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How Can We Effectively Address the Medical and Psychological Concerns of Survivors of Pelvic Malignancies? : Page 2 of 2

How Can We Effectively Address the Medical and Psychological Concerns of Survivors of Pelvic Malignancies? : Page 2 of 2

Oncology (Williston Park). 31(4):268-294.
Table 1. Continence Rates Following RRP, RPP, and RALP
Table 2. Incidence of Grade ≥ 2 or Grade ≥ 3 Genitourinary Toxicity Fo...

Urinary and Sexual Complications Associated With Chemotherapy and Hormonal Therapy

Urinary complications associated with chemotherapy have been well documented, especially in pediatric populations in whom high doses of chemotherapeutic agents, particularly cyclophosphamide and ifosfamide, have been extensively studied. The most common and severe urinary complication is hemorrhagic cystitis, which can vary from relatively asymptomatic microscopic hematuria to life-threatening hemorrhage. In a large retrospective series from St. Jude Children’s Research Hospital, several risk factors for grade 3 or higher hemorrhagic cystitis were identified, including pelvic RT, bone marrow transplantation, BK virus positivity, acute lymphocytic leukemia, cyclophosphamide exposure, and male sex.[57] The cause of hemorrhagic cystitis resulting from treatment with cyclophosphamide or ifosfamide is believed to be the conversion of cyclophosphamide or ifosfamide to urotoxic metabolites, such as acrolein. Mesna is an organosulfur frequently administered with alkylating agents to assist in detoxifying their metabolites via reaction of its sulfhydryl group with α,β-unsaturated carbonyl-containing compounds such as acrolein.[58] Other anti-inflammatory agents have also demonstrated effectiveness in decreasing the severity of hemorrhagic cystitis in preclinical models, including ketamine and interleukin-1 receptor antagonists.[59,60] This is obviously an area where the value of prophylactic treatment is well established. However, early recognition of the signs of this toxicity (eg, microscopic hematuria) and discontinuation of treatment for progressive symptoms are critical to its successful management.

Sexual dysfunction associated with chemotherapy is common and likely underreported in the literature. Premature ovarian failure is a common consequence of chemotherapy in reproductive-age women, and, as a result, fertility issues and sexual dysfunction occur frequently in women who have undergone chemotherapy. Sexual dysfunction associated with estrogen withdrawal and psychological stress is also widespread in female cancer survivors. Women who suffer from sexual dysfunction may benefit from counseling and targeted interventions.[61] A recent Cochrane review of the literature evaluated several clinical trials looking at psychoeducational interventions, as well as pharmaceutical interventions and pelvic floor exercise, but failed to definitively identify a pattern of benefit associated with any of these interventions.[62]

Sexual dysfunction in men is related to chemotherapy primarily when the agents used cause hypogonadism. Chemotherapy-induced hypogonadism is well documented with several agents, especially alkylating agents, and is more common in patients with renal disease and in those undergoing treatment for Hodgkin lymphoma; it may be proportional to gonadal activity.[63] It remains unclear whether gonadal quiescence during chemotherapy is protective.

ADT, by definition, lowers testosterone and commonly results in loss of libido and erectile dysfunction.[64] While these side effects are expected during therapy, recovery once androgen suppression is discontinued can be variable. Recognizing the signs and symptoms associated with an ongoing hypogonadal state is the first step in identifying the problem. In many cases, the side effects are transient and men recover once the therapy is complete; however, chronic symptoms associated with low levels of testosterone persisting for 12 months or longer after completion of therapy may be an indication for testosterone supplementation. This complication is likely underappreciated by many cancer survivors, who end up suffering from a treatable condition.

Overview of Treatment of Urinary and Sexual Complications in Cancer Survivors

In general, cancer survivors experiencing urinary side effects are bothered by symptoms of urinary incontinence, urinary retention, bladder overactivity, hematuria, and/or bladder pain. These symptoms may be isolated or overlapping, making treatment challenging to physicians—and confusing and frustrating to patients.

KEY POINTS
  • After cancer treatment, patients report difficulty adjusting to changes in physical appearance, daily functioning, and social roles.
  • Urinary and sexual dysfunction are common and burdensome sequelae of treatment of pelvic malignancies.
  • Numerous pharmacologic and surgical therapies exist to address urinary and sexual dysfunction that can follow treatment of pelvic malignancies.
  • Recognition of the sequelae of oncologic treatment allows for early intervention and subsequent improvement in the quality of life of cancer survivors.

In men with urinary incontinence, an assessment of the driving cause of their incontinence is critical if the practitioner is to provide adequate counseling regarding management options. Stress incontinence can be managed, after a detailed urologic evaluation, with PFMT, a transobturator urethral sling, or an artificial urinary sphincter.[65,66] These interventions have been shown to improve overall QOL in these patients, as in the patient in Case 1. Women with stress urinary incontinence after treatment of a gynecologic malignancy should be evaluated for fistulous disease or cancer recurrence. In the absence of an ominous finding, surgical treatment with a midurethral sling, retropubic colposuspension, or injection of bulking agents is feasible. The choice of approach is driven by the effect of the incontinence on the patient’s QOL, the severity of leakage, and the degree of lower urinary tract dysfunction.

Urinary frequency, urgency, and nocturia classically are considered irritative lower urinary tract symptoms secondary to bladder overactivity. These changes may occur after either an insult to bladder mucosa or bladder innervation. Surgery, chemotherapy, and RT can all lead to bothersome irritative urinary tract symptoms. Such symptoms may respond to dietary modifications (avoiding bladder irritants), antimuscarinic drugs, treatment with a β3 agonist, onabotulinum toxin A intravesical injections, or neuromodulation. When these therapies are exhausted, urinary diversion may be indicated in very-well-selected patients—such as the woman in Case 2.

Urinary retention after pelvic surgery may present as overflow incontinence or frank retention. In this setting, appropriate bladder drainage is necessary. Urethral catheterization is reasonable in the acute setting; however, urethral catheterization or suprapubic catheterization is not an appropriate long-term form of bladder management and is discouraged. Clean intermittent catheterization carries a lower risk of urinary tract infection, allows more flexibility in daily activities, and is a safe mode of bladder management in patients who are able to reliably self-catheterize or who have an adequate support structure to assist with catheterization.

Erectile dysfunction is commonly seen in men treated for pelvic malignancies. Erectile dysfunction is normally managed initially with phosphodiesterase type 5 (PDE5) inhibitors. PDE5 inhibitors are excellent treatments for erectile dysfunction resulting from RT.[67-69] A recent survey of erectile function in prostate cancer patients treated with hormonal therapy and IMRT showed that PDE5 inhibitors provided satisfactory response in 66% of men using the medications.[70] Additional therapies include vacuum erection devices, intraurethral alprostadil suppositories, intracavernosal injections (papaverine, phentolamine, alprostadil), and penile prostheses. All of these modalities have been shown to improve QOL in patients with erectile dysfunction.

Sexual dysfunction may be present in both men and women with pelvic malignancies. The interplay between physical, psychological, and social factors influences sexual desire, libido, and satisfaction. Therapists specializing in psychosexual care can help address the psychological and social component of sexual dysfunction at the same time that medical and surgical therapies are being used to address the biological facets of the problem. This is an area where a great need for additional support has been identified. However, this need is not yet well addressed in the comprehensive care of cancer survivors.

Exercise and Physiotherapy in the Management of Urinary and Sexual Dysfunction Resulting From Treatment of Pelvic Malignancies

Exercise and physiotherapy are of interest for management of both urinary and sexual dysfunction after treatment of pelvic malignancies because many of the etiologies of these dysfunctions are physical in nature. Making maximal use of exercise and physiotherapy has numerous advantages, including improvement in other comorbid conditions, overall well-being, low cost, ease of implementation, and relatively few side effects.

Data supporting exercise or physiotherapy as interventions in sexual dysfunction are limited. A recent Cochrane review identified 11 contemporary randomized controlled trials that assessed the effectiveness of treatments for sexual dysfunction resulting from cancer treatment in women.[62] Only one of the trials evaluated the effect of exercise on sexual function.[71] Of 34 patients with gynecologic cancers and pelvic floor dysfunction following radical hysterectomy and pelvic lymph node dissection, 24 completed a 4-week pelvic floor rehabilitation program (PFRP) or usual care. Outcomes included pelvic floor dysfunction (as measured by the pelvic floor dysfunction questionnaire), pelvic floor muscle strength, motor-evoked potential of the sacral nerve, and patient-reported health-related QOL. At 4 weeks, there were improvements in the PFRP group in pelvic floor strength and sexual functioning, as well as QOL. However, the systematic review concluded that the evidence that pelvic floor exercise improves sexual function is weak.[62]

In men, the evidence for the impact of exercise or physiotherapy is most abundant by far in prostate cancer patients. One trial randomized men post radical prostatectomy to usual care or exercise for 6 months. While improvements in measures of physical fitness were found in the exercise group, exercise had no impact on recovery of erectile function.[72] Recently, higher levels of physical activity have been correlated with better erectile and sexual function in men treated for prostate cancer.[73]Overall, given the likely favorable risk-benefit ratio, PFRP for women and exercise for men with sexual dysfunction seem reasonable.

There is somewhat stronger evidence that physiotherapy may improve urinary incontinence in patients following treatment of pelvic malignancies. In the case of stress incontinence, the chief culprit appears to be pelvic floor weakness. Although an earlier systematic review concluded that PFMT for the treatment of urinary incontinence after radical prostatectomy hastens the return to continence, a more recent systematic review concluded that the benefit of conservative measures is uncertain.[74,75] The authors of the more recent review did, however, note moderate evidence of an overall benefit from PFMT vs no PFMT in reduction of urinary incontinence.

Physiotherapy in survivors of gynecologic cancers may increase recovery of urinary function. A small pilot randomized controlled trial (N = 40) in which the majority of patients had uterine cancer (60%) and were treated with multimodality therapy (RT, 18%; surgery, 95%; chemotherapy, 35%) randomly assigned patients to 12 weeks of PFMT plus behavioral therapy or to usual care. After 12 weeks, the PFMT group had significantly improved urinary continence. Of note, a Cochrane review found that there is evidence of widespread recommendation of PFMT for women without cancer who have stress or any other type of urinary incontinence.[76] Overall, given this evidence, PFMT seems reasonable as conservative treatment of urinary incontinence, particularly anatomic or stress incontinence, in patients with a history of treatment of a pelvic malignancy.

Conclusion

The management of pelvic malignancies with surgery, chemotherapy, and RT is complicated by the prevalent urinary and sexual side effects that affect long-term patient QOL. Recognition of possible problems with urinary function, such as urge or stress incontinence or hemorrhagic cystitis, is critical if practitioners are to adequately counsel patients and manage their posttreatment course. Similarly, sexual dysfunction—including dyspareunia, vaginal shortening/stenosis, sensory loss, erectile dysfunction, and ejaculatory dysfunction—affects patients psychologically and socially. Having a clear understanding of the sequelae of treatment of pelvic malignancies allows for clinical recognition and improvement in health-related QOL outcomes.

Financial Disclosure: Dr. Peterson is a consultant for American Medical Systems/Boston Scientific. Boston Scientific provides an educational grant for the reconstructive urology fellowship at Duke University Medical Center. The other authors have no significant financial interest in or other relationship with the manufacturer of any product or provider of any service mentioned in this article.

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References

1. American Cancer Society. Cancer facts & figures 2016. Atlanta: American Cancer Society; 2016.

2. DeSantis CE, Lin CC, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64:252-71.

3. Reuben SH. Living beyond cancer: finding a new balance. President’s Cancer Panel 2003-2004 annual report. National Cancer Institute, National Institutes of Health, US Department of Health and Human Services; 2004.

4. Duran E, Tanriseven M, Ersoz N, et al. Urinary and sexual dysfunction rates and risk factors following rectal cancer surgery. Int J Colorectal Dis. 2015;30:1547-55.

5. Andersson J, Abis G, Gellerstedt M, et al. Patient-reported genitourinary dysfunction after laparoscopic and open rectal cancer surgery in a randomized trial (COLOR II). Br J Surg. 2014;101:1272-9.

6. Lange MM, van de Velde CJ. Urinary and sexual dysfunction after rectal cancer treatment. Nat Rev Urol. 2011;8:51-7.

7. Vironen JH, Kairaluoma M, Aalto AM, Kellokumpu IH. Impact of functional results on quality of life after rectal cancer surgery. Dis Colon Rectum. 2006;49:568-78.

8. Tekkis PP, Cornish JA, Remzi FH, et al. Measuring sexual and urinary outcomes in women after rectal cancer excision. Dis Colon Rectum. 2009;52:46-54.

9. Junginger T, Kneist W, Heintz A. Influence of identification and preservation of pelvic autonomic nerves in rectal cancer surgery on bladder dysfunction after total mesorectal excision. Dis Colon Rectum. 2003;46:621-8.

10. Kneist W, Heintz A, Wolf HK, Junginger T. [Identification of pelvic autonomic nerves during partial and total mesorectal excision—influence parameters and significance for neurogenic bladder]. Chirurg. 2004;75:276-83.

11. Lim RS, Yang TX, Chua TC. Postoperative bladder and sexual function in patients undergoing surgery for rectal cancer: a systematic review and meta-analysis of laparoscopic versus open resection of rectal cancer. Tech Coloproctol. 2014;18:993-1002.

12. Bruheim K, Guren MG, Dahl AA, et al. Sexual function in males after radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys. 2010;76:1012-7.

13. Bruheim K, Tveit KM, Skovlund E, et al. Sexual function in females after radiotherapy for rectal cancer. Acta Oncol. 2010;49:826-32.

14. Bonnel C, Parc YR, Pocard M, et al. Effects of preoperative radiotherapy for primary resectable rectal adenocarcinoma on male sexual and urinary function. Dis Colon Rectum. 2002;45:934-9.

15. Ko YH, Coelho RF, Chauhan S, et al. Factors affecting return of continence 3 months after robot-assisted radical prostatectomy: analysis from a large, prospective data by a single surgeon. J Urol. 2012;187:190-4.

16. Hoyland K, Vasdev N, Abrof A, Boustead G. Post-radical prostatectomy incontinence: etiology and prevention. Rev Urol. 2014;16:181-8.

17. Coakley FV, Eberhardt S, Kattan MW, et al. Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol. 2002;168:1032-5.

18. Wagner AA, Cheng PJ, Carneiro A, et al. Clinical Use of EPIC for Clinical Practice (EPIC-CP) to assess patient-reported prostate cancer quality-of-life following robot-assisted radical prostatectomy. J Urol. 2017;197:109-14.

19. Menon M, Shrivastava A, Sarle R, et al. Vattikuti Institute Prostatectomy: a single-team experience of 100 cases. J Endourol. 2003;17:785-90.

20. Zorn KC, Gofrit ON, Orvieto MA, et al. Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation. Eur Urol. 2007;51:755-62; discussion 763.

21. Eastham JA, Kattan MW, Rogers E, et al. Risk factors for urinary incontinence after radical prostatectomy. J Urol. 1996;156:1707-13.

22. Roumeguere T, Bollens R, Vanden Bossche M, et al. Radical prostatectomy: a prospective comparison of oncological and functional results between open and laparoscopic approaches. World J Urol. 2003;20:360-6.

23. Lepor H, Kaci L, Xue X. Continence following radical retropubic prostatectomy using self-reporting instruments. J Urol. 2004;171:1212-5.

24. Fu Q, Moul JW, Sun L. Contemporary radical prostatectomy. Prostate Cancer. 2011;2011:645030.

25. Peterson AC, Chen Y. Patient reported incontinence after radical prostatectomy is more common than expected and not associated with the nerve sparing technique: results from the Center for Prostate Disease Research (CPDR) database. Neurourol Urodyn. 2012;31:60-3.

26. Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375:1425-37.

27. Harris MJ. Radical perineal prostatectomy: cost efficient, outcome effective, minimally invasive prostate cancer management. Eur Urol. 2003;44:303-8; discussion 308.

28. Matsubara A, Yasumoto H, Mutaguchi K, et al. Impact of radical perineal prostatectomy on urinary continence and quality of life: a longitudinal study of Japanese patients. Int J Urol. 2005;12:953-8.

29. Krambeck AE, DiMarco DS, Rangel LJ, et al. Radical prostatectomy for prostatic adenocarcinoma: a matched comparison of open retropubic and robot-assisted techniques. BJU Int. 2009;103:448-53.

30. Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute Prostatectomy: contemporary technique and analysis of results. Eur Urol. 2007;51:648-57; discussion 657-8.

31. Walsh PC, Lepor H, Eggleston JC. Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations. Prostate. 1983;4:473-85.

32. Bang SL, Almallah YZ. The impact of post-radical prostatectomy urinary incontinence on sexual and orgasmic well-being of patients. Urology. 2016;89:1-5.

33. Capogrosso P, Ventimiglia E, Serino A, et al. Orgasmic dysfunction after robot-assisted versus open radical prostatectomy. Eur Urol. 2016;70:223-6.

34. Barnas JL, Pierpaoli S, Ladd P, et al. The prevalence and nature of orgasmic dysfunction after radical prostatectomy. BJU Int. 2004;94:603-5.

35. O’Neil BB, Presson A, Gannon J, et al. Climacturia after definitive treatment of prostate cancer. J Urol. 2014;191:159-63.

36. Geraerts I, Van Poppel H, Devoogdt N, et al. Pelvic floor muscle training for erectile dysfunction and climacturia 1 year after nerve sparing radical prostatectomy: a randomized controlled trial. Int J Impot Res. 2016;28:9-13.

37. Zelefsky MJ, Poon BY, Eastham J, et al. Longitudinal assessment of quality of life after surgery, conformal brachytherapy, and intensity-modulated radiation therapy for prostate cancer. Radiother Oncol. 2016;118:85-91.

38. Gore JL, Kwan L, Lee SP, et al. Survivorship beyond convalescence: 48-month quality-of-life outcomes after treatment for localized prostate cancer. J Natl Cancer Inst. 2009;101:888-92.

39. Sanda MG, Dunn RL, Michalski J, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358:1250-61.

40. Stankovic V, Dzamic Z, Pekmezovic T, et al. Acute and late genitourinary toxicity after 72 Gy of conventionally fractionated conformal radiotherapy for localised prostate cancer: impact of individual and clinical parameters. Clin Oncol (R Coll Radiol). 2016;28:577-86.

41. Wortel RC, Incrocci L, Pos FJ, et al. Late side effects after image guided intensity modulated radiation therapy compared to 3D-conformal radiation therapy for prostate cancer: results from 2 prospective cohorts. Int J Radiat Oncol Biol Phys. 2016;95:680-9.

42. Bryant C, Smith TL, Henderson RH, et al. Five-year biochemical results, toxicity, and patient-reported quality of life after delivery of dose-escalated image guided proton therapy for prostate cancer. Int J Radiat Oncol Biol Phys. 2016;95:422-34.

43. Raleigh DR, Chang AJ, Tomlin B, et al. Patient- and treatment-specific predictors of genitourinary function after high-dose-rate monotherapy for favorable prostate cancer. Brachytherapy. 2015;14:795-800.

44. Evans JR, Zhao S, Daignault S, et al. Patient-reported quality of life after stereotactic body radiotherapy (SBRT), intensity modulated radiotherapy (IMRT), and brachytherapy. Radiother Oncol. 2015;116:179-84.

45. Bruner DW, Hunt D, Michalski JM, et al. Preliminary patient-reported outcomes analysis of 3-dimensional radiation therapy versus intensity-modulated radiation therapy on the high-dose arm of the Radiation Therapy Oncology Group (RTOG) 0126 prostate cancer trial. Cancer. 2015;121:2422-30.

46. Suardi N, Gallina A, Lista G, et al. Impact of adjuvant radiation therapy on urinary continence recovery after radical prostatectomy. Eur Urol. 2014;65:546-51.

47. Mak RH, Hunt D, Efstathiou JA, et al. Acute and late urinary toxicity following radiation in men with an intact prostate gland or after a radical prostatectomy: a secondary analysis of RTOG 94-08 and 96-01. Urol Oncol. 2016;34:430.e1-7.

48. Kimura M, Yan H, Rabbani Z, et al. Radiation-induced erectile dysfunction using prostate-confined modern radiotherapy in a rat model. J Sex Med. 2011;8:2215-26.

49. Roach M 3rd, Nam J, Gagliardi G, et al. Radiation dose-volume effects and the penile bulb. Int J Radiat Oncol Biol Phys. 2010;76:S130-S134.

50. Sullivan JF, Stember DS, Deveci S, et al. Ejaculation profiles of men following radiation therapy for prostate cancer. J Sex Med. 2013;10:1410-6.

51. Westin SN, Sun CC, Tung CS, et al. Survivors of gynecologic malignancies: impact of treatment on health and well-being. J Cancer Surviv. 2016;10:261-70.

52. Bergmark K, Avall-Lundqvist E, Dickman PW, et al. Vaginal changes and sexuality in women with a history of cervical cancer. N Engl J Med. 1999;340:1383-9.

53. Maas CP, ter Kuile MM, Laan E, et al. Objective assessment of sexual arousal in women with a history of hysterectomy. BJOG. 2004;111:456-62.

54. Selcuk S, Cam C, Asoglu MR, et al. Effect of simple and radical hysterectomy on quality of life - analysis of all aspects of pelvic floor dysfunction. Eur J Obstet Gynecol Reprod Biol. 2016;198:84-8.

55. Katepratoom C, Manchana T, Amornwichet N. Lower urinary tract dysfunction and quality of life in cervical cancer survivors after concurrent chemoradiation versus radical hysterectomy. Int Urogynecol J. 2014;25:91-6.

56. Hill EK, Sandbo S, Abramsohn E, et al. Assessing gynecologic and breast cancer survivors’ sexual health care needs. Cancer. 2011;117:2643-51.

57. Johnston D, Schurtz E, Tourville E, et al. Risk factors associated with severity and outcomes in pediatric patients with hemorrhagic cystitis. J Urol. 2016;195:1312-7.

58. Thurston DE. Chemistry and pharmacology of anticancer drugs. Boca Raton: CRC Press/Taylor & Francis; 2007. pp. 53-4.

59. Ozguven AA, Yilmaz O, Taneli F, et al. Protective effect of ketamine against hemorrhagic cystitis in rats receiving ifosfamide. Indian J Pharmacol. 2014;46:147-51.

60. Leite CA, Alencar VT, Melo DL, et al. Target inhibition of IL-1 receptor prevents ifosfamide induced hemorrhagic cystitis in mice. J Urol. 2015;194:1777-86.

61. Turan V, Oktay K. Sexual and fertility adverse effects associated with chemotherapy treatment in women. Expert Opin Drug Saf. 2014;13:775-83.

62. Candy B, Jones L, Vickerstaff V, et al. Interventions for sexual dysfunction following treatments for cancer in women. Cochrane Database Syst Rev. 2016;2:CD005540.

63. Rivkees SA, Crawford JD. The relationship of gonadal activity and chemotherapy-induced gonadal damage. JAMA. 1988;259:2123-5.

64. Canalichio K, Jaber Y, Wang R. Surgery and hormonal treatment for prostate cancer and sexual function. Transl Androl Urol. 2015;4:103-9.

65. Gupta S, Peterson AC. Stress urinary incontinence in the prostate cancer survivor. Curr Opin Urol. 2014;24:395-400.

66. Lavien G, Zaid U, Peterson AC. Genitourinary prosthetics: a primer for the non-urologic surgeon. Surg Clin North Am. 2016;96:533-43.

67. Incrocci L, Koper PC, Hop WC, Slob AK. Sildenafil citrate (Viagra) and erectile dysfunction following external beam radiotherapy for prostate cancer: a randomized, double-blind, placebo-controlled, cross-over study. Int J Radiat Oncol Biol Phys. 2001;51:1190-5.

68. Incrocci L, Slagter C, Slob AK, Hop WC. A randomized, double-blind, placebo-controlled, cross-over study to assess the efficacy of tadalafil (Cialis) in the treatment of erectile dysfunction following three-dimensional conformal external-beam radiotherapy for prostatic carcinoma. Int J Radiat Oncol Biol Phys. 2006;66:439-44.

69. Watkins Bruner D, James JL, Bryan CJ, et al. Randomized, double-blinded, placebo-controlled crossover trial of treating erectile dysfunction with sildenafil after radiotherapy and short-term androgen deprivation therapy: results of RTOG 0215. J Sex Med. 2011;8:1228-38.

70. Son CH, Chennupati SK, Kunnavakkam R, Liauw SL. The impact of hormonal therapy on sexual quality of life in men receiving intensity modulated radiation therapy for prostate cancer. Pract Radiat Oncol. 2015;5:e223-e228.

71. Yang EJ, Lim JY, Rah UW, Kim YB. Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: a randomized controlled trial. Gynecol Oncol. 2012;125:705-11.

72. Jones LW, Hornsby WE, Freedland SJ, et al. Effects of nonlinear aerobic training on erectile dysfunction and cardiovascular function following radical prostatectomy for clinically localized prostate cancer. Eur Urol. 2014;65:852-5.

73. Simon RM, Howard L, Zapata D, et al. The association of exercise with both erectile and sexual function in black and white men. J Sex Med. 2015;12:1202-10.

74. MacDonald R, Fink HA, Huckabay C, et al. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int. 2007;100:76-81.

75. Anderson CA, Omar MI, Campbell SE, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2015;1:CD001843.

76. Dumoulin C, Hay-Smith EJ, Habée-Séguin GM, Mercier J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women: a short version Cochrane systematic review with meta-analysis. Neurourol Urodyn. 2015;34:300-8.

 
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