International Journal of Colorectal Disease

, Volume 28, Issue 4, pp 519–526

Impact of late anorectal dysfunction on quality of life after pelvic radiotherapy

  • Robin Krol
  • Robert Jan Smeenk
  • Emile N. J. T. van Lin
  • Wim P. M. Hopman
Original Article

Abstract

Purpose

Anorectal dysfunction is common after pelvic radiotherapy. This study aims to explore the relationship of subjective and objective anorectal function with quality of life (QoL) and their relative impact in patients irradiated for prostate cancer.

Methods

Patients underwent anal manometry, rectal barostat measurement, and completed validated questionnaires, at least 1 year after prostate radiotherapy (range 1–7 years). QoL was measured by the Fecal Incontinence Quality of Life scale (FIQL) and the Expanded Prostate Cancer Index Composite Bowel domain (EPICB)-bother subscale. Severity of symptoms was rated by the EPICB function subscale.

Results

Anorectal function was evaluated in 85 men. Sixty-three percent suffered from one or more anorectal symptoms. Correlations of individual symptoms ranged from r = 0.23 to r = 0.53 with FIQL domains and from r = 0.36 to r = 0.73 with EPICB bother scores. They were strongest for fecal incontinence and urgency. Correlations of anal sphincter pressures, rectal capacity, and sensory thresholds ranged from r = 0.00 to r = 0.42 with FIQL domains and from r = 0.15 to r = 0.31 with EPICB bother scores. Anal resting pressure correlated most strongly. Standardized regression coefficients for QoL outcomes were largest for incontinence, urgency, and anal resting pressure. Regression models with subjective parameters explained a larger amount (range 26–92 %) of variation in QoL outcome than objective parameters (range 10–22 %).

Conclusions

Fecal incontinence and rectal urgency are the symptoms with the largest influence on QoL. Impaired anal resting pressure is the objective function parameter with the largest influence. Therefore, sparing the structures responsible for an adequate fecal continence is important in radiotherapy planning.

Keywords

Quality of life Anorectal toxicity Anorectal function Prostate carcinoma External beam radiotherapy 

References

  1. 1.
    Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, Lin X, Greenfield TK, Litwin MS, Saigal CS, Mahadevan A, Klein E, Kibel A, Pisters LL, Kuban D, Kaplan I, Wood D, Ciezki J, Shah N, Wei JT (2008) Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 358(12):1250–1261. doi:10.1056/NEJMoa074311 PubMedCrossRefGoogle Scholar
  2. 2.
    Al-Mamgani A, van Putten WL, Heemsbergen WD, van Leenders GJ, Slot A, Dielwart MF, Incrocci L, Lebesque JV (2008) Update of Dutch multicenter dose-escalation trial of radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 72(4):980–988. doi:10.1016/j.ijrobp.2008.02.073 PubMedCrossRefGoogle Scholar
  3. 3.
    De Meerleer GO, Fonteyne VH, Vakaet L, Villeirs GM, Denoyette L, Verbaeys A, Lummen N, De Neve WJ (2007) Intensity-modulated radiation therapy for prostate cancer: late morbidity and results on biochemical control. Radiother Oncol 82(2):160–166. doi:10.1016/j.radonc.2006.12.007 PubMedCrossRefGoogle Scholar
  4. 4.
    Yeoh EK, Russo A, Botten R, Fraser R, Roos D, Penniment M, Borg M, Sun WM (1998) Acute effects of therapeutic irradiation for prostatic carcinoma on anorectal function. Gut 43(1):123–127PubMedCrossRefGoogle Scholar
  5. 5.
    Yeoh EE, Botten R, Russo A, McGowan R, Fraser R, Roos D, Penniment M, Borg M, Sun W (2000) Chronic effects of therapeutic irradiation for localized prostatic carcinoma on anorectal function. Int J Radiat Oncol Biol Phys 47(4):915–924PubMedCrossRefGoogle Scholar
  6. 6.
    Andreyev J (2007) Gastrointestinal symptoms after pelvic radiotherapy: a new understanding to improve management of symptomatic patients. Lancet Oncol 8(11):1007–1017. doi:10.1016/S1470-2045(07)70341-8 PubMedCrossRefGoogle Scholar
  7. 7.
    Gami B, Harrington K, Blake P, Dearnaley D, Tait D, Davies J, Norman AR, Andreyev HJ (2003) How patients manage gastrointestinal symptoms after pelvic radiotherapy. Aliment Pharmacol Ther 18(10):987–994PubMedCrossRefGoogle Scholar
  8. 8.
    Miller DC, Sanda MG, Dunn RL, Montie JE, Pimentel H, Sandler HM, McLaughlin WP, Wei JT (2005) Long-term outcomes among localized prostate cancer survivors: health-related quality-of-life changes after radical prostatectomy, external radiation, and brachytherapy. J Clin Oncol 23(12):2772–2780. doi:10.1200/JCO.2005.07.116 PubMedCrossRefGoogle Scholar
  9. 9.
    Wei JT, Dunn RL, Litwin MS, Sandler HM, Sanda MG (2000) Development and validation of the expanded prostate cancer index composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology 56(6):899–905PubMedCrossRefGoogle Scholar
  10. 10.
    Yeoh EE, Holloway RH, Fraser RJ, Botten RJ, Di Matteo AC, Moore JW, Schoeman MN, Bartholomeusz FD (2004) Anorectal dysfunction increases with time following radiation therapy for carcinoma of the prostate. Am J Gastroenterol 99(2):361–369PubMedCrossRefGoogle Scholar
  11. 11.
    Yeoh EK, Holloway RH, Fraser RJ, Botten R, Di Matteo A, Moore JW, Schoeman MN, Bartholomeusz DL (2009) Anorectal function after three- versus two-dimensional radiation therapy for carcinoma of the prostate. Int J Radiat Oncol Biol Phys 73(1):46–52. doi:10.1016/j.ijrobp.2008.03.058 PubMedCrossRefGoogle Scholar
  12. 12.
    Berndtsson I, Lennernas B, Hulten L (2002) Anorectal function after modern conformal radiation therapy for prostate cancer: a pilot study. Tech Coloproctol 6(2):101–104. doi:10.1007/s101510200022 PubMedCrossRefGoogle Scholar
  13. 13.
    Smeenk RJ, van Lin EN, van Kollenburg P, Kunze-Busch M, Kaanders JH (2009) Anal wall sparing effect of an endorectal balloon in 3D conformal and intensity-modulated prostate radiotherapy. Radiother Oncol 93(1):131–136. doi:10.1016/j.radonc.2009.05.014 PubMedCrossRefGoogle Scholar
  14. 14.
    Smeenk RJ, Hopman WP, Hoffmann AL, van Lin EN, Kaanders JH (2010) Differences in radiation dosimetry and anorectal function testing imply that anorectal symptoms may arise from different anatomic substrates. Int J Radiat Oncol Biol Phys. doi:10.1016/j.ijrobp.2010.08.023
  15. 15.
    Fonteyne V, De Neve W, Villeirs G, De Wagter C, De Meerleer G (2007) Late radiotherapy-induced lower intestinal toxicity (RILIT) of intensity-modulated radiotherapy for prostate cancer: the need for adapting toxicity scales and the appearance of the sigmoid colon as co-responsible organ for lower intestinal toxicity. Radiother Oncol 84(2):156–163. doi:10.1016/j.radonc.2007.06.013 PubMedCrossRefGoogle Scholar
  16. 16.
    O’Brien PC (2001) Radiation injury of the rectum. Radiother Oncol 60(1):1–14PubMedCrossRefGoogle Scholar
  17. 17.
    Krol R, Hopman WP, Smeenk RJ, Van Lin EN (2012) Increased rectal wall stiffness after prostate radiotherapy: relation with fecal urgency. Neurogastroenterol Motil. doi:10.1111/j.1365-2982.2011.01858.x
  18. 18.
    Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43(1):9–16, discussion 16–17PubMedCrossRefGoogle Scholar
  19. 19.
    Bharucha AE, Seide B, Fox JC, Zinsmeister AR (2004) Day-to-day reproducibility of anorectal sensorimotor assessments in healthy subjects. Neurogastroenterol Motil 16(2):241–250. doi:10.1111/j.1365-2982.2004.00499.x PubMedCrossRefGoogle Scholar
  20. 20.
    Caruana BJ, Wald A, Hinds JP, Eidelman BH (1991) Anorectal sensory and motor function in neurogenic fecal incontinence. Comparison between multiple sclerosis and diabetes mellitus. Gastroenterology 100(2):465–470PubMedGoogle Scholar
  21. 21.
    Bharucha AE (2003) Fecal incontinence. Gastroenterology 124(6):1672–1685PubMedCrossRefGoogle Scholar
  22. 22.
    Raizada V, Bhargava V, Karsten A, Mittal RK (2011) Functional morphology of anal sphincter complex unveiled by high definition anal manometery and three dimensional ultrasound imaging. Neurogastroenterol Motil 23(11):1013–1019, e1460. doi:10.1111/j.1365-2982.2011.01782.x Google Scholar
  23. 23.
    Fox M, Thumshirn M, Fried M, Schwizer W (2006) Barostat measurement of rectal compliance and capacity. Dis Colon Rectum 49(3):360–370. doi:10.1007/s10350-005-0295-2 PubMedCrossRefGoogle Scholar
  24. 24.
    Wijffels NA, Angelucci G, Ashrafi A, Jones OM, Cunningham C, Lindsey I (2011) Rectal hyposensitivity is uncommon and unlikely to be the central cause of obstructed defecation in patients with high-grade internal rectal prolapse. Neurogastroenterol Motil 23(2):151–154, e130. doi:10.1111/j.1365-2982.2010.01625.x
  25. 25.
    Bordeianou L, Rockwood T, Baxter N, Lowry A, Mellgren A, Parker S (2008) Does incontinence severity correlate with quality of life? Prospective analysis of 502 consecutive patients. Colorectal Dis 10(3):273–279. doi:10.1111/j.1463-1318.2007.01288.x PubMedCrossRefGoogle Scholar
  26. 26.
    Smeenk RJ, Teh BS, Butler EB, van Lin EN, Kaanders JH (2010) Is there a role for endorectal balloons in prostate radiotherapy? A systematic review. Radiother Oncol 95(3):277–282. doi:10.1016/j.radonc.2010.04.016 PubMedCrossRefGoogle Scholar
  27. 27.
    al-Abany M, Helgason AR, Cronqvist AK, Svensson C, Wersall P, Steineck G (2002) Long-term symptoms after external beam radiation therapy for prostate cancer with three or four fields. Acta Oncol 41(6):532–542PubMedCrossRefGoogle Scholar
  28. 28.
    Geinitz H, Zimmermann FB, Thamm R, Erber C, Muller T, Keller M, Busch R, Molls M (2006) Late rectal symptoms and quality of life after conformal radiation therapy for prostate cancer. Radiother Oncol 79(3):341–347. doi:10.1016/j.radonc.2006.05.004 PubMedCrossRefGoogle Scholar
  29. 29.
    Koper PC, Jansen P, van Putten W, van Os M, Wijnmaalen AJ, Lebesque JV, Levendag PC (2004) Gastro-intestinal and genito-urinary morbidity after 3D conformal radiotherapy of prostate cancer: observations of a randomized trial. Radiother Oncol 73(1):1–9. doi:10.1016/j.radonc.2004.07.020 PubMedCrossRefGoogle Scholar
  30. 30.
    Bacon CG, Giovannucci E, Testa M, Glass TA, Kawachi I (2002) The association of treatment-related symptoms with quality-of-life outcomes for localized prostate carcinoma patients. Cancer 94(3):862–871. doi:10.1002/cncr.10248 PubMedCrossRefGoogle Scholar
  31. 31.
    Felt-Bersma RJ, Sloots CE, Poen AC, Cuesta MA, Meuwissen SG (2000) Rectal compliance as a routine measurement: extreme volumes have direct clinical impact and normal volumes exclude rectum as a problem. Dis Colon Rectum 43(12):1732–1738PubMedCrossRefGoogle Scholar
  32. 32.
    Irvine EJ, Whitehead WE, Chey WD, Matsueda K, Shaw M, Talley NJ, Veldhuyzen van Zanten SJ (2006) Design of treatment trials for functional gastrointestinal disorders. Gastroenterology 130(5):1538–1551. doi:10.1053/j.gastro.2005.11.058 PubMedCrossRefGoogle Scholar
  33. 33.
    Cotterill N, Norton C, Avery KN, Abrams P, Donovan JL (2008) A patient-centered approach to developing a comprehensive symptom and quality of life assessment of anal incontinence. Dis Colon Rectum 51(1):82–87. doi:10.1007/s10350-007-9069-3 PubMedCrossRefGoogle Scholar
  34. 34.
    Bharucha AE, Wald AM (2010) Anorectal disorders. Am J Gastroenterol 105(4):786–794. doi:10.1038/ajg.2010.70 PubMedCrossRefGoogle Scholar
  35. 35.
    Bharucha AE (2008) Management of fecal incontinence. Gastroenterol Hepatol (N Y) 4(11):807–817Google Scholar
  36. 36.
    Lam TJ, Kuik DJ, Felt-Bersma RJ (2012) Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients. Colorectal Dis 14(2):214–223. doi:10.1111/j.1463-1318.2011.02548.x PubMedCrossRefGoogle Scholar
  37. 37.
    Buyyounouski MK, Horwitz EM, Price RA, Hanlon AL, Uzzo RG, Pollack A (2004) Intensity-modulated radiotherapy with MRI simulation to reduce doses received by erectile tissue during prostate cancer treatment. Int J Radiat Oncol Biol Phys 58(3):743–749. doi:10.1016/S0360-3016(03)01617-1 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • Robin Krol
    • 1
  • Robert Jan Smeenk
    • 2
  • Emile N. J. T. van Lin
    • 2
  • Wim P. M. Hopman
    • 1
  1. 1.455 Department of Gastroenterology and HepatologyRadboud University Medical CentreNijmegenThe Netherlands
  2. 2.Department of Radiation OncologyRadboud University Medical CentreNijmegenThe Netherlands

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