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BackTable / Urology / Article
Addressing Sexual Health After Cystectomy: Improving Outcomes for Women
Sam Strauss • Updated Apr 16, 2025 • 31 hits
Sexual dysfunction is a common and often life-altering consequence of radical cystectomy in women, yet it remains under-addressed in both surgical planning and survivorship care. Treatments may lead to vaginal dryness, pain with intimacy, changes in orgasmic response, or a complete loss of libido—all of which can deeply affect identity, self-image, and quality of life. Despite this, many patients report never having discussed these outcomes with their urologist prior to surgery. In contrast to the detailed, structured counseling often provided to men regarding erectile function, female patients are too often left unprepared for the intimate, functional, and emotional repercussions of treatment.
Improving sexual function outcomes for women requires a shift in both culture and clinical workflow—one that recognizes sexual health as a key component of recovery. Drawing on clinical guidance from urologic oncologist Dr. Sara Psutka, sexual medicine specialist Dr. Rachel Rubin, and urologist Dr. Aditya Bagrodia, this article outlines practical strategies to better integrate sexual health into the care of women undergoing bladder cancer surgery. These include early hormone management, anatomy-preserving surgical techniques, prehabilitation protocols, and a renewed emphasis on compassionate, individualized communication.
The BackTable Urology Brief
• Genitourinary syndrome of menopause (GSM) is a common but under-recognized condition that can worsen sexual and urinary symptoms in women undergoing bladder cancer treatment.
• Vaginal estrogen and dehydroepiandrosterone (DHEA) therapies are effective, evidence-based treatments for GSM that fall within the urologist’s scope of care.
• Pelvic organ-sparing techniques during radical cystectomy can help preserve vaginal length, innervation, and blood supply, supporting postoperative sexual function.
• Prehabilitation—including pelvic floor physical therapy, hormone optimization, and expectation-setting—can significantly improve postoperative outcomes.
• Empathetic, open communication about sexual health should be initiated early and revisited often, especially for female patients who are less likely to bring up these concerns themselves.
Table of Contents
(1) Hormonal Health & the Overlooked Impact of Menopause
(2) Pelvic Organ-Sparing Strategies in Radical Cystectomy
(3) Prehabilitation & Post-Op Recovery
(4) Compassion, Communication & Removing the Stigma
Hormonal Health & the Overlooked Impact of Menopause
In women undergoing bladder cancer treatment, symptoms related to menopause often go unaddressed despite their direct impact on both urologic and sexual health. Genitourinary syndrome of menopause (GSM)—which includes vaginal dryness, irritation, loss of elasticity, and urinary discomfort—can significantly exacerbate post-treatment challenges, particularly for those receiving pelvic surgery or systemic cancer therapy. These symptoms are not rare or incidental; they are biologically expected outcomes of estrogen deficiency and can meaningfully affect recovery, intimacy, and quality of life.
Interventions like vaginal estrogen or intravaginal DHEA can restore vaginal tissue integrity, reduce discomfort with intimacy, and prevent secondary complications such as recurrent infections. Yet these therapies are often left out of treatment planning. Many urologists either feel unqualified to prescribe hormone therapy or view it as the responsibility of another specialty. However, treating GSM falls squarely within the scope of urologic care, and addressing it proactively can help women feel more comfortable, functional, and supported through every stage of treatment.
Even simple steps—like including GSM in the review of systems or listing vaginal estrogen as part of post-cystectomy survivorship planning—can normalize the conversation and remove unnecessary barriers to care.
[Dr. Rachel Rubin]
I have many issues with the healthcare system, but the oncologists, whether it's medical or surgical, y'all sometimes get long visits, right? You actually do get some time with your new patients, with your cancer patients, sometimes, maybe not always.
[Dr. Sara Psutka]
Not enough.
[Dr. Rachel Rubin]
Not enough time, but that's the whole point, is how are you going to educate your patient on menopause and the safety of hormone therapy, and how there's other things going on here, and what's the pelvic floor? We avoid it all together. I don't know how to fix it, necessarily, because there is so much, right? At menopause, and that could be as early as in the 40s, even late 30s, people start developing genitourinary symptoms of menopause, so they get dryness, irritation, urinary frequency, urinary urgency, and then if they have bladder cancer, some of those symptoms may be from bladder cancer, but a lot of them are from GSM.
Getting them to understand how the foundation, the tissue, the urethra, the bladder, the vulva, the vagina, are swimming with estrogen and testosterone receptors, right? When you are in menopause, you lose that, and so everything gets thin, raw, irritated, inflamed, and what if that even increases your risk of bladder cancer, because of the inflammation that you have there? I don't think it's been looked at, but this is the thing where it is absolutely the urologist's responsibility to understand that every urinary symptom in a woman over, let's say 40, needs to be understood, the hormonal aspects, right? Because we know vaginal hormones decrease the risk of future urinary tract infections by more than half.
We have to make menopause a urologic condition, because it is, and thank goodness the AUA is now investing in guidelines for GSM, and saying, we can't just say this is gynecology's problem, because actually, the parts that kill you are urology's problem…
[Dr. Sara Psutka]
…Oncofertility and sexual health in oncology, that's a really important part of the cancer center healthcare practice. We definitely don't have the same thing. We just need more people. There are people I have in the community who I do refer people to. Then like we were just talking about, I've definitely made myself get super comfortable with prescribing things like vaginal estrogen, which I never used to do. Now I do every day.
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Pelvic Organ-Sparing Strategies in Radical Cystectomy
Radical cystectomy has historically been designed with oncologic control as its primary endpoint, often at the expense of anatomical preservation in female patients. However, when appropriate, pelvic organ-sparing techniques can offer a meaningful opportunity to maintain sexual function without compromising cancer outcomes. Sparing structures such as the vaginal wall, clitoral neurovascular bundles, and portions of the uterus or ovaries may preserve vaginal length, lubrication potential, and orgasm function—critical elements of post-treatment quality of life that are rarely prioritized in surgical planning.
Patient selection is key: organ-sparing approaches should only be considered in patients with non-invasive or organ-confined disease, and decisions must be based on high-quality imaging, multidisciplinary input, and shared decision-making. But even when organ-sparing is not a feasible option, the surgical conversation can include other methods to support postoperative sexual health, such as vaginal reconstruction, postoperative hormone therapy, or early referral to sexual health specialists. The absence of preservation does not have to mean the absence of care.
Too often, women undergoing radical cystectomy are not informed about how the procedure may alter their sexual anatomy, sensory experience, or ability to be intimate.Bringing this into the preoperative conversation allows patients to make informed decisions about their bodies and prepares them emotionally for the changes ahead. There isn’t yet enough data out there to give definitive answers for all of the potential aspects of these interactions. Urologists don’t need to have all the answers, but they do need to be willing to initiate the conversation, be engaged, and explain what is being removed or preserved.
[Dr. Sara Psutka]
…The vast majority of the people that I see actually are still in that camp because we tend to see some pretty bulky, high risk disease. Patients who have gone through neoadjuvant chemotherapy and still have residual disease. We have to remember that at the end of the day, oncologic outcomes are paramount. I tell patients, whether I'm doing it in a male or a female, first order of business is to get all the cancer out because a positive margin in bladder cancer is a lethal disease. There's really nothing good that we can do if we leave disease behind.
Radiating the pelvis after you've done a urinary diversion is a terrible thing and often still doesn't have long-term durable oncologic benefits…I talk to patients really honestly about what this looks like. We talk about things like the risk of vaginal foreshortening, vaginal stenosis. If you are in that situation, obviously, taking everything locally, there is a high risk of prolapse.
…We actually need to talk to make sure we ask our female patients about the degree of pelvic organ prolapse they experienced before going into bladder cancer surgery. That's something that may or may not be traditionally discussed, and that's a really important baseline status to check in on. Then you've got to talk about disruption of the parasympathetic nerves and change in sexual sensation, anorgasmia, dyspareunia, all of those risks afterwards….
[Dr. Aditya Bagrodia]
…I also remain healthily paranoid anytime I'm doing a vaginal closure about having a dehiscence and having a fistula or basically, having their complete interior continence come out of the vaginal cuff. Thank God it's never happened to me. I've seen it once from a partner over the course of my career. Sounded awful. I say that because when you actually do a virginal closure, as you mentioned, you have three suture lines coming together right there at the distalmost part of the vagina. Just from even bladder, neck reconstructions and prostate, if there's going to be a bit of a dehiscence, I have to imagine it's there.
When an anterior vaginectomy is required, I do go with the clamshell. I think if you cannot insert a penis, and if we're talking about receptive intercourse, that's game over right there. If it's stenotic and you can't, that's challenging. What I'm hearing is, really, across the gamut, libido, vaginal health, ability to receive receptive intercourse, body image, it's a big deal.
[Dr. Rachel Rubin]
This is where we need your data. We need your data and we can't get the data if we don't ask the questions, right? Because what our textbooks say is, oh, pudendal nerve is the only thing that innervates the clitoris. You're not going to screw with the pudendal nerve so their orgasm will be fine…
That data doesn't actually exist even in the gynecology space. Nobody's talking about it. Nobody's looking at it. No one's doing the dissections or even asking patients before these big surgeries, how do you orgasm? Is it from clitoral stimulation? How do you feel arousal? Our questions aren't good enough to even tease out the data. If you take hysterectomy patients, like in the general gynecology space, oh, hysterectomy is good for sexual function. Why? Because when you take massive amounts of data, most people have hysterectomies because they're bleeding, right? Because they have fibroids, because they have pelvic pain. When you remove it, they feel better…
That doesn't mean you can't take the tissue, but you really got to go have that period where you say, listen, I'm going to do the best I can, but the most important thing here is margins and closure that actually is the right thing…
Prehabilitation & Post-Op Recovery
Optimizing sexual health after cystectomy begins long before the first incision. Prehabilitation is an emerging concept in urologic oncology, referring to the process of preparing patients physically, hormonally, and psychologically for surgery. For women, this may include initiating vaginal estrogen therapy prior to cystectomy, starting pelvic floor physical therapy to maintain muscle tone and awareness, and engaging in structured conversations about expectations around intimacy and identity after surgery.
These interventions are not about returning patients to a preoperative baseline—they’re about giving patients the best chance to heal with agency, dignity, and a sense of continuity in their lives. Pelvic floor physical therapy, for instance, can improve both urinary and sexual function, and when introduced preoperatively, it gives patients a head start in understanding their anatomy and regaining control post-surgery. Hormonal support can be introduced early to condition vaginal tissue, and patients can be coached on what to expect in terms of sensation, lubrication, and changes in body image.
When these strategies are introduced early, they also create a framework of trust. Patients are more likely to bring up questions about sexuality if their providers have already opened that door. Setting expectations ahead of time—acknowledging what may change, what can be preserved, and what support exists—can dramatically reduce distress and feelings of isolation during recovery. Empowered patients are better equipped to advocate for themselves, and providers who prepare them are better positioned to support their long-term outcomes.
[Dr. Rachel Rubin]
Every day, I see patients in my office, they have these huge endometriosis surgeries, these huge hysterectomies, all of these things. I say, well, you had your knee replacement and you had PT three times a week after your knee replacement. That was standard of care. What about after your hysterectomy? They say, what's pelvic floor physical therapy? I think we need to really understand the team in this. That's going to be the hormone perspective, the pelvic floor, and the mental health perspective. Getting those mental health professionals involved.
[Dr. Sara Psutka]
You can't possibly counsel these patients enough about how hard it is to recover from this operation. I don't care how amazing of a surgeon you are, going through a radical cystectomy is hell for these patients. It's a huge, huge change. The recovery is not for most of our patients, four to six weeks. The recovery can be months, especially in our older and medically complex patients. I'm a huge fan of preoperative exercise.
…Pelvic floor prehab is just so important. Talking to patients, setting appropriate expectations about what recovery is going to look like, and letting them know, again, what are our priorities. Our priority is get the cancer out and do an oncologically sound procedure and then maximize functional recovery based on that.
[Dr. Rachel Rubin]
Problems are going to happen. Bad things are going to happen.…When you show that you're paying attention and not just to their margins, they understand problems will happen. They can understand that, but they will feel truly seen. They know when the issues come up that you may not have all the answers, but they'll send you down the street and you'll give them a name or you'll reach out to a colleague or you say, "Hey, that podcast, go listen to that podcast." That, again, shows them that you're paying attention.
Compassion, Communication & Removing the Stigma
Even the most thoughtful urologic surgical plan or evidence-based hormone regimen can fall short if patients don’t feel safe discussing their sexual health. For many women, especially those navigating cancer, conversations about intimacy feel secondary to handling their more dire medical issues. But beyond that, these conversations carry layers of vulnerability, grief, and fear. That’s why the role of the urologist isn’t just technical—it’s relational. Patients remember whether their physician created space for honest questions, used inclusive language, and validated concerns that are often internalized as taboo.
Clinicians don’t need to be sexual medicine experts to make a meaningful impact. Simply normalizing the topic, acknowledging that sexual function matters, and following up over time can transform a patient’s experience of care. These small, deliberate acts of compassion reduce stigma and reinforce that sexual health must be a part of fully comprehensive urologic medicine.
[Dr. Rachel Rubin]
Never underestimate the power of saying, "I'm so sorry. This isn't what you expected. I deeply care about what happens to you. I deeply care about you as a human being. I know you, I know about your family. I know about what you care about." Ask about hobbies. Ask about are they spiritual. What do they care about? What is the spice of life for them? That will always save you in the end with that human connection…
[Dr. Sara Psutka]
I think it's actually important to check in about it routinely as patients are going through care. That's an important part of survivorship, is checking in on functional recovery and changes in life situations and changes in what's important. Understanding that and having patients just know that you are someone who that's a safe topic to talk. It should be, we're urologists, like Rachel point, this is what we are supposed to talk about. You've got to make that a safe space and make them understand that it's a priority.
[Dr. Rachel Rubin]
I think education is power, and our patients make excellent decisions when they have the right education. When you counsel them properly, they can make really smart decisions about what to do with their bodies… Remember, quality of life is life. It is not the length in years, it is not the number of years you give them, but it is the quality of those years. If you don't know what your patients want out of those years, you can't help them.
Podcast Contributors
Dr. Rachel Rubin
Dr. Rachel Rubin is a urologist and sexual medicine specialist in North Bethesda, Maryland.
Dr. Sara Psutka
Dr. Sara Psutka is an associate professor and urologic oncologist at UW in Seattle, Washington.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 29). Ep. 139 – Gynecologic-Sparing Cystectomy & More: Prioritizing Female Sexual Health [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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