Sexual function after rectal excision

Rectal excision is associated with a risk of autonomic nerve damage and associated sexual dysfunction (SD). The evolution of our understanding of the anatomy and physiology of sexual function together with continual refinement of surgery for both benign and malignant disease has led to a decrease in the incidence of SD after rectal surgery. A knowledge of the degree of risk of postoperative SD is important both for the patient and as a benchmark for audit of individual colorectal practice.

The available literature on the anatomy, physiology and surgical aspects of this topic has been researched through the Medline database. The more recently available data are reviewed in the context of the historical evolution of surgery for benign and malignant rectal disease.

In the best hands, permanent impotence occurs in less than 2% of patients following restorative proctocolectomy and at a similarly low rate after proctocolectomy and ileostomy. Isolated ejaculatory dysfunction is also numerically a minor problem post operation for benign disease. Patient age is the most important predictor of SD after surgery for rectal cancer. The incidence of permanent impotence remains high (>40%) after abdomino-perineal excision of the rectum (APE) but the continued decline in the use of this operation in favour of low anterior resection (LAR), which carries about half the risk of impotence compared to sphincter ablating surgery, is likely to have resulted in a fall in the absolute number of patients rendered impotent as a result of rectal cancer surgery. Anatomical dissection of the pelvis with preservation of the named autonomic fibres results in a low and predictable rate of sexual morbidity. Surgeons could profitably spend more time with their patients discussing the possible effects of surgery on sexual function. Further research is required to determine the effects of adjuvant therapy for rectal cancer on sexual function.