response is dilation and relaxation of the
ciliary muscle for far vision (parasympathetic does the opposite)
 Urination: the parasympathetic system relaxes the sphincter muscle
and promotes contraction of muscles of the bladder wall ->
urination (sympathetic blocks urination)
 Defecation: the parasympathetic system causes relaxation of the
anal sphincter and stimulates colon and rectum to contract ->
defecation (sympathetic blocks defecation)

7. Organ
Parasympathetic Response
"Rest and Digest"
Sympathetic Response
"Fight or Flight"
Heart
(baroreceptor
reflex)
Decreased heart rate
Cardiac output decreases
Increased rate and strength of
contraction
Cardiac output increases
Lung Bronchioles Constriction Dilation
Liver Glycogen No effect
Glycogen breakdown
Blood glucose increases
Fat Tissue No effect
Breakdown of fat
Blood fatty acids increase
Basal Metabolism No effect Increases ~ 2X
Stomach
Increased secretion of HCl & digestive enzymes
Increased motility
Decreased secretion
Decreased motility
Intestine
Increased secretion of HCl & digestive enzymes
Increased motility
Decreased secretion
Decreased motility
Urinary bladder
Relaxes sphincter
Detrusor muscle contracts
Urination promoted
Constricts sphincter
Relaxes detrusor
Urination inhibited
Rectum
Relaxes sphincter
Contracts wall muscles
Defecation promoted
Constricts sphincter
Relaxes wall muscles
Defecation inhibited
Eye
Iris constricts
Adjusts for near vision
Iris dilates
Adjusts for far vision
Male Sex Organs Promotes erection Promotes ejaculation

10.  The great plexuses of the sympathetic are
aggregations of nerves and ganglia, situated
in the thoracic, abdominal, and pelvic cavities,
and named the cardiac, celiac, and
hypogastric plexuses. They consist not
only of sympathetic fibers derived from the
ganglia, but of fibers from the medulla
spinalis, which are conveyed through the
white rami communicantes. From the
plexuses branches are given to the thoracic,
abdominal, and pelvic viscera.
The Great Plexuses of the
Sympathetic System

11. The abdominal aortic plexus (plexus aorticus
abdominalis; aortic plexus)
 Formed by branches
derived, on either side, from
the celiac plexus and
ganglia, and receives
filaments from some of the
lumbar ganglia. It is situated
upon the sides and front of
the aorta, between the
origins of the superior and
inferior mesenteric arteries.
From this plexus arise part of
the spermatic, the inferior
mesenteric, and the
hypogastric plexuses; it also
distributes filaments to the
inferior vena cava.

12. The inferior mesenteric plexus (plexus
mesentericus inferior)
 Derived chiefly from the aortic plexus. It
surrounds the inferior mesenteric artery, and
divides into a number of secondary plexuses,
which are distributed to all the parts supplied
by the artery, viz., the left colic and
sigmoid plexuses, which supply the
descending and sigmoid parts of the colon;
and the superior hemorrhoidal plexus,
which supplies the rectum and joins in the
pelvis with branches from the pelvic
plexuses.

14. The Hypogastric Plexus (Plexus
Hypogastricus)
 The hypogastric plexus is situated in front
of the last lumbar vertebra and the
promontory of the sacrum, between the two
common iliac arteries, and is formed by the
union of numerous filaments, which descend
on either side from the aortic plexus, and from
the lumbar ganglia; it divides, below, into two
lateral portions which are named the pelvic
plexuses on both sides of pelvic wall.

15. The Pelvic Plexuses
 Supply the viscera of the pelvic cavity, and are
situated at the sides of the rectum in the male, and at
the sides of the rectum and vagina in the female.
They are formed on either side by a continuation of
the hypogastric plexus, by the sacral
parasympathetic fibers from the second, third, and
fourth sacral nerves, and by a few filaments from the
first two sacral ganglia. At the points of junction of
these nerves small ganglia are found. From these
plexuses numerous branches are distributed to the
viscera of the pelvis. They accompany the branches
of the hypogastric artery.

18. The Vesical Plexus (plexus vesicalis)
 Arises from the forepart of the pelvic plexus.
The nerves composing it are numerous, and
contain a large proportion of spinal nerve
fibers. They accompany the vesicle arteries,
and are distributed to the sides and fundus of
the bladder. Numerous filaments also pass to
the vesiculæ seminales and ductus
deferentes; those accompanying the ductus
deferens join, on the spermatic cord, with
branches from the spermatic plexus.

19. The Prostatic Plexus (plexus prostaticus)
 Is continued from the lower part of the pelvic
plexus. The nerves composing it are of large
size. They are distributed to the prostate
vesiculæ seminales and the corpora
cavernosa of the penis and urethra. The
nerves supplying the corpora cavernosa
consist of two sets, the lesser and greater
cavernous nerves, which arise from the
forepart of the prostatic plexus, and, after
joining with branches from the pudendal
nerve, pass forward beneath the public arch.

20.  The Vaginal Plexus
arises from the lower part
of the pelvic plexus. It is
distributed to the walls of
the vagina, to the erectile
tissue of the vestibule,
and to the clitoris. The
nerves composing this
plexus contain, like the
vesical, a large proportion
of spinal nerve fibers.
 The Uterine Plexus
accompanies the uterine
artery to the side of the
uterus, between the layers
of the broad ligament; it
communicates with the
ovarian plexus.

22. Vulnerable sites for injury
 Where the hypogastric nerve cross
sacral promontry. (s)
 During dissection of left ureter. (s)
 During dissecting and dividing the
lateral rectal ligaments. (S&?PS)
 At the level of Denonvilliers’ fasia.
(S&PS)

23. Urinary and sexual dysfunction are
common problems after rectal cancer
surgery, and the likely cause is
damage to the pelvic autonomic
nerves during surgery. In recent
years, attention has been focused on
preserving the autonomic nerves
through a technique which is usually
combined with total mesorectal
excision or radical pelvic
lymphadenectomy
Background

24. Sexual and bladder dysfunctions following surgery for
rectal carcinoma.
Fegiz G, Trenti A, Bezzi M, Ambrogi V, Papini Papi M,
Tucci G, Angelini L.

A series of 475 patients who underwent surgery for rectal carcinoma were
followed up and entered this study. Sexual and bladder function before and
after surgery with respect to the surgical procedure was considered. 221
patients gave suitable information about their urinary function: bladder
dysfunction was observed in 20% of amputated patients as against 13-14% of
resected patients. 144 patients (103 males and 41 females) were available
for a follow-up study of the sexual function. Sexual intercourse, libido,
erection, ejaculation, dyspareunia, vaginal humidification,
orgasm were the parameters examined. Almost all of them
were more affected after abdominoperineal resection than
after low anterior resection with manual or stapled
anastomosis, although the difference was not always
significant. In a few instances the rates were inverted. It is believed that
these dysfunctions are not related to the type of surgery, but to required extent
of radicality. Extreme care should be always taken when dissecting the end
portion of the rectum to avoid injuries to the hypogastric plexus and the
pudendal nerve.
PMID: 3771176 [PubMed - indexed for MEDLINE]

25. Bladder and sexual dysfunction after mesorectal excision
for rectal cancer.
Nesbakken A, Nygaard K, Bull-Njaa T, Carlsen E, Eri LM.
Department of Surgery, Aker Hospital, Oslo, Norway.
 METHODS: Spontaneous flowmetry, residual volume of urine measurement
and urodynamic examination, including cystometry and simultaneous detrusor
pressure and urinary flow recording, was carried out before and 3 months after
curative rectal excision. Urinary symptoms and sexual function were evaluated
by means of questionnaires before and after operation. Each patient served as
his or her own control. RESULTS: Forty-nine consecutive patients, 39 of whom
had a total mesorectal excision (TME) and ten a partial mesorectal excision,
were examined before surgery and 35 again after operation. In two patients, a
weak detrusor was detected before operation. Two patients developed signs of
bladder denervation after operation. Transitory moderate urinary
incontinence appeared in four other women. Six of 24 men reported
some reduction in erectile function and one became impotent. Two men reported
retrograde ejaculation. All the complications were seen in the TME group.
CONCLUSION: Mesorectal excision for rectal cancer resulted in a low
frequency of serious bladder and sexual dysfunction.
PMID: 10671929 [PubMed - indexed for MEDLINE]

26. Male and female sexual and urinary function after total mesorectal
excision with autonomic nerve preservation for carcinoma of the
rectum.
Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J.
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY,
USA.
 STUDY DESIGN: We studied retrospectively postoperative sexual and urinary
function in 136 (78 percent) of 175 eligible patients (82 males and 54 females)
who responded to a standardized questionnaire. RESULTS: The ability to
engage in intercourse was maintained by 86 percent of the patients younger
than 60 years of age, and by 67 percent of patients 60 years and older. Eighty-
seven percent of male patients maintained their ability to achieve orgasm. The
type of surgery (abdominoperineal resection compared to low anterior
resection), and age equal to or greater than 60 years were significantly
associated with male sexual dysfunction. Of the female patients, 85
percent were able to experience arousal with vaginal lubrication and
91 percent could achieve orgasm. The majority of patients had few
or no complaints related to urinary function. Serious urinary
dysfunction such as neurogenic bladder was not encountered.
CONCLUSIONS: Autonomic nerve preservation in association with total
mesorectal excision reduces the operative morbidity rate and is successful in
minimizing sexual and urinary dysfunction in the operative treatment of patients
with carcinoma of the rectum.

27. Intraoperative identification and neurophysiologic parameters to verify
pelvic autonomic nerve function during total mesorectal excision for
rectal cancer.
Kneist W, Heintz A, Junginger T.
Clinic of General and Abdominal Surgery, Johannes Gutenberg-University, Mainz,
Germany.
 STUDY DESIGN: In a prospective pilot study, 17 patients, 11 men and 6 women,
underwent TME with pelvic autonomic nerve preservation performed by an
experienced surgeon. The parasympathetic nerves were stimulated by an
electrostimulation device (Screener 3625, Medronic), and the resulting bladder
contraction was measured manometrically in all patients . Variations in pulse rate and
voltage were measured to determine optimal stimulation parameters. A standardized
questionnaire was used to record urogenital function disturbances. Residual urine volume was
measured by ultrasound pre- and postoperatively. Shortterm outcomes data were evaluated to
establish a possible association between intraoperative test results and postoperative bladder
function. RESULTS: In 15 of 17 patients undergoing TME with pelvic autonomic nerve
preservation for rectal carcinoma, the parasympathetic nerves were identified based on nerve
stimulation-induced bladder contraction. Two patients with negative results on intraoperative
nerve stimulation had persisting bladder dysfunction requiring an indwelling catheter after
discharge from hospital. In spite of a short median followup of 2 months (range 1 to 4 months), in
7 of 10 men with intact erectile function prior to surgery, postoperative erectile dysfunction could
be excluded. The study showed a pulse rate of 35 Hz and an electric potential of 12 V to be
optimal stimulation parameters, associated with a mean intravesical pressure rise of 12.7 cm
H(2)O (range 2.8 to 18.0 cm H(2)O). CONCLUSIONS: Intraoperative nerve stimulation
with monitoring of intravesical pressure represents a technically simple procedure
for the identification and verification of function of pelvic parasympathetic nerves
during TME for rectal carcinoma.

29. Urinary and sexual dysfunction after rectal cancer operation]
Naito H, Sasaki M, Nakamura K, Ogita M, Akasaka Y, Nagase
A, Sagawa H, Ookawa Y, Nakajima H.
Department of Surgery, Sapporo National Hospital.
 Using a questionnaire, the urinary function of 68 patients and the sexual
function of 81 patients were evaluated after rectal cancer operation. The
patients with carcinoma of the rectum suffered from severe damage to the urinary
system following Miles' operation (Miles) which included 85.7% of the male and
42.9% female. On the other hand, 31.8% male and 33.3% female suffered
following anterior resection or pull through operation (AR). Following Miles 64.3%
male and 71.4% female had developed urinary incontinence while 36.4% male and
33.3% female developed the same following AR. These results indicate that
dysfunction of the urinary voiding system was more common in the males while the
females experienced urinary incontinence. This difference may be due to the
severity of the surgical intervention to the bladder neck and partly to
the anatomical difference of pelvic floor and of urethra. The recovery
was poor in the patients who had developed disorder of the urinary voiding system
and unfortunately 84% patients following Miles and 75% patients after AR could not
return to normal voiding even five years after operation. Urinary incontinence
persisted after Miles and after AR in 77.8% and 31% patient respectively. Sexual
activity was remarkably reduced following Miles. The males lost the power of
erection and ejaculation, the females suffered due to the existence of
artificial colostomy. In order to maintain the normal physiological activity of the
urogenital system following operation, it is important to avoid any damage
preferably to the bladder neck and urethra in case of males and to avoid artificial
stoma in females.

30. Prevalence of male and female sexual dysfunction is high following
surgery for rectal cancer.
Hendren SK, O'Connor BI, Liu M, Asano T, Cohen Z, Swallow CJ, Macrae
HM, Gryfe R, McLeod RS.
Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada.
 OBJECTIVE: To measure sexual function and quality of life (QOL) after rectal cancer
treatment. METHODS: Patients undergoing curative rectal cancer surgery from 1980 to
2003 were administered a questionnaire, including the Female Sexual Function Index
(FSFI) or International Index of Erectile Function (IIEF), and the EORTC QLQ-C30/CR-38.
Multiple logistic regression was used to test associations of clinical factors with outcomes.
RESULTS: Eighty-one women (81.0%) and 99 men (80.5%) returned the questionnaire;
32% of women and 50% of men are sexually active, compared with 61% and 91%
preoperatively (P < 0.04); 29% of women and 45% of men reported that "surgery
made their sexual lives worse." Mean (SD) FSFI and IIEF scores were 17.5 (11.9)
and 29.3 (22.8). Specific sexual problems in women were libido 41%, arousal
29%, lubrication 56%, orgasm 35%, and dyspareunia 46%, and in men libido
47%, impotence 32%, partial impotence 52%, orgasm 41%, and ejaculation
43%. Both genders reported a negative body image. Patients seldom
remembered discussing sexual risks preoperatively and seldom were
treated for dysfunction. Current age (P < 0.001), surgical procedure (P = 0.003), and
preoperative sexual activity (P = 0.001) were independently associated with current sexual
activity. Gender (male, P = 0.014), surgical procedure (P = 0.005), and radiation therapy
(P = 0.0001) were independently associated with the outcome "surgery made sexual life
worse." Global QOL scores were high. CONCLUSIONS: Sexual problems after surgery
for rectal cancer are common, multifactorial, inadequately discussed, and untreated.

31. [Analysis of mailed questionnaire for female sexual
dysfunction after intra-pelvic surgery]
Amano T, Takemae K, Sakai H, Sugase M, Kondou K.
Department of Urology, Nagano Red Cross Hospital, Nagano,
Japan.
 MATERIALS AND METHODS: A mailed questionnaire regarding female sexual dysfunction
was sent to 174 patients, including 118 that had undergone a hysterectomy (Group A) and 56
ostomates (Group B) and the results were analyzed. These patients had received only intra-pelvic
surgery, without radiation or chemotherapy. Of the 56 patients in Group B, 50 with rectal cancer
had received a colostomy, and 6 with bladder cancer had received ileal conduits. The content of
the questionnaire was as follows: age; with or without a male partner; key person for
consultation in regard to sexual dysfunction; importance of sex life. Also, a before and after
operation comparison was made regarding sexual frequency, sexual desire, genital response,
genital transformation, dyspareunia, genital pain and itching, and orgasm. RESULTS: Seventy-
eight of 174 (45%) patients returned the questionnaire. Nineteen patients without a male partner
and 18 patients with a male partner had no sexual intercourse, very low sexual desire, and did not
consider their sex life of importance. Twenty-five patients with a male partner (18 in Group A and 7
in Group B) had no trouble in their sexual activity after the operations. However, the other 16
patients (5 in Group A and 11 in Group B) had unsatisfactory sexual intercourse after their
operations because of a decrease in sexual desire, poor genital response, and/or
decrease of orgasms. Furthermore, the patients in Group B suffered significantly from sexual
trouble compared with the patients in Group A. Especially, all the patients in Group B complained
that their stoma prevented satisfactory sexual intercourse. CONCLUSIONS: Based
on this data, we do not need to worry about female sexual dysfunction for patients
without a male partner and patients with a partner but who are not sexually active
before their operations. More than 60% of patients who had been sexually active
before their operations maintained fair sexual activity after intra-pelvic surgery.
However, we have to take care of the approximately 40% of patients who suffer from female
sexual dysfunction after their operation, especially the ostomate patients.

32. Bladder and sexual function following resection for rectal
cancer in a randomized clinical trial of laparoscopic versus
open technique.
Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P, Guillou PJ.
Academic Unit of Surgery, St James's University Hospital, Leeds, UK.
 METHODS:: Bladder and sexual function were assessed in patients who had
undergone laparoscopic rectal, open rectal or laparoscopic colonic resection as part
of the UK Medical Research Council Conventional versus Laparoscopic-Assisted
Surgery In Colorectal Cancer (CLASICC) trial, using the International Prostatic
Symptom Score, the International Index of Erectile Function and the Female Sexual
Function Index. Sexual and bladder function data from the European Organization for
Research and Treatment of Cancer QLQ-CR38 collected in the CLASICC trial were
used for comparison. RESULTS:: Two hundred and forty-seven (71.2 per cent) of
347 patients completed questionnaires. Bladder function was similar after
laparoscopic and open rectal operations for rectal cancer. Overall sexual function
and erectile function tended to be worse in men after laparoscopic rectal
surgery than after open rectal surgery (overall function: difference - 11.18 (95
per cent confidence interval (c.i.) -22.99 to 0.63), P = 0.063; erectile function:
difference -5.84 (95 per cent c.i. -10.94 to -0.74), P = 0.068). Total mesorectal
excision (TME) was more commonly performed in the laparoscopic rectal group than
in the open rectal group. TME (odds ratio (OR) 6.38, P = 0.054) and conversion to
open operation (OR 2.86, P = 0.041) were independent predictors of postoperative
male sexual dysfunction. No differences were detected in female sexual
function. CONCLUSION:: Laparoscopic rectal resection did not adversely affect
bladder function, but there was a trend towards worse male sexual function. This may
be explained by the higher rate of TME in the laparoscopic rectal resection group.
Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley &
Sons, Ltd.

33. Anatomy of Denonvilliers' fascia and pelvic nerves,
impotence, and implications for the colorectal surgeon.
Lindsey I, Guy RJ, Warren BF, Mortensen NJ.
Departments of Colorectal Surgery and Cellular Pathology, John
Radcliffe Hospital, Oxford, UK.
 BACKGROUND: The development and anatomy of
Denonvilliers' fascia have been controversial for many years
and confusion exists about its operative appearance. Better
appreciation of this poorly understood anatomy, and its significance for
impotence after rectal dissection, may lead to further functional
improvements in pelvic surgery. METHOD: A literature review of
the embryology and anatomy of Denonvilliers' fascia and
impotence after pelvic rectal surgery was undertaken.
RESULTS: Denonvilliers' fascia has no macroscopically discernible
layers. The so-called posterior layer refers to the fascia propria of the
rectum. The incidence of erectile and ejaculatory dysfunction after
rectal excision is high in older patients, and when performed for rectal
cancer. There is no consensus about the relationship of Denonvilliers'
fascia to the plane of anterior dissection for rectal cancer.
CONCLUSION: Colorectal surgeons should focus on the important
anatomy between the rectum and the prostate to improve functional
outcomes after rectal excision. A classification of the available anterior
dissection planes is proposed. Surgeons should be encouraged to
document the plane used as well as outcome in terms of sexual
function.

34. Conclusions

35. Conclusions
 Sexual and urinary dysfunctions(in both sex)
can be consequences of pelvic surgery as the
median age (Abroad) is 62 years old.
 Sites of potential injury occupay the entire
field of pelvic dissection for rectal cancer from
sacral promontry to Denonvilliers’ fascia.

36. Conclusions
Risk factors for postoperative sexual
and bladder dysfunction are related to
patients and tumour characteristics and
to the operative technique,for instance
male gender, tumours invading through
muscularis propria (pT3 ⁄ pT4), using
the extramesorectal plane for anterior
rectal dissection,abdominoperinal
resection and the learning curve.

37. Conclusions
 When a dilemma exists between preservation of
autonomic function and determining a negative
margin of resection, one must choose in favour of
complete eradication of the tumor.
 Surgeons could profitably spend more time with their
patients discussing the possible effects of surgery on
sexual and urinary function.
 Further research is required to determine the effects
of adjuvant therapy for rectal cancer on sexual
function.

38. Conclusions
 Currently, individual surgeons have embarked
upon efforts to design operations that
combine adequate pelvic resection and nerve
preservation.
 This can only be accomplished with a detailed
knowledge of pelvic anatomy and mastery of
pelvic dissection.

39. Thank you