Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality? Hari S.G.R. Tunuguntla, MD and Angelo E. Gousse, MD*

Address *Division of Female Urology, Pelvic Floor Dysfunction, Neurourology, Voiding Dysfunction, and Reconstructive Urology, Department of Urology, University of Miami School of Medicine, 1400 NW 10th Avenue, Suite #507-A, Miami, FL 33136, USA. E-mail: [email protected] Current Urology Reports 2004, 5:403–411 Current Science Inc. ISSN 1527-2737 Copyright © 2004 by Current Science Inc.

This article reviews the mechanisms by which vaginal surgery affects female sexual function and related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as they apply to vaginal surgery. Methods to avoid neurovascular damage during pelvic floor surgery have been corroborated by supporting literature. The incidence of female sexual dysfunction after various transvaginal procedures for indications such as stress urinary incontinence and pelvic organ prolapse, anterior/posterior colporrhaphy, perineoplasty, and vaginal vault prolapse has been discussed. Current literature regarding female sexual dysfunction following other procedures such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair also are reviewed.

Introduction The female sexual response cycle is a three-phase model consisting of desire, arousal, and orgasm [1]. The perception of sexual satisfaction depends on many complex interactions: emotional well-being, intimacy with one’s partner, quality of life, and physical health. The American Federation for Urological Disease consensus conference held in 1998 classified female sexual dysfunction into hypoactive sexual desire disorders, sexual arousal disorders, orgasmic disorders, and sexual pain disorders [2]. The close anatomic proximity of the bladder and urethra to the vagina allows for an association between lower urinary dysfunction and sexual difficulties. The effects may be bidirectional; sexual activity can cause or aggravate urinary problems and urinary problems can result in sexual dysfunction. Female sexual dysfunction (FSD) is a significant problem that affects the quality of life of many women. Manifestations of FSD include diminished vaginal lubrication,

pain and discomfort during intercourse, decreased arousal, and difficulty in achieving orgasm. This review addresses the incidence, possible etiologic factors, and pathophysiologic mechanisms involved in sexual dysfunction following transvaginal surgery.

Anatomy and Nerve Supply of Female Genital Tract in Relation to Sexual Dysfunction Female sexual anatomy includes external and internal genitalia. External genitalia are collectively known as the vulva and consist of the labia majora and labia minora, interlabial space, and female erectile organs, including the clitoris and the vestibular bulbs. The clitoris is made up of the outermost glans, the midline corpus or body, and innermost crura. Autonomic innervation to the vagina originates from the hypogastric plexus and the sacral plexus, giving rise to the uterovaginal nerves containing sympathetic and parasympathetic fibers; somatic sensory innervation is provided by the pudendal nerve. The clitoral innervation to the clitoris derives from sympathetic (T1-L3) and parasympathetic (S2-S4) fibers. Somatic sensory innervation arising from the skin travels through the dorsal nerve of the clitoris and continues in the pudendal nerve. Internal genitalia consist of the vagina, uterus, uterine tubes, and the ovaries. The pelvic floor is made up of several tissues spanning the opening within the bony pelvis; it supports abdominal and pelvic organs, maintains continence of urine and stool, and allows for intercourse and parturition. Among the pelvic floor musculature, the pelvic diaphragm is formed by the levator ani muscle, the urogenital diaphragm, and the perineal membrane. These structures are important for pelvic organ support and for sexual function. For example, the perineal membrane consisting of the ischiocavernous, bulbocavernosus, and superficial transverse perineal muscles plays a crucial role in sexual response. All of the previously mentioned structures may be altered during transvaginal surgery.

Intrapelvic Nerve Supply in Relation to Pelvic Floor Surgery Yucel et al. [3•] emphasize that during pelvic surgery, every effort should be made to avoid injury to the intrapelvic somatic nerve originating from the pudendal nerve that courses on the lateral border of the midurethra to reach the endopelvic fascia. The autonomic nerve

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plexus occupies the anterolateral sides of the rectum at the 2 and 10 o'clock positions. These nerves give off branches to the lateral vaginal walls to form the vaginal nervous plexus at the 2 and 10 o'clock positions on the anterolateral vaginal walls. These autonomic nerves are immunoreactive to neuronal nitric oxide synthase (nNOS) and vesicular acetylcholine transporter (specific for cholinergic nerves), whereas the pudendal nerve, which is a somatosensory and motor mixed nerve, was devoid of nNOS immunoreactivity. The anterior and lateral vaginal walls are innervated most densely by nNOS immunoreactive nerves. Pelvic autonomic nerves that innervating the vagina, urethra, and bladder are critical to preserve sexual function and urinary continence in women [3•] (Fig. 1). Caution should be exercised during the posterior dissection of the proximal and midurethra during vaginal surgery to preserve the cavernous nerves and continence nerves [3•].

Physiology of Female Sexual Response Sexual arousal results in increased vaginal lubrication, vaginal wall engorgement, and luminal diameter and an increase in clitoris length and diameter. Nitric oxide, phosphodiesterase-V, and vasoactive intestinal peptide have been considered to play a role in mediating female sexual response at the neurogenic level [3•]. Estrogen (estradiol) and testosterone play a role in the regulation of female sexual response.

Sexual (Dys)Function Following Vaginal Surgery Maintenance of sexual function requires preservation of vaginal length and caliber adequate for sexual intercourse.

The surgical procedure and psychosocial issues may contribute to altered sexual function after vaginal surgery. Improvements in sexual function after vaginal surgery were thought to result from cessation of incontinence during intercourse, whereas worsening sexual function was thought to be caused by dyspareunia after perineorrhaphy.

Incidence and prevalence Haase and Skibsted [4] reported that 91% of 55 women who underwent an anterior-posterior repair with or without colposuspension experienced an improvement or no change in their sexual life after surgery for incontinence. Black et al. [5] noted that 78% of 355 women (most of whom had undergone colposuspension or anterior colporrhaphy) considered their sex life improved or the same compared with their preoperative condition. Lemack and Zimmern [6••] reported that 20% of women noted pain during intercourse following anterior vaginal wall suspension for stress urinary incontinence (SUI), which was slightly lower than the preoperative incidence (29%) (Table 1). Eighteen percent reported intercourse to be worse after surgery. They found that premenopausal women and postmenopausal women undergoing hormone replacement therapy (HRT) were more likely to be sexually active after surgery (46%) than those not undergoing HRT (17%).

Etiology of Sexual Dysfunction Following Vaginal Surgery Sexual dysfunction may be affected positively or negatively by the surgical treatment of SUI. Psychologic factors that may contribute to FSD include presumed altered body image after vaginal surgery and apprehension of sexual intercourse by the patient or partner.

Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality? • Tunuguntla and Gousse

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Table 1. Effect of surgery for stress urinary incontinence on sexual function Sexually active, % Procedure Colposuspension, needle, or A/C9 Colpourethropexy 10 A/C, A/C + Burch, or Burch8 Retropubic urethropexy or pubococcygeal repair11

Mean age, y Preoperative Postoperative 52

Not given

68

41 49

100 100

95 100

50

91

86

Sexual dysfunction, % Preoperative Postoperative Not given

22 deteriorated

Not given 20 deteriorated 42 dyspareunia 28 dyspareunia 39 orgasm dysfunction

48 orgasm dysfunction

55 decreased lubrication 27 decreased desire

48 decreased lubrication 20 decreased desire

Mean followup, mo 12 12–24 6 12

A/C—anterior colporraphy. Data adapted from Lemack and Zimmern [6••].

The causes of sexual dysfunction after vaginal surgery may be classified as organic, emotional, and psychologic. Organic causes include anatomic, physiologic, vascular, neural, and hormonal factors. Colpoperineorrhaphy can result in dyspareunia as a result of narrowing of the vagina [4]. However, vaginal narrowing may not be entirely responsible for altered sexual functioning and sexual dissatisfaction after vaginal surgery. Vaginal innervation is concentrated on the anterior and distal aspects of the vaginal wall [8] and may be affected by operations for SUI and paravaginal repair of cystocele that typically are directed toward this region. Others [9] think that altered sexual functioning (dysfunction during orgasm phase) may be attributed to other causes, such as unreasonable expectations after surgery among women with SUI, many of whom had pre-existing sexual dysfunction. Vaginal narrowing/shortening after posterior repair has been reported to result in sexual dysfunction in 17% of women surveyed [8]. Sexual intercourse in these patients was painful or completely avoided. Lemack and Zimmern [6••] reported that women on HRT are more than twice as likely to be sexually active as those who are not and recommend HRT (if not medically contraindicated) to optimize the likelihood of remaining sexually active or resuming sexual activity following vaginal surgery for SUI. Strauss et al. [10] reported that sexual dysfunction after vaginal hysterectomy more likely is related to the preoperative psychologic traits rather than the surgery.

Pelvic Organ Prolapse and Stress Urinary Incontinence Sexual function may be improved, unchanged, or worsened by surgical treatment of SUI, such as various sling

procedures and laparoscopic/open colposuspension. The improvement may be related to emotional amelioration because of cessation of incontinence. On the other hand, deterioration may occur as a result of organic causes such as fibrosis, stenosis, or neuronal or vascular damage to the anterior vaginal wall and clitoral region, which may result in sexual pain disorder and consequent arousal and orgasmic disorders. Although some studies have reported worsening sexual function with dyspareunia or apareunia caused by vaginal narrowing after posterior colporrhaphy [4,8] or sacrospinous ligament fixation [11], these studies have not correlated patients’ symptoms with objective measures of postoperative vaginal dimensions. Weber et al. [12••] reported that sexual function and satisfaction improved or did not change in most women after surgery for prolapse or urinary incontinence or both (Tables 2 and 3). However, they could not correlate symptoms with objective changes in vaginal length/caliber in those women with sexual dysfunction after surgery. They found that a combination of Burch colposuspension and posterior colporrhaphy was particularly likely to result in dyspareunia (pain during sexual intercourse usually or always). Dyspareunia following Burch colposuspension is caused by the posterior vaginal ridge occurring with the procedure. Forty-nine percent of women (mean age, 54 years) were sexually active before and after surgery for stress incontinence or pelvic organ prolapse. Mean frequency of intercourse did not change after surgery. Eight percent of women had preoperative dyspareunia compared with 19% after surgery. Dyspareunia occurred in 26% after posterior colporrhaphy and in 38% following Burch colposuspension with concomitant posterior colporrhaphy. Although vaginal dimensions decreased after surgery, they did not correlate with any change in sexual function. Eighty-two percent of women had satisfactory preoperative

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Table 2. Median vaginal dimensions before and after surgery in 15 women with and 65 women without dyspareunia Postoperative introital caliber (cm, median and range) With dyspareunia Without dyspareunia Change in introital caliber* (cm, median and range) With dyspareunia Without dyspareunia Postoperative vaginal length (cm, median, and range) With dyspareunia Without dyspareunia Change in vaginal length* (cm, median, and range) With dyspareunia Without dyspareunia

9.5 (8.0–12.0) 10.0 (8.0–12.0) –1.0 (-3.0–0.5) –1.0 (-7.0–4.0) 9.75 (9.0–11.0) 10.0 (7.0–12.0) –1.0 (-5.0–4.0) –1.0 (-3.0–3.5)

*Change represents the median change from preoperative to postoperative measurement. Negative numbers represent a decrease and positive numbers represent an increase. Data adapted from Weber et al. [12••].

sexual relationships compared with 89% postoperatively. Vaginal dryness (dryness that interfered with sexual activity usually or always) occurred in 24% before surgery and in 26% after surgery. Vaginal dryness was not significantly associated with postoperative vaginal dimensions, changes in preoperative to postoperative dimensions, or with the women’s perception of vaginal length or introital caliber.

Posterior Colporrhaphy, Rectocele Repair, and Sexual Dysfunction Dyspareunia occurs in 21% to 27% of women after posterior colporrhaphy if the latter involves plication of levator ani [13]. Introital caliber was reduced by a mean of 1.4 cm after this procedure [4,8,13]. However, this is not associated with the development of symptoms in most women and there is no significant difference in the reduction of caliber in women who did and did not have symptoms [12••]. Dyspareunia caused by introital narrowing can be avoided with meticulous posterior colporrhaphy and perineoplasty. Caution should be exercised while performing posterior colporrhaphy with Burch procedure, taking care to avoid exacerbation of posterior vaginal ridging by excessive plication or excision of vaginal epithelium. In a study of 343 women (age, > 45 years), Barber et al. [14] found that compared with women with SUI, those with grade-3 or grade-4 prolapse were more likely to implicate pelvic floor symptoms as the reason for preoperative sexual inactivity, with one third reporting moderate to severe adverse influence on their ability to have sexual relations. However, the overall sexual satisfaction rates were similar in both groups after surgery.

Age was not an independent predictor of sexual satisfaction in this study. In the absence of specific data to the contrary, it seems reasonable to restore or maintain a normal (average) vaginal length of 8 to 11 cm at the time of vaginal reconstructive surgery. We commonly refer to finger breadths with the objective of restoring or maintaining adequate caliber to admit two or three fingers at the time of vaginal reconstructive surgery. Although this measurement is variable, two finger breadths measure approximately 8 to 10 cm of vaginal diameter and three finger breadths measure approximately 10 to 12 cm. It is essential to allow for postoperative involution and senile contracture in correctly judging vaginal dimensions at the time of surgery [11]. It is recommended that sexual activity start as soon as postoperative tenderness is resolved (usually by 6 weeks) [11]. Porter et al. [15] reported that posterior colporrhaphy, alone or with other vaginal surgery, does not adversely affect sexual function and actually may aid in the resumption of sexual activity, significantly improving quality of life and social aspects of daily living (Tables 4 and 5). Dyspareunia significantly improved or was cured after surgery in 73% of 125 patients, worsened in 19% of patients, and developed de novo in 3%. There was no change in vaginal dryness, orgasm ability, sexual desire, sexual frequency, or sexual satisfaction. It was thought that the defect-specific repair (without levator ani placation) appears to improve sexual function [15]. In 1961, Francis and Jeffcoate [11] reported a 50% rate of dyspareunia after vaginal operations as a result of narrowing of introital narrowing. Another study [3•] reported a dyspareunia rate of 9%, with 24% of patients reporting improvement in sexual life after the operation. These authors concluded that this low rate of dyspareunia was caused by early return to sexual intercourse only 3 weeks after the operation.

Tension-free Vaginal Tape and Sexual Dysfunction Maaita et al. [16•] reported no significant change in sexual function/activity after the tension-free vaginal tape (TVT) procedure in 67 women based on a questionnaire administered 6 to 36 months after surgery. On the other hand, Yeni et al. [17••] demonstrated a statistically insignificant decrease in the mean domain scores of Index of Female Sexual Function (desire, arousal, orgasm, pain, and overall satisfaction) 6 months after TVT. However, when compared with control subjects, all of the patients had significant decreases in all of the scores (except for desire and arousal) after TVT; overall, the surgery negatively affected sexual function. Maaita et al. [16•] think that TVT decreases genital sensation and vaginal lubrication or wetness, which may result in painful intercourse and inevitably inhibit orgasm. Further studies are clearly needed to confirm these observations.

Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality? • Tunuguntla and Gousse

Table 3. Patients' perception and objective measures of vaginal dimensions in 81 women after prolapse or incontinence surgery (n = 78) Postoperative Patient's perception measurement Vaginal caliber (cm, median, and range) Too loose (n = 4) Not a problem (n = 66) Too tight (n = 8) Vaginal length (cm, median, and range) Too short (n = 8) Not a problem (n = 68) Too long (n = 2)

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are the contributing factors coupled with their partners’ fear of harming the women after vaginal surgery. Counseling may play a crucial role in returning these women to their preoperative level of sexual function.

Change*

10.25 (9.0–11.5) 9.75 (8.0–12.0)

–0.25 (-1.0–1.5) –1.0 (-7.0–1.0)

9.5 (8.0–11.5)

–1.50 (-3.0–4.0)

9.0 (7.0–12.0) 10.0 (7.0–12.0)

–1.25 (-4.0–1.0) –1.0 (-5.0–4.0)

9.5 (8.0–11.0)

–2.5 (-5.0–0.0)

*Median change in preoperative to postoperative measurement. Data adapted from Weber et al. [12••].

Prospective Data on Female Sexual Dysfunction Following Vaginal Surgery In a multicenter, prospective study of sexual function following surgery for stress incontinence or pelvic organ prolapse, Rogers et al. [18••] reported mixed results with improved sexual function in 21% and worsened function in 22% using two validated, condition-specific questionnaires (Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire, which assesses the effect of prolapse and incontinence on sexual function, and the Incontinence Impact Questionnaire-7, which assesses the impact of incontinence on social function) preoperatively and at 3 and 6 months after surgery in 102 women with a mean age of 47 years. They brought forth the caveat of postoperative anatomic measures as indicators of sexual function. These authors found deterioration of postoperative sexual function despite improvement in the scores. Women also reported diminished arousal with sexual activity with their partners (4% had normal arousal after surgery compared with 83% before). The proportion of women reporting weekly sexual desire dropped from 63% to 11%; arousal with sexual activity declined from 83% to 4%, while frequency of orgasm (with masturbation and sexual intercourse) universally declined, although reported intensity of orgasm did not change. They also were less satisfied with their sexual relationships after surgery. However, they also noted some positive postoperative changes. Coital incontinence improved from 60% to 25%. None of the patients reported dyspareunia after surgery. Diminished postoperative sexual function scores are significant in view of the younger age of the study population and the fact that patients did not report more pain with sexual activity after surgery. The authors of the study think that women’s perception of genital health changes; surgical alteration of the genitalia and fear of harming themselves by engaging in sexual activity after surgery

Can Vaginal Erosion of Slings for Stress Urinary Incontinence Contribute to Female Sexual Dysfunction? Vaginal erosion of various synthetic slings (occurs in 1% to 12%) can mechanically contribute to sexual dysfunction. Kobashi and Govier [19] reported on the conservative management of vaginal erosion by using the SPARC (American Medical Systems, Minnetonka, MN) sling and recommend abstinence from sexual intercourse until spontaneous epithelialization over the mesh occurs, which occurred in 6 weeks in four patients. On the other hand, Sweat et al. [20] suggested that polypropylene tape erosion should be treated with complete removal of the mesh.

Hysterectomy and Sexual Dysfunction It is thought that women are concerned that hysterectomy may affect their sexual well-being or their sexual attractiveness [21]. Hysterectomy has been reported as having adverse and beneficial effects on sexual well-being [22–27]. Because hysterectomy disrupts the local nerve supply and anatomic relations of the pelvic organs, it has been thought that the function of these organs may be adversely affected. The idea that sexual well-being may differ according to type of hysterectomy is based on the hypothesis that the techniques damage the innervation and supportive structures of the pelvic floor differently. During a hysterectomy, the pelvic plexus may be damaged in four ways: the main branches of the plexus passing beneath the uterine arteries may be damaged during the division of the cardinal ligaments [28], the major part of the vesical innervation, which enters the bladder base before spreading throughout the detrusor muscle, may be damaged during blunt dissection of the bladder from the uterus and cervix [28], the extensive dissection of the paravaginal tissue may disrupt the pelvic neurons passing from the lateral aspect of the vagina [29], or the removal of the cervix results in loss of a large segment of intimately related plexus [29]. Dragisic and Milad [30] reported no change in sexual desire, orgasm frequency, or orgasm intensity in 75 patients after hysterectomy. They found that decreased pain after surgery contributes to improved sexual relations.

Sacrospinous Fixation and Sexual Function Holley et al. [8] reported that sacrospinous ligament fixation did not predispose to dyspareunia unless vaginal narrowing caused by repair of associated defects was present. Paraiso et al. [7] noted that approximately 20% of 243 women who underwent sacrospinous ligament fixation for

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Table 4. Sexual symptoms and conditions before and after surgery Before operation Number Sexually active Sex important Sexual satisfaction Dyspareunia Vaginal dryness Sexual desire Orgasm Coital frequency

39/72 39/39 37/39 26/39 27/39 33/39 35/39 33/39

% 54 100 95 67 69 85 90 85

After operation Number 40/72 39/39 37/39 18/39 29/39 34/39 35/39 33/39

% 55 100 95 46 74 87 90 85

Improvement or cure Number NA 4/39 13/37 19/26 9/27 8/33 12/35 6/33

% NA 10 35 73 33 24 34 18

Statistical significance P = 1.0000 P = 1.0000 P = 0.5235 P = 0.0357 P = 0.5034 P = 0.6072 P = 0.3593 P = 1.0000

NA—not applicable Data adapted from Porter et al. [15].

vaginal vault prolapse had sexual dysfunction before surgery. Long-term (74 months) follow-up of patients after surgery revealed worsening of sexual dysfunction [7].

Martius Flap Harvest and Sexual Function Petrou et al. [31] reported that Martius flap harvest is not associated with significant perceived cosmetic disfigurement of the labium majus by the patients and has little effect on sexual relations despite associated numbness and decreased sensation at the harvest site in 62% of a group of eight patients. During a mean follow-up of 17 months, only one of the eight patients reported interference with coital relations because of associated pain. Three patients (38%) experienced lingering pain over the harvest site 1 year after surgery. Those who noticed a cosmetic change noted that the labium majus was rougher after surgery. However, the potential alteration in body image should be considered, particularly in young patients who are sexually active. The authors think that concomitant transvaginal urethrolysis cont r i b u t e d t o p o s t o p e r a t i ve n u m b n e s s , p a i n , a n d decreased sensation in their patients. Further studies in a larger group of patients clearly are indicated. In addition to the usage of the Martius flap after transvaginal urethrolysis, it also is used in transvaginal fistula (vesicovaginal fistula and rectovaginal fistula) repairs. Elkins et al. [32] reported a 25% incidence of dyspareunia over the Martius flap harvest site following vesicovaginal and rectovaginal fistula repair. In 37 complex fistula repairs in 35 patients, they noted a dual blood supply for the Martius graft: posterior labial branches of the internal pudendal artery and vein posteroinferiorly and from the branches of the external pudendal vessels anterosuperiorly. In a similar study, Webster et al. [33] reported decreased sensation at the labial harvest site in 17% using the Martius flap as a posturethrolysis interposition flap. Data suggest that patients undergoing Martius flap interposition should be cautioned about the possibility of FSD postoperatively.

Surgical Correction of Imperforate Hymen and Sexual Dysfunction Liang et al. [34] reported improved sexual function following hymenectomy in a retrospective study of 15 girls older than 8.5 years of age. The patients responded to a questionnaire through a telephone interview regarding sexuality, fertility, menstrual problems, micturition, and defecation after surgical correction. The mean age at diagnosis was 13.2 years. The most common clinical symptom was cryptomenorrhea in 15 girls, followed by pelvic pain in 11, palpable abdominal mass in nine, urinary retention and other voiding problems in eight, and problems of defecation in four. None of the girls admitted previous intercourse attempts. Two patients also had uterine anomalies, but none had urinary tract or bowel anomalies. During the follow-up period, most of the patients had irregular menstrual cycles and were worried about their future fertility. Six patients had dysmenorrhea; of eleven patients who began having intercourse, two had babies and none complained of sexual dysfunction. After hymenectomy, patients were relieved of cryptomenorrhea and problems of micturition and defecation also greatly improved. Although irregular menstruation and dysmenorrhea became more symptomatic during follow-up, most of the patients fared well in terms of fertility and sexual function.

Conclusions Surgical procedures for the correction of prolapse and incontinence emphasize the preservation of a functional vagina, with caliber and length adequate for sexual intercourse. However, the current literature does not support an association between vaginal length after vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. It is important to make a distinction between the overall sexual function and individual parameters (eg, self/ body image, sexual desire, frequency of orgasm, and overall sexual satisfaction). Evidence indicates that sling surgery for urinary incontinence does not appear to adversely

57 54

13 8

100 88

22

9 8

27 38

22 33

15

40 12

16

25 12

64 36

39 25

33

13 8

30 33

8 8

29 8

50

18

29 19

6 19

27

82

76

Difficulty emptying Pelvic pressure Fecal bowels, % or pain, % Vaginal lump, % Splinting, % incontinence, % Dyspareunia, % Anatomic cure, %

46 13

*Site-specific repair. Data adapted from Porter et al. [15].

Cundiff et al.* Preoperative Postoperative Kahn and Stanton Preoperative Postoperative Francis and Jeffcoate Murthy et al. Preoperative Postoperative Mellgren et al. Preoperative Postoperative Janssen and van Dijke Preoperative Postoperative Arnold et al. Preoperative Postoperative, transanal Postoperative, transvaginal

Constipation, %

Table 5. Cure rates and effects on bowel and sexual function from other studies Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality? • Tunuguntla and Gousse 409

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affect the overall sexual function, although individual parameters of sexual function scores may be impacted (eg, significant percentage report pain during intercourse). In fact, some patients report improved overall sexual function as a result of complete relief from coital incontinence, thereby improving self/body image and confidence despite dyspareunia. Further studies are needed in this area. Symptomatic vaginal narrowing is rare, even among those undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse, although individual parameters may vary. However, condition-specific sexual function questionnaires specifically designed to elucidate the complex interaction among different types of vaginal surgery and sexual function are essential. Unfortunately, they have not been routinely used in outcome data reporting. Posterior colporrhaphy and perineorrhaphy have been noted to cause dyspareunia as a result of vaginal stenosis. Because of the potential risk for postoperative dyspareunia, posterior colpoperineorrhaphy may be unnecessary in lowgrade posterior compartment pelvic organ prolapse. Defect-specific posterior colporrhaphy with avoidance of levator ani plication may be less morbid and may improve sexual function. Thus, attention to surgical technique may be critical. The woman’s perception of vaginal dryness or tightness does not appear to correlate with objective measures of introital caliber. A perception of genital health change as a result of surgical alteration of the genitalia and fear of harming themselves by engaging in sexual activity after surgery are contributing factors, particularly coupled with their partners’ fear of harming them after vaginal surgery. Counseling may play a crucial role in returning these women to their preoperative level of sexual function. The relationship of dyspareunia and vaginal dryness and sexual function in postmenopausal women and the influence of hormone replacement therapy appear to be evident, but still deserves further research. Future prospective, long-term studies should focus on vaginal changes associated with aging, changes in sexual activity, and use of estrogen with regard to symptoms and sexual dysfunction. The possible etiologic factors for sexual dysfunction following vaginal surgery deserve further investigations.

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1. 2.

Kaplan HS: The New Sex Therapy. London: Bailliere Tindall; 1974. Goldstein I, Berman JR: Vasculogenic female sexual dysfunction: vaginal engorgement and clitoral insufficiency syndromes. Int J Impot Res 1998, 10:S84–S90.

3.• Yucel S, de Souza A Jr, Baskin LS: Neuroanatomy of the human female lower urogenital tract. J Urol 2004, 172:191–195. This recently published article describes the distribution of autonomic nerves immunoreactive to nNOS and vesicular acetylcholine transporter (specific for cholinergic nerves) and gives an excellent description of intrapelvic nerve supply applicable to pelvic floor surgery. 4. Haase P, Skibsted L: Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand 1988, 67:659–661. 5. Black NA, Bowling A, Griffiths JM, et al.: Impact of surgery for stress incontinence on the social lives of women. Br J Obstet Gynaecol 1998, 105:605–612. 6.•• Lemack GE, Zimmern PE: Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire. Urology 2000, 56:223–227. In this landmark article, the authors discuss the incidence of sexual dysfunction following different surgical procedures for stress incontinence such as colposuspension, colpourethropexy, Burch procedure, retropubic urethropexy, or pubococcygeal repair. They also discussed the effect of surgery on different aspects of sexual function in sexually active women and in those with sexual dysfunction. The paper also discusses whether there is any role for hormone replacement therapy on sexual function in postmenopausal women and whether there is any difference in the incidence of sexual dysfunction between premenopausal and postmenopausal women after surgery for stress urinary incontinence. 7. Paraiso MF, Ballard LA, Walters MD, et al.: Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 1996, 175:1423–1431. 8. Holley RL, Varner RE, Gleason BP, et al.: Sexual function after sacrospinous ligament fixation for vaginal vault prolapse. J Reprod Med 1996, 41:355–358. 9. Berglund AL, Eisemann M, Lalos O: Personality characteristics of stress incontinent women: a pilot study. J Psychosom Obstet Gynaecol 1994, 15:165–170. 10. Strauss B, Jakel I, Koch-Dorfler M, et al.: Psychiatric and sexual sequelae of hysterectomy: a comparison of different surgical methods. Geburtshilfe Frauenheilkd 1996, 56:473–481. 11. Francis WJ, Jeffcoate TN: Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw 1961, 68:1–10. 12.•• Weber AM, Walters MD, Piedmonte MR: Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 2000, 182:1610–1615. In this important article, the authors reported that combined Burch colposuspension and posterior colporrhaphy is particularly likely to result in dyspareunia and they highlight the contribution of posterior vaginal ridge to sexual dysfunction following posterior colporrhaphy. They also conclude that vaginal dryness is not related to postoperative vaginal dimensions or the woman's perception of vaginal length/introital caliber. Vaginal dimensions, although decreased after surgery, did not correlate with any change in sexual function in their experience. 13. Kahn MA, Stanton SL: Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol 1997, 104:82–86. 14. Barber MD, Visco AG, Wyman JF, et al., for the Continence Program for Women Research Group: Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002, 99:281–289. 15. Porter WE, Steele A, Walsh P, et al.: The anatomic and functional outcomes of defect-specific rectocele repairs. Am J Obstet Gynecol 1999, 181:1353–1358. 16.• Maaita M, Bhaumik J, Davies AE: Sexual function after using tension-free vaginal tape for the surgical treatment of genuine stress incontinence. BJU Int 2002, 90:540–543. This important article discusses the incidence of sexual function following TVT procedure based on a questionnaire. There was no significant sexual dysfunction following TVT in their patients.

Female Sexual Dysfunction Following Vaginal Surgery: Myth or Reality? • Tunuguntla and Gousse

17.•• Yeni E, Unal D, Verit A, et al.: The effect of tension-free vaginal tape (TVT) procedure on sexual function in women with stress urinary incontinence. Int Urogynecol J 2003, 14:390–394. In this paper, the authors discuss the sexual dysfunction following TVT in terms of Index of Female Sexual Function 6 months after surgery. They compared the sexual function in their patients with control subjects and concluded that TVT negatively affected the sexual function in their patients compared with control subjects and discuss the role of vaginal lubrication and genital sensation in orgasm. 18.•• Rogers R, Kammerer-Doak D, Darrow A, et al.: Sexual function after surgery for stress urinary incontinence and/or pelvic organ prolapse: a multicenter prospective study. Poster Presented at the American Urogynecologic Society 2003 Scientific Meeting. Hollywood, FL: September 11–13, 2003. In this paper, the authors discuss the sexual dysfunction following TVT in terms of Index of Female Sexual Function 6 months after surgery. They compared the sexual function in their patients with control subjects and concluded that TVT negatively affected the sexual function in their patients compared with control subjects and discuss the role of vaginal lubrication and genital sensation in orgasm. 19. Kobashi KC, Govier FE: Management of vaginal erosion of polypropylene mesh slings. J Urol 2003, 169:2242–2243. 20. Sweat SD, Itano NB, Clemens JQ, et al.: Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction. J Urol 2002, 168:144–146. 21. Sloan D: The emotional and psychosexual aspects of hysterectomy. Am J Obstet Gynecol 1978, 131:598–605. 22. Rhodes JC, Kjerulff KH, Langenberg PW, Guzinski GM: Hysterectomy and sexual functioning. JAMA 1999, 282:1934–1941. 23. Helstrom L, Lundberg PO, Sorbom D, Backstrom T: Sexuality after hysterectomy: a factor analysis of women's sexual lives before and after subtotal hysterectomy. Obstet Gynecol 1993, 81:357–362.

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25.

26.

27. 28.

29.

30.

31. 32.

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34.

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Helstrom L, Sorbom D, Backstrom T: Influence of partner relationship on sexuality after subtotal hysterectomy. Acta Obstet Gynecol Scand 1995, 74:142–146. Kilkku P, Gronroos M, Hirvonen T, Rauramo L: Supravaginal uterine amputation vs. hysterectomy: effects on libido and orgasm. Acta Obstet Gynecol Scand 1983, 62:147–152. Virtanen H, Makinen J, Tenho T, et al.: Effects of abdominal hysterectomy on urinary and sexual symptoms. Br J Urol 1993, 72:868–872. Polivy J: Psychological reactions to hysterectomy: a critical review. Am J Obstet Gynecol 1974, 118:417–426. Smith PH, Ballantyne B: The neuroanatomical basis of denervation of the urinary bladder following major pelvic surgery. Br J Surg 1968, 55:929–933. Parys BT, Haylen B, Hutton JL, Parsons KF: The effect of simple hysterectomy on vesicourethral function. Br J Urol 1989, 64:594–599. Dragisic KG, Milad MP: Sexual functioning and patient expectations of sexual functioning after hysterectomy. Am J Obstet Gynecol 2004, 190:1416–1418. Petrou SP, Joyce J, Parra RO: Martius flap harvest site: patient self-perception. J Urol 2002, 167:2098–2099. Elkins TE, DeLancey JO, McGuire EJ: The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol 1990, 75:727–733. Webster GD, Guranick ML, Amundsen CL: Use of the Martius labial fat pad as an adjunct in the management of urinary fistulae and urethral obstruction following anti-incontinence procedures [Abstract 335]. J Urol 2000, 163(suppl):76. Liang CC, Chang SD, Soong YK: Long-term follow-up of women who underwent surgical correction for imperforate hymen. Arch Gynecol Obstet 2003, 269:5–8.