CANCER OF VULVA
( By JASCAP )

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After treatment

Follow up after treatment for vulval cancer

After your treatment has finished, your specialist will ask you to go back to the hospital for regular check-ups. These are a good opportunity to discuss any worries or problems you may be having. You can also see your GP or your specialist doctor if, between your follow-up visits, you have a symptom which you cannot explain, lasts more than a week or is not getting better.
For people whose treatment is over apart from regular check-ups, our section on life after cancer, gives useful advice on how to keep healthy and adjust to life after cancer.

After surgery for vulval cancer

Your care and how quickly you recover after the operation will depend on the type of surgery you have had. Your doctor will explain all this to you beforehand. If the cancer is very small and only a minimal amount of skin is removed, the wound is likely to heal quickly. If your lymph nodes are removed, and particularly if you need more major surgery (such as a radical vulvectomy), healing and recovery will take longer.

Drips and drains
Pain
Physiotherapy
Dressings
Bowel movements
Going home
Lymphoedema

Drips and drains

When you go back to the ward you will have a drip in your arm, which gives you fluids into a vein. Once you can eat and drink normally again, probably after a couple of days, the drip will be taken out. You may also be given antibiotics through the drip to prevent you getting any infections. You will be given injections of blood thinning medicine just under the skin to prevent blood clots.

You will usually have a tube to drain urine from your bladder (catheter) put in while you are under the anaesthetic. You may have the catheter in for up to ten days. You may also have a dressing over the operation site. If your lymph glands have been removed you will probably have two tubes, called drains, going into the groin. This is to drain any fluid that may collect there. The drains are connected to small suction bottles.

Pain

After your operation you may have some pain or discomfort for a few days. You will be given painkillers, which are generally very effective at controlling any pain. At first you may be given the painkillers by injection into a muscle, or directly into your drip. Sometimes a small pump can be used to give painkillers into your bloodstream for the first few days. Many of these pumps allow you to control how much painkiller you receive (they are programmed so that you can not give yourself too much). Once you are eating and drinking properly again, you can be given your painkillers as tablets or a liquid.

Always let your doctor or nurse know if you have any pain or discomfort, as your painkillers, or the dose, can be changed to suit your needs. You may have a tube put into the fluid around your spinal cord (an epidural) so that painkillers can be given directly to this area.

Physiotherapy

If you have had major surgery you may be nursed in bed for the first 48 hours after your operation. After this you will be helped to get out of bed and encouraged to start gently moving around as soon as possible. The nurse or a physiotherapist will also help you do regular gentle leg exercises to prevent blood clots forming and deep breathing exercises to prevent any chest infections.

Dressings

You may not have any dressings on the vulval wound, as the area is likely to be kept clean by gently rinsing it with fluid. This is usually done three times a day until you go home. If you do have a dressing, it will be removed after a few days and changed regularly to keep the area clean and to help the skin to heal. Your stitches, if they are not dissolvable, will be removed when the skin has healed properly, usually in about 7−10 days.

If you have any groin wounds they will be covered with dressings, which will need to be changed regularly. The tubes will be removed from your groin when most of the excess fluid has been drained away. This may take about ten days, or sometimes longer. When the skin has healed your stitches will be removed and you will be able to go home.

Once you are at home, you will not need to put dressings on the area, but it is important to keep it clean and dry. The nurses on the ward will show you the best way to do this before you go home. In some situations a district nurse will be able to visit you at home to help with rinsing and keeping the area clean.

If you have had a skin graft, you may need dressings on the area where the skin was taken (the donor site). Usually these dressings stay in place until new skin has formed. Your nurse will explain more about this to you.

Bowel movements

You may find that your bowels do not open for a few days after your operation. This is quite usual. Once you are back to eating and drinking again, which is generally within a few days, your bowels should start to work normally again. It is likely that you will be prescribed laxatives after your operation to prevent constipation. If opening your bowels is painful, or difficult, let your doctors know and they can prescribe extra laxatives to help.

Going home

When you go home you will need to take things easy for a few weeks. The time it takes you to recover will depend on the extent of the surgery you have had.

If you have had major surgery, it is very important not to lift any heavy objects for at least six to eight weeks. This will help the skin to heal completely. It is advisable to wait about eight weeks before going back to work, but you may need longer if you heal more slowly. You can usually start driving after six weeks. Your car insurance company may specify a longer time before you can drive again, so it is helpful to contact them to check.

If your operation involved removing only a small amount of skin, your recovery will be much quicker. Your doctor will advise you on what to expect and on the precautions you should take. Here are some other helpful tips to consider:

Avoid tight clothing and any lotions, perfumes and powders in the area of your operation.
Donít overdo walking until the skin has healed comfortably.
Frequent baths can soothe the wound and help healing (but avoid scented bath oils/bubble bath).
If passing urine makes your wound sting, try pouring a small jug of warm or tepid water over the wound while you are still sitting on the toilet.
A hair dryer on a cool setting can be a more comfortable way of drying the vulval skin than a towel.
Wear a loose fitting skirt and underslip (but no underwear) wherever possible as this may be more comfortable. (If you have to keep pads in place it will not be possible to avoid wearing underwear).
If you tend to be constipated ask your doctor to prescribe some gentle laxatives for you.

If your skin is healing slowly, you may need to stay longer in hospital for further dressings. Sometimes a district nurse can come to your home to do these dressings.

Before you leave hospital the staff can arrange district nurses and other help for you at home.

You will be seen by your surgeon in the outpatients clinic after four to six weeks to check how well the skin is healing and to discuss any problems. This is called a follow-up appointment. If you have any problems or worries before your follow-up appointment, contact your hospital doctor or the nurses on your ward for advice.

Lymphoedema

If the lymph nodes in your groin have been removed by surgery, or if you have had radiotherapy to this part of your body, there is a risk of swelling of your leg or legs. The lymph nodes normally help to remove lymph fluid from your legs. Taking them away can block the flow of lymph. If this happens fluid will collect in the tissues under your skin. This can make your legs swell and is called lymphoedema. The condition can develop a few months or several years after treatment.

Lymphoedema can be treated with special massage techniques, exercises, bandaging and support stockings. Many hospitals have a nurse or physiotherapist who specialises in this treatment. The earlier it is started, the more likely treatment for lymphoedema is to be successful, so let your doctor know if you notice even mild swelling of your leg or foot.

If you have lymphoedema, your leg and foot will be more vulnerable to infection.

Listed below are some simple tips to help you care for your skin and reduce the risk of infection:

Treat even small grazes and cuts with antiseptic and keep them clean until they heal. See your GP at the first signs of any infection Ė if the cut is inflamed or feels warm and tender.
Wear long trousers when gardening to avoid being scratched.
Avoid getting sunburnt.
Keep your skin clean and dry and apply moisturising cream daily to keep it supple.
To avoid cuts, use an electric razor if you shave your legs.
If you are going on a long journey, wear support stockings.
Do not have any injections in your legs.
Dry between your toes carefully. If you notice any signs of athleteís foot (soreness and/or peeling between the toes) treat it straightaway.
Use nail clippers instead of scissors to cut your nails (as there is less risk of accidentally cutting the skin with clippers).

How surgery for vulval cancer may affect your sex life

Most women feel shocked and upset by the idea of having surgery to the vulva. When these strong feelings are combined with the trauma of surgery, as well as all the emotions that go with having a cancer diagnosis, it is understandable that your sex life will be affected.

Surgery to a part of the body which is normally associated only with the most intimate and private areas of our lives Ė sexuality and womanhood Ė can evoke all kinds of feelings, from deep shame to fear and anger. It is not something any of us would choose, and yet you will have had to do this in order to do the best thing for your health. This is a hard choice to make.

ulvectomy can permanently alter the outward appearance of the body and is a change that many women may find hard to accept. It may have an effect on how you feel about your sexuality and womanhood, and may well affect your needs and wants in relation to your sex life.

Although the area of the operation can heal within about six weeks, the emotional effects will probably take much longer to deal with, and need gentleness and sensitivity from yourself and the people close to you.

Sex

Some women find that, at first, intercourse is not physically possible because of the way the wound has healed. For example, there may be some tightening or scar tissue from either surgery or radiotherapy. Things can be done to help with this, so itís important to mention it to your medical team.

It may take some months before you really begin to enjoy sex again. Donít be surprised if you feel very unsure about it. Talk to your partner and be as honest as you can about what you want and donít want. Remember that you need to make yourself and your healing a priority. Allow yourself to say no to any kind of sexual contact that does not feel right. How you approach looking at the vulval area after your operation will be very personal to you. Some women do not want to look at the area at all and this is very natural. Some women may want a nurse to be with them if or when they look for the first time. A nurse can explain what has happened to the area and can offer professional support and advice. Other women may want to look alone or with a friend, partner or relative. Whoever you choose, make sure it is someone that you trust and can talk to about your feelings. If you have never have looked at your vulva before the idea of doing so may seem strange.

Donít force yourself to do things before you feel ready. If you do decide to look at the area where your surgery was it will probably seem odd, however well prepared you may have been. You may feel shocked, and this is understandable. If the labia have been removed, you may be able to see the opening to the vagina much more clearly. If the clitoris has been removed there will be an area of flat skin without the usual folds of the vulva.

Many women worry that if their clitoris has been removed they will not be able to have orgasms. This is not necessarily the case, although you may need to be patient while exploring different ways to reach a climax. Your doctor or nurse may be able to discuss this with you. You may also wish to speak to a sex therapist or counsellor experienced in this area.

For most women sex is more than just being able to feel aroused, or to have orgasms. It involves fundamental feelings about intimacy and about being able to give and receive love. If we are not comfortable with the way our bodies look, this may affect our feelings about sex.

Some women worry about being rejected by their partner, or any potential new partner, because of the changes to their body. Intimate sexual relationships always have the challenge of sharing your fears, worries and needs with your partner. The time after surgery or treatment to the vulva is no different. You may be surprised by the amount of tolerance and trust, tenderness and love that exists between you and your partner. However, sometimes difficulties may arise in your relationship. If this happens, you may find counselling helpful, either with your partner or on your own. If you can do this, you may find that it is possible to work through these feelings to a new closeness and understanding.

We have a section on sexuality and cancer, which you may find helpful.

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