International Journal of Impotence Research (2010) 22, 105–114 & 2010 Nature Publishing Group All rights reserved 0955-9930/10 $32.00 www.nature.com/ijir REVIEW Impact of gynecological surgery on female sexual function RN Pauls Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA Sexual function is complex and involves interaction of many factors, including emotional connection, body image, intact physical response and partner sexual function. Disease processes such as abnormal uterine bleeding, endometriosis, urinary incontinence and pelvic organ prolapse may have a negative impact on various parameters of sexual health. Gynecological surgery to address these common complaints may correct the pathological process. However, despite improvements in symptoms related to the disease, improvements in sexuality are not guaranteed and occasionally there may be deteriorations. This review will summarize the current literature assessing sexual symptoms following benign gynecological surgery, including hysterectomy, and bilateral salpingo-oophorectomy, tubal ligation, anti-incontinence surgery and pelvic organ prolapse reconstruction with and without mesh. In the majority of cases, sexual function and quality of life benefit from these surgical interventions. However, it is critical that physicians remain aware of the potential for negative outcomes. Subjects who experience worsening should undergo thorough evaluation early in the postoperative period in order to mitigate symptoms. Treatment modalities for sexual dysfunction following surgery should be the focus of future research. International Journal of Impotence Research (2010) 22, 105–114; doi:10.1038/ijir.2009.63; published online 14 January 2010 Keywords: female sexual function; gynecological surgery; hysterectomy Introduction Pathological diseases of the pelvic organs impact sexual function. Abnormal uterine bleeding, endo- Female sexual function is a complex phenomenon, metriosis and ovarian or uterine pathology may with current estimates suggesting between 35 and interfere with sexual activity, and cause pain. 50% of women in the general population suffer from Urinary incontinence and pelvic organ prolapse a sexual problem.1,2 However, these issues are can impact sexual function through a variety of infrequently discussed between patients and their means, including embarrassment of leakage with physicians. Lack of time, uncertainty of therapeutic intercourse, coexisting depression and discomfort options and poor training are some reasons cited for or low body image.5–7 In spite of this, corresponding this deficiency.3 Nevertheless, sexual health is a enhancement of sexual function has not been noted basic human right, as mandated by the World Health consistently after surgical correction of the pre- Organization. Previous reports have shown that existing problem. Deterioration in sexual symptoms sexual disorders lead to impaired quality of life may occur following repair.8 and health morbidity.4 Thus, it is clear that we must The purpose of this review is to summarize the improve awareness and understanding of the patho- current literature assessing sexual function follow- physiology of sexual complaints. ing benign gynecological surgery, including hyster- ectomy, bilateral salpingo-oophorectomy (BSO), tubal ligation, anti-incontinence surgery and pelvic organ prolapse reconstruction. The goal is to assist Correspondence: Dr RN Pauls, Division of Urogynecology providers in counseling patients and to identify and Reconstructive Pelvic Surgery, Good Samaritan areas for future research. Hospital, 3219 Clifton Avenue, Suite 100, Cincinnati, OH 45220, USA. E-mail: [email protected] Received 3 November 2009; revised 3 December 2009; Anatomic considerations accepted 5 December 2009; published online 14 January Female sexual anatomy comprises both internal and 2010 external genitalia and includes the labia, interlabial Gynecological surgery and female sexual function RN Pauls 106 space and perineum, clitoris and vagina.9 These The clitoris is a multi-planar structure with broad structures are intricately related to each other and attachments to the pubic arch. MRI and cadaver are anatomically adjacent to the bladder, urethra and dissections have suggested the clitoris to be 9–10 cm rectum. Nerve fibers are derived from the uterova- in length, with a wishbone configuration and close ginal nerves, including the sympathetic and para- proximity to the anterior vaginal wall.24,25 Orgasms sympathetic branches, as well as the pudendal may arise from direct and indirect clitoral stimula- nerve, which provides somatic innervation. Disrup- tion.26 Coincident changes in innervation or blood tion of nerve supply has been documented after supply of the clitoris could result in alterations in pelvic surgery. Benson and McClellan10 described sexual function following surgical treatment. increases in pudendal nerve latency following Finally, mechanical factors may influence vaginal as compared with abdominal surgery. Others postoperative sexual response. Close proximity of have noted quantifiable sensory loss to vibration vaginal grafts or scar tissue formation at incision and thermal stimuli in the vagina after elective lines could result in stiffness or pain in the hysterectomy.11 Although such nerve disruptions vagina. Synthetic meshes used during repair may have not been correlated with changes in sexual contract, fold or extrude, and lead to a myriad function, a relationship between surgical damage of problems, including bleeding, discharge, pain, to these fibers and sexual function might be partner discomfort, low body image and sexual expected.12 dysfunction.27–29 The blood supply to these organs participates in sexual response. An intact arousal pathway involves appropriate blood flow and adequate engorgement, as well as transudative secretions across the vaginal Hysterectomy wall. A recent study assessed clitoral blood flow The impact of hysterectomy on subsequent sexual before and 6 months following tension-free vaginal function has been the subject of numerous review tape (Johnson and Johnson), as opposed to transob- articles and peer-reviewed research. Hypothetical turator tape procedures. The tension-free vaginal reasons for this relationship include the anatomic tape is passed via the retropubic space, in closer considerations outlined above, removal of the cervix proximity to clitoral tissue, while the transobturator and perception that this structure is involved in the sub-urethral tape is placed through the obturator sexual response, and concerns that the uterus membrane, potentially avoiding this area. Indeed, contributes to a sense of well-being and femininity. clitoral blood flow was reduced after tension-free Loss of sexual function is a major cause of anxiety vaginal tape.13 Others have shown iliohypogastric for women scheduled for hysterectomy.30 Indeed, and pudendal arterial blood flow may be compro- physician education is critical to mitigate this stress; mised following radical as opposed to simple a recent study showed that education about possible abdominal hysterectomies.14 However, in neither negative sexual outcomes predicted overall satisfac- study did these changes result in subjectively tion with hysterectomy.31 diminished arousal. Unfortunately, despite the significance of this The role of estrogens and androgens have been issue, the literature is not consistent or clear. Many well established with respect to parameters such studies assessing the impact of hysterectomy use a as lubrication, libido and orgasm.15–17 Removal of variety of different techniques, including supracer- ovaries prior to natural menopause induces im- vical/subtotal, total, laparoscopic, abdominal, vagi- mediate loss of these important hormones. In nal, with and without oophorectomy. In 2000, a addition, the postmenopausal ovary continues to review by Farrell and Kieser32 demonstrated that the secrete androgens,18 thereby leading to the possibi- available research was of poor quality. Most reports lity that removal of the ovaries at any time in a suggested sexual function and quality of life woman’s life could result in changes in sexual improved or were unchanged following hysterect- function. omy. The variables felt to impact sexual function Vaginal topography may be impacted by surgical significantly included a good partner relationship repair. Studies have suggested that normal vaginal and preoperative dysmenorrhea.33,34 length ranges between 41 and 95 mm,19 with significant variation in length as well as width throughout the vagina. Although there is no con- sistent length that has been found to correlate with Total hysterectomy and sexual functioning poor sexual function,20 certainly discomfort and In 1999, JAMA published a prospective study of apareunia after these procedures has been docu- hysterectomy and sexual function,35 which was mented.21 Surgical repairs, including Burch colpo- completed by 1101 women. A validated question- suspension, anterior colporrhaphy, sub-urethral naire was developed and addressed pain with sling and posterior colporrhaphy, have all been intercourse, orgasm, dryness and libido 2 years after found to cause structural changes of the vagina and surgery. Procedures were performed both vaginally adverse symptoms with intercourse.8,22,23 and abdominally, 44% with BSO. The authors International Journal of Impotence Research Gynecological surgery and female