Organs that may be involved in pelvic surgery for cancer

The female genital and reproductive organs include the uterus, (or womb), cervix (the entrance to the womb at the top of the vagina), fallopian tubes, ovaries (the organs that produce eggs and hormones), vagina, vulva, bladder (the storage area for urine), and rectum (the bottom end of the intestines).

Radical hysterectomy

Radical hysterectomy is an operation used to treat some cancers of the cervix. The surgeon takes out the uterus and the ligaments (tissue fibers) that hold it in place in the pelvis. The cervix and an inch or two of the deep vagina around the cervix is also removed. A hysterectomy for uterine or ovarian cancer removes less tissue.

After taking out the cervix, the surgeon stitches the vagina at its top. Some fluid drains from the vagina during healing. The top of the vagina soon seals with scar tissue and becomes a closed tube. The vagina does not, as some women fear, become an open tunnel into the pelvis.

The ovaries may or may not be removed

If a woman is less than 40 years old, the surgeon will often try to leave an ovary or part of one during a hysterectomy. Even one ovary can produce enough hormones to keep a woman from going through early menopause. Because the uterus is removed, a woman will not have menstrual periods and she will not be able to get pregnant after hysterectomy.

If a woman is between 40 and 50 when she has surgery, doctors weigh the benefits of removing both ovaries to prevent ovarian cancer against the costs of causing sudden early menopause. Women should discuss these choices with their doctor before surgery. Many cancer centers have sexual health programs where trained health care professionals (gynecologists and sex therapists) can help women with any concerns. Many women will talk with other women before surgery so they can discuss their concerns about how surgery will affect their sexual function.

A surgeon most often removes both ovaries in women over the age of 50 having this surgery.

Effects of hysterectomy on sexual function

Hysterectomy does not usually change a woman's ability to feel sexual pleasure. The vagina is shortened, but the area around the clitoris and the lining of the vagina generally stay as sensitive as before.

Some women feel less feminine after a hysterectomy. They may view themselves as "an empty shell" or not feel like a "real" woman. Such negative thoughts can keep women from thinking about the sexual function that they still have. A trained therapist often can help you with such concerns.

If cancer is causing pain or bleeding with intercourse, a hysterectomy can help stop those symptoms and actually improve a woman's sex life. Although the vagina may be shorter after surgery, couples usually adjust to this change. Extra time spent on caressing and other forms of foreplay can help ensure that the vagina has lengthened enough to allow intercourse.

If the vagina seems too shallow, there are ways a woman can give her partner the feeling of more depth. She may spread some lubricating gel on her outer genital lips and the tops of her thighs and press her thighs together during intercourse. She can also cup her hands around the base of her partner's penis during intercourse.

A radical hysterectomy can affect a woman's ability to pass urine while the nerves in the tissue around the uterus are recovering from surgery. Often a woman cannot fully empty her bladder for a few weeks after surgery. To prevent urinary tract infections, she may be taught to slip a small tube, called a catheter, through the urethra and into the bladder to drain out the remaining urine. This is called self-catheterizing. A few women may need to do this several times a day for the rest of their lives. If you are self-catheterizing, make sure your bladder is empty before intercourse to help prevent urinary tract infections or discomfort during sex.

Orgasm after radical hysterectomy

Women who have had a radical hysterectomy sometimes ask if the surgery will affect their ability to have orgasms. This has not been studied a great deal, and there isn't as much information as we'd like. One study in Denmark looked at the effect of radical hysterectomy on sexual function by comparing women who had the surgery to women who hadn't. The women had the surgery for stage I or stage IIA cervical cancer. This means that the cancer had not spread into the tissues next to the cervix, even though it may have grown into the upper part of the vagina.

Just after the surgery, more than 1 in 10 women noticed problems with lubrication and pain during sex. Almost 8 in 10 women reported little or no interest in sex. Compared to women who didn't have surgery, about twice as many reported problems reaching orgasm. Nearly 1 in 5 said that their vaginas felt too small.

The good news is that most of the problems with sex caused by the radical hysterectomy were gone by 6 months after the surgery. By the end of 2 years, 9 of 10 women were back to having sex. At that point, the number of women who usually had orgasms during sex was about the same as that of the women who hadn't had surgery -- about 1 in 3 reported that they never or only occasionally had orgasms.

For women who have pelvic radiation along with radical hysterectomy, sex problems were likely to be somewhat worse and last longer. See the section, "Pelvic radiation therapy" for more information.

Radical cystectomy

A radical cystectomy is done to control bladder cancer. This means the surgeon removes the bladder, uterus, ovaries, fallopian tubes, cervix, front wall of the vagina, and the urethra. Although women who have this surgery are often past the age of menopause, many still have active sex lives.

If you have bladder cancer, talk with your doctor about the kind of surgery that is right for you (see the section, "Orgasm after radical cystectomy"). The most common type of radical cystectomy can result in less ability to have orgasms in some women. It can also cause less lubrication, as well as pain during intercourse. Some women report less desire for sex.

Vaginal reconstruction after radical cystectomy

Radical cystectomy often removes half of the vagina, but intercourse is still possible. Surgeons sometimes rebuild the vagina with a skin graft. More commonly, they use the remaining back wall of the vagina to rebuild the vaginal tube. There are pros and cons with both types of vaginal reconstruction. When the penis enters a narrow vagina, it may cause pain at first. This is especially true if a woman has had radiation to her bladder, which makes the vaginal walls less elastic. It is easier to start intercourse when the vagina is shorter and wider. But with a shorter and wider vagina, thrusting may be awkward because of the lack of depth. Surgeons try to spare as much of the front vaginal wall as possible to help avoid this problem.

Intercourse can be made less painful by using lubricating gels or vaginal moisturizers, replacement hormones, and vaginal dilators. See the section, "Using a vaginal dilator."

Sex without vaginal reconstruction

If your vagina is short because it has not been reconstructed, you may still enjoy intercourse. Certain sexual positions, such as those where the partners are side-by-side or with you on top, limit the depth of penetration. Also, you can spread lubricating gel on your outer genital lips and the top of your thighs as you press your thighs together during intercourse. If intercourse remains painful, a couple can still reach orgasm by touching each other with their hands.

Orgasm after radical cystectomy

Many women who have had the front walls of their vaginas removed as part of a cystectomy say that this has little or no effect on their orgasms. But others say that they were less able to have orgasms. Women have 2 nerve bundles, which run along each side of the vagina, and it is easy to damage these nerve bundles when removing the front of the vagina during radical cystectomy. Small studies have suggested that women who had surgery that preserved these nerve bundles had much better sexual function after surgery than those whose nerve bundles were removed or cut. Talk with your doctor about whether these nerves can be left in place during surgery. This can increase your chance of having more normal orgasms after surgery.

Another possible problem that can happen during radical cystectomy is that the surgeon takes out the end of the urethra where it opens outside the body. This can make the clitoris lose a good deal of its blood supply and may affect some parts of sexual arousal -- remember that, like the penis, the clitoris fills with blood when a woman is excited. Talk with your surgeon about whether the end of the urethra can be spared, and how that may affect your chances of normal clitoris function. It is not always necessary to remove the end of the urethra when you have surgery for bladder cancer.

Urostomy

Women who have had a radical cystectomy will also have an ostomy. An ostomy is an opening on the woman's belly (abdomen) where waste can pass out of the body. Since this is an opening for urine after the bladder is removed, this type of ostomy is called a urostomy. The urine flows through the urostomy into a plastic pouch, called an appliance, which fits into a plastic face plate glued to the skin around the ostomy. For ideas on how to manage an ostomy during sex, see the section, "Urostomy, colostomy, or ileostomy" under "Special aspects of some cancer treatments." Some women now have continent ostomies that stay dry and are emptied with a catheter. (If you would like to read more about urinary ostomies, see our document, Urostomy: A Guide.)

Abdominoperineal resection

Abdominoperineal (AP) resection for colon cancer is surgery that removes the lower colon and rectum. It also creates a colostomy so that stool can pass out of the body. There are many different ways to do AP resections. In a younger woman, just the colon and rectum may be removed. But sometimes the uterus, ovaries, and even the rear wall of the vagina must be removed, too. The remaining vaginal tube must then be repaired with skin grafts or with a flap made of skin and muscle.

AP resection does not damage the nerves that control the feeling in a woman's genitals and allow orgasm. Some women may notice vaginal dryness, especially if their ovaries were removed. If so, a water-based gel can help make intercourse more comfortable.

Intercourse in some positions may be uncomfortable or even painful. Without a rectum to cushion the vagina, the vagina may move more during intercourse. When this happens, it may pull on the tissues that hold the vagina and uterus in place inside the pelvis. A couple may need to try different positions to find one that works for them. If a skin graft or flap was used to repair the vagina, the section "Vaginal reconstruction after total pelvic exenteration" may be helpful.

For suggestions on how to manage an ostomy during sex, see the section "Urostomy, colostomy, or ileostomy" under "Special aspects of some cancer treatments." (If you would like to read more about colostomies, see our document, Colostomy: A Guide.)

Surgery for cancer of the vulva (vulvectomy)

Cancer of the vulva is sometimes treated by removing all or part of the vulva. This operation is called a vulvectomy. A partial vulvectomy, removes only the affected area and an edge (or margin) of normal tissue around it. The modified radical vulvectomy removes the affected area, an edge of normal tissue, and sometimes lymph nodes in the groin area. If there is cancer in or very near the clitoris, it may be need to be removed to be sure the cancer is taken out. The most extensive surgery is called a radical vulvectomy. Here the surgeon removes the whole vulva. This includes the inner and outer lips and the clitoris, and often the lymph nodes that drain lymph fluid from the vulva. The vagina, uterus, and ovaries remain intact.

Doctors often try to spare as much of the vulva as they safely can, knowing that it sometimes can be hard for a patient to adjust to the effects of radical surgery.

After part or all of the vulva has been removed, women often feel discomfort if they wear tight slacks or jeans since the "padding" around the urethral opening and vaginal entrance is gone. The area around the vagina also looks very different.

Women often fear their partners may be turned off by the scarring and loss of outer genitals, especially if they enjoy oral stimulation as part of lovemaking. Some women may be able to have reconstructive surgery to rebuild the outer and inner lips of the genitals. Although it may look more normal, the feeling (sensation) may be different.

When touching the area around the vagina, and especially the urethra, a light caress and the use of a lubricant can help prevent painful irritation. If scar tissue narrows the entrance to the vagina, penetration may be painful. Vaginal dilators can sometimes help stretch the opening. When scarring is severe, the surgeon may use skin grafts to widen the entrance.

When the lymph nodes in the groin have been removed, women often have swelling of their genital areas or legs. Though swelling just after surgery may go away, it can become a long-term problem. This condition, called lymphedema, can cause pain, a feeling of heaviness, and fatigue. It also can be a problem during sex. Couples should discuss these issues to decide what solutions work best for them. (If you want to read more about lymphedema in the groin or legs, you can get Understanding Lymphedema (for Cancers other than Breast Cancer). See the "Additional resources" section.)

Orgasm after vulvectomy

Women who have had a vulvectomy may have problems reaching orgasm, depending on how much of the vulva has been removed. The outer genitals, especially the clitoris, are important in a woman's sexual pleasure. If surgery has removed the clitoris and lower vagina, then orgasms may not be possible.

Some women find that stroking the front inside (stomach side) part of the vagina, about 1 to 4 inches inside the opening, can feel pleasurable.

Also, after vulvectomy, women may notice numbness in their genital area. Feeling may return slowly over the next few months.

Total pelvic exenteration

Total pelvic exenteration is the most extensive pelvic surgery. It is used most often when cancer of the cervix has come back (recurred) in the pelvis after surgery or radiation therapy. In this surgery, the uterus, cervix, ovaries, fallopian tubes, vagina, bladder, urethra, and rectum are removed. Two ostomies are created, one for urine and one for stool. The vagina is usually rebuilt. Because total pelvic exenteration is such a major surgery, some cancer centers offer counseling sessions before surgery to help the woman prepare for the changes in her body and her life.

Recovery from total pelvic exenteration takes a long time. Most women don't begin to feel totally healed for up to 6 months after surgery. Some say it takes at least 1 or 2 years to fully adjust to the changes in their bodies.

Even so, having a total pelvic exenteration doesn't mean that a woman can't lead a happy and productive life. With practice and determination, some women who have had this procedure can again have sexual desire, pleasure, and orgasm. Often the outer genitals, including the clitoris, are not removed, which means a woman may still feel pleasure when touched in this area. Because the nerve bundles on either side of the vagina are usually removed, there may be less fullness with arousal and less sensation in the clitoris. Again, lymphedema may be a problem after surgery (see "Surgery for cancer of the vulva," above.)

Vaginal reconstruction after total pelvic exenteration

If all or most of the vagina must be removed, it is possible to build a vagina with tissue from another part of the body. A new vagina can be surgically created out of skin, or by using both muscle and skin grafts. This new vagina can allow a woman to have intercourse.

Skin grafts: When the vagina is repaired with skin grafts, the woman must use a vaginal stent. This stent is a special form or mold worn inside the vagina to keep it stretched. At first, the stent must be worn all the time. Then it is worn for most of each day for many months after surgery. After about 3 months, regular sexual intercourse or the use of a plastic tube or dilator to stretch out the vagina for a few minutes each day is enough to keep the vagina open. Without frequent stretching, the new vagina may shrink or scar shut.

Muscle flaps and skin grafts: There are other ways to rebuild the vagina using muscle tissue and skin from other parts of the body. One way to rebuild the vagina is to use flaps of muscle and skin from the lower chest and abdomen. This method is called a VRAM (vertical rectus abdominis muscle) flap, and over the past few years it has been shown to work very well. The blood vessels and nerves for this tissue stay attached to their original site. They are tunneled through an incision that extends from the chest to the groin. This means that the new vagina is sensitive and stays open without a stent. The surgeon forms the flaps into a closed tube which is lined by the skin surface. It is then sewn into the area where the vagina has been removed. Part of the muscle is used to fill in the space in the pelvis where organs have been removed. When the new vagina heals, it is much like the original in size and shape. An older, less-used method takes skin and muscle from both inner thighs. Other graft sites can also be used.

A vagina that is rebuilt with muscle flaps and skin makes little or no natural lubricant when a woman becomes excited. A woman will need to prepare for intercourse by spreading a gel inside the vagina. If hair was present on the skin where the graft came from, she may still have a little hair inside the vagina. During intercourse with a rebuilt vagina, a woman may feel as if the area the skin came from is being stroked. This is because the walls of the vagina are still attached to their original nerve supply. Over time, these feelings become less distracting. They can even become sexually stimulating.

Care of the rebuilt vagina: A natural vagina has its own cleansing system. Its fluids drain out, along with any dead cells. The rebuilt vagina needs to be cleaned with a douche to prevent discharge and odor. A doctor or nurse can offer advice on how often to douche and what type to use.

Women also notice that the muscles around the vaginal entrance no longer can be squeezed together. A woman may miss being able to tighten her vagina. After the vagina is rebuilt, partners need to try different intercourse positions to find one that is best. Minor bleeding or "spotting" after intercourse is not a cause for alarm, but heavy or increased bleeding should be discussed with a doctor.

Orgasm after total pelvic exenteration:

With a total pelvic exenteration, all or part of the vagina may be removed which can affect the nerves that supply the clitoris. Still, some women are able to have orgasms after this type of surgery, though it takes practice and persistence.

Since the exact surgical procedure can vary from one person to another, it may help to speak with your surgeon about the full extent of the surgery before you have it. Find out what you can expect in the way of sexual function, including orgasm, after surgery.

Last Medical Review: 11/10/2008
Last Revised: 11/10/2008