Pelvic Physiotherapy after Pelvic Radiation Treatment

Lauren (Laurie) Bickerton PT, FCAMPT, AFCI

Complications in the Vulva

It is one of the often-overlooked complications from radiation treatment: fibrosis. Radiation to treat cancers in the pelvis can affect all of the tissues including the cells of the vagina, the pelvic floor muscles, and the outer tissues called the vulva.  The thickening and tightening comes on months and even years after treatment has been completed and can limit intimacy and cause considerable pain. Pelvic physiotherapy is one of the mainstays of care for this, but patients are often unaware that the tightening can be helped. Cramping, burning, pulling or pricking pain are common symptoms.

Radiation Treatment

Radiation is directed at the cancer with a beam, or sometimes the dose is inserted into the vagina and left in for a period of time to do its work.  The healthy tissues in the area get some dose of radiation as well as the cancer tumor. Radiation can also be directed daily at the tumor for a period of weeks. Tissue in the path of the beam gets some of the radiation dose.  Research continues to improve the focus and minimize the beam to target the cancer more precisely while sparing healthy tissue as much as possible.  Scarring post-radiation therapy is much better than it was in previous decades.

Effect on Local Tissues and Symptoms

The purpose of radiation, of course, to kill cancer cells, or make them much more vulnerable to chemotherapy that can follow. Changes in the cells called fibrosis cause scarring and tightening which can become tough and painful to move and stretch. Changes include decreased, tighter, smaller blood vessels so that the tissues are not able to get enough oxygen and nutrients.  Adipose (fat) tissue tends to become more fibrous and tough. Thickening of the muscle fibers, ligaments, nerves and lymphatic happens slowly in the months or even years after the treatment is finished, and becomes a long-term challenge.  For the vulva, it can become thickened and lose its elasticity.  The vagina will narrow, and in some cases, the vaginal opening can close completely if not managed.  Hair loss over the labia is common, and the delicate genital tissues and their layers adhere to each other, causing a loss of mobility of the area.  Poor blood supply can make the mucosa thinner and it can tear with pressure.   Vaginal dryness is very common, as is irritation of the bladder (usually causes urgency) and bowel (diarrhea is common) . Intimacy can become limited and painful.

Typical Treatment with a Pelvic Physiotherapist

The soft moist (mucosal) tissues of the vulva respond to gradual stretching with soft silicone tools called dilators used by pelvic physiotherapists.    Early, gentle, consistent care is the best approach, so contact a pelvic physiotherapist as early as your oncologist feels you can begin.  Early in the treatment, it will be especially tender, and the smallest dilator is used to become accustomed to touch again.  Slight bleeding is not uncommon. When the vulvar skin is quite raw, it is especially important to use lubricant and small movements.  We start with water based lubricants.  Using a vulvar moisturizer can also be helpful to ease tightness, fissuring and dryness. Nearly always, the goal is to teach the individual to use the dilators at home for a few minutes daily or a few times a week.  Some people prefer to use their fingers, and some involve a partner. As treatment progresses, women return for a check-in and progressions to the treatment. Regaining strength with what are often known as “Kegel exercises” can be useful.  A pelvic floor physiotherapist can assess the strength and endurance of the pelvic muscles and help tailor a program for your activity level and concerns (urinary incontinence, weak orgasm, fecal incontinence ) if anything else happens with the tissue changes.

Keep your pelvic physiotherapist  aware of any joint stiffness, muscle spasms, tightening, dryness or irritation you notice.  She will be able to treat them with mobilization, and modify your exercises to help.  Muscles, nerves and tendons respond well to relaxation exercises and gentle mobilization and both can be helpful to improve blood supply to affected areas.

Consider Your Own Goals

Goals varying from one person to another.  Many women want to retain a ‘normal’ appearance and anatomy.  Depending on life stage, this type of work on the pelvic floor can allow women to maintain a vaginal opening for future intimacy.  Unfortunately, if the opening to the vagina closes completely, there is little a pelvic health physiotherapist can do at that stage.  Like so many things, it is best managed early.  It also takes considerable commitment, particularly since the early part of the treatment is so sensitive.  Each individual should consider the options available at the time whether medications, vulvar skincare products, hyperbaric oxygen or new treatments, but the gentle, physical treatment and guidance of a pelvic physiotherapist should be a part of the treatment choices.

References:

Abhishek Purkayastha, MBBS, DNB, MNAMS, PDCR, PCPV, OCTT,1 Neelam Sharma,2 Arti Sarin,3 Sharad Bhatnagar,4 Nilotpal Chakravarty,2 Hari Mukundan,5 Virender Suhag,1 and Sankalp Singh4 : Radiation Fibrosis Syndrome: the Evergreen Menace of Radiation Therapy, Asia Pac J Oncol Nurs. 2019 Jul-Sep; 6(3): 238–245., doi: 10.4103/apjon.apjon_71_18,  PMCID: PMC6518980,  PMID: 31259219

https://www.cancerresearchuk.org/about-cancer/coping/physically/sex/women/radiotherapy#:~:text=Pelvic%20radiotherapy%20can%20make%20the,might%20help%20to%20prevent%20this.