The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [212]
The possibility of sexual impairment for both men and women after stoma surgery depends on the nature of the operation, and the ensuing damage to the nerves and tissues involved. The psychological impact of the surgery and its effect on the individual’s body image must also be taken into consideration. Surgery that results in physical sexual disability will have psychological repercussions, while some sexual difficulties may be of psychological origin (Black 2004, Borwell 1997, Salter 1996). Impairment may be permanent or temporary. In the latter case, resolution of the difficulty may take anything up to 2 years. Pre- and postoperative counselling should be offered for both patient and partner.
All patients may experience loss of libido and sexual desire. Ejaculatory disturbances occur following cystectomy so men facing this surgery should be offered sperm banking prior to surgery. Erectile dysfunction is a common complication of pelvic surgery and there are a number of treatment options available. These include oral medications (sildenafil, tadalafil, vardenafil), sublingual apomorphine, intraurethral and intracavernosal alprostadil, vacuum devices and penile implants (Ashford 1998, Kirby et al. 1999, Newey 1998).
Female patients may experience dyspareunia; this may be due to narrowing or shortening of the vagina, a reduction in the volume of vaginal secretions or changes in genital sensations (Black 2004, Borwell 1999, Schover 1986). The use of a lubricant, adopting different positions during lovemaking or encouraging greater relaxation by extending foreplay may help resolve painful intercourse (Black 2004, Borwell 1999, Bryant 1993).
Discharge planning
Discharge planning for the patient with a stoma should commence once the patient is admitted. It is important to set a provisional discharge date and set realistic goals with the patient. The patient needs to be discharged home with:
adequate stoma supplies (approx. 2 weeks’ supply)
contact details of community stoma care nurse
prescription details of products being used
information on delivery company, if relevant.
Continuity of care for these patients is crucial. Effective communication and collaboraton between healthcare professionals are key to psychological adaptation and successful rehabilitation (Borwell 2009).
Follow-up support
The patient is discharged with adequate supplies until a prescription is obtained from the general practitioner. Written reminders are provided of how to care for the stoma, how to obtain supplies of appliances, and any other information that may be required. The patient should have details of non-medical stoma clinics, details about the relevant agencies and information about voluntary associations. Arrangements should also have been made for a home visit from the stoma care nurse and/or the community nurse (Blackley 1998, Cronin 2005). Figure 6.18 provides an example of a discharge checklist.
Figure 6.18 Discharge checklist. From The Royal Marsden Hospital NHS Foundation Trust, Stoma Care Pathway.
Obtaining supplies
All NHS patients with a permanent stoma are entitled to free prescriptions for their stoma care products, and should complete the relevant forms for exemption from payment. Appliances can then be obtained from the local chemist, free home delivery services or directly from the appropriate manufacturers.
Complications
As a healthcare professional providing support and care to stoma patients, it is important to be able to distinguish normal from abnormal. The observational index (see Figure 6.17) provides a reference guide to use when observing, recording and reporting. If any of the complications are noted, it is important to ensure that the medical team and/or stoma care nurse is informed. Advice on how to manage these problems should be obtained from your specialist stoma care nurse. Recognition of problems and complications early can prevent more serious complications later.
Websites
Medic-Alert Foundation: www.medicalert.org.uk
Sexual Dysfunction Association: www.sexualdysfunctionassociation.com
Urostomy