Impact of Gynecological Surgery on Female Sexual Function

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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 hysterectomy, 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 consistent 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 sexual function RN Pauls 107 reported the frequency of sexual relations to have including decreased frequency of intercourse, de- increased, while dyspareunia decreased dramati- creased sexual desire and difficulty with orgasm. cally from 41 to 15%. Strength of orgasm, libido and However, these findings were attributed to increas- vaginal dryness improved. Pre-hysterectomy depres- ing age and menopausal status rather than surgical sion and dyspareunia were associated with poorer technique. sexual function after surgery. Others have also attempted to compare total and Goetsch36 conducted a prospective study asses- supracervical (subtotal) hysterectomy. Kupperman sing the effect of total hysterectomy on specific et al.43 published the findings of the TOSH Research sexual sensations. One hundred and five women Trial, which randomly assigned 135 women to either were followed up to 18 months after total hyster- a total or supracervical procedure. The primary ectomy (abdominal and vaginal) and completed outcome was sexual functioning at 2 years as a mailed survey. Thirty-four percent had removal assessed by the Sexual Problems Scale. Secondary of their ovaries and took supplemental estrogen. The outcomes included health-related quality of life at author specifically outlined the details for seven 6 months and 2 years. Although groups differed at women with distressing sexual changes, including baseline with respect to sexual function, by 2 years diminished arousal, difficulty achieving orgasm and there were no significant differences. Both the low desire. The vast majority was enthusiastic for groups demonstrated substantial improvement in the benefits and had improved sexual satisfaction. most health-related quality-of-life measures. Unfor- Several other studies have addressed this ques- tunately, this study was not blinded, potentially tion, and shown improvements in sexual function leading to bias. Nevertheless, this still provides after hysterectomy.37,38 In contrast, Celik et al.39 reassuring confirmation that the cervix is not critical described the effect of hysterectomy and BSO on the to sexual function. parameters of the Female Sexual Function Index in Laparoscopy-assisted vaginal hysterectomy and postmenopausal women. Ninety-two women under- supracervical laparoscopic hysterectomy were com- went vaginal or abdominal hysterectomy and BSO, pared in a randomized controlled trial assessing with half of them using hormone replacement. In sexual pain and psychological outcomes.44 These subjects who underwent vaginal hysterectomy, researchers used two additional groups: non- scores in the domain of orgasm significantly surgical controls and subjects undergoing minor worsened. In the abdominal hysterectomy group gynecological surgery. Postoperative follow-up desire, arousal, lubrication, satisfaction and total was approximately 6 months after surgery. In both scores deteriorated. However, data were not avail- hysterectomy groups, the parameters of sexual able beyond the 6-month period. functioning did improve, as did pain abdominally and during pelvic exams. Although some adverse effects were noted in psychosocial well-being after Total versus subtotal/supracervical hysterectomy surgery, these were not different from those in the The role of the cervix in intact sexual response is controls. controversial. Early reports suggested that removal Finally, Gorlero et al.45 compared subtotal and of this structure could lead to changes in the total hysterectomy in 105 women with 1-year follow intensity of orgasm for some women. Several studies up in a randomized, controlled trial. Validated have thus sought to answer this important question. surveys were used for body image, sexual activity Thakar et al.40 published in The New England and quality of life. All surgeries were via laparotomy Journal of Medicine their report of total versus (abdominal incision) without removal of the ovaries. subtotal abdominal hysterectomy. Sexual function In both groups sexual activity improved after sur- was evaluated by a questionnaire designed by the gery. A modest, non-statistically significant differ- authors, and restricted to those who were sexually ence was noted between the groups with respect to active 12 months postoperatively. The frequency, pleasure from sexual intercourse, favoring subtotal desire, initiation of intercourse and sexual function hysterectomy. All women had notable improve- were not significantly different between the groups. ments in health-related quality of life and body Two subsequent papers were published reporting data image; however, body image was significantly better from this population.41,42 The first assessed quality in subjects who underwent subtotal hysterectomy. of life and psychiatric symptoms using validated questionnaires at 12 months. In both groups, quality of life improved in the majority of domains. A small Abdominal versus vaginal surgery difference in ‘emotions’ was noted between the Some authors have chosen to compare the route of groups, which showed greater improvement after hysterectomy to determine whether these impact subtotal hysterectomy. The final paper describes the sexual function differently. Roovers et al.46 assessed, 9-year follow up data for 65% of the subjects. There in a prospective manner, 413 women who under- were no long-term differences in outcomes between went vaginal, subtotal abdominal and total abdom- total and subtotal hysterectomy. Several changes inal hysterectomy. A 36-item questionnaire was were noted in sexual function, in both the groups, used to assess sexual function. Three hundred and

International Journal of Impotence Research Gynecological surgery and female sexual function RN Pauls 108 ten patients were sexually active after surgery and Hysterectomy versus minimally invasive treatments were included in the analysis. Non-significant differ- Several studies have assessed hysterectomy as ences were suggested in lubrication and sensation, compared with minimally invasive or medical which appeared worse in the laparotomy groups. New treatments. Kupperman et al. performed a multi- sexual problems occurred in nine women after center trial involving women with abnormal uterine vaginal, eight women after subtotal and 12 women bleeding who were dissatisfied with standard after total abdominal hysterectomy. The authors medical treatment. They randomized the women to concluded that sexual well-being does not depend hysterectomy or expanded medical therapy with on surgical technique and generally improves. estrogen and/or progesterone, and/or prostaglandin Another group prospectively assessed sexual synthesis inhibitor. Quality of life and sexual behavior, body image and satisfaction between functioning were measured. The authors had diffi- vaginal and abdominal procedures in 90 women culty with enrollment and retention of subjects. up to 2 years postoperatively.47 The vaginal hyster- Hysterectomy was superior to medical treatment in ectomy cohort also had concurrent anti-inconti- improvement of health-related quality of life after 6 nence procedures and prolapse repair. Outcomes months; half of the women randomized to medicine were assessed using validated questionnaires and elected to undergo a hysterectomy.50 telephone interview; however, over 30% of the Hehenkamp et al. assessed sexuality and body sample did not complete the validated question- image after uterine artery embolization or hyster- naires postoperatively. Both groups had improved ectomy for treating uterine fibroids in a randomized sexual function. Women in the abdominal group manner. The Sexual Activity Questionnaire and described dissatisfaction related to their scar and Body Image Scale were used. In both the groups more pain. Regression analysis revealed that sexual functioning and body image improved; postmenopausal status, frequency of sexual inter- however, significant increases were seen more often course and severity of preoperative gynecological in the uterine artery embolization group.51 complaints were associated with improved sexual Others conducted a large study comparing hyster- outcomes. ectomy with endometrial ablation for dysfunctional uterine bleeding. This was a prospective cohort of over 11 000 women, of whom 8900 completed Oophorectomy and sexual function questions related to psychosexual function 5 years The role of oophorectomy in subsequent sexual after treatment. Psychosexual problems were function is very difficult to assess independent higher after hysterectomy than after ablation, and of hysterectomy. Bellerose and Binik48 assessed five appeared to be more prevalent in those who under- groups of women: (i) hysterectomy only; (ii) hyster- went concurrent BSO despite hormone replacement ectomy with BSO and no estrogen; (iii) hysterect- therapy.52 omy, BSO and estrogen replacement; (iv) Finally, hysterectomy and levonorgestrel intrau- hysterectomy, BSO and androgen/estrogen replace- terine device were compared for women with ment (v) and non-surgical controls. The authors menorrhagia in a randomized, control trial. The interviewed subjects to document mood, body image McCoy Sexual Scale was used to evaluate sexual and sexual functioning. All surgical groups had functioning 5 years after intervention. In women more sexual problems than in the control group treated by hysterectomy, sexual satisfaction im- between 4 months and 5 years post surgery. The proved, while it decreased in the intrauterine device worst body image was seen in the untreated group users. The authors concluded that hysterectomy was (ii), while the untreated and estrogen groups (ii and superior to intrauterine device in terms of sexual iii) also had lower desire and arousal than the other functioning when treating menorrhagia.53 three groups as evidenced from self-report. Teplin et al.49 described the impact of oophorectomy on health-related quality of life and sexual Summary functioning (sub-analysis of subjects in the TOSH The results of the studies, although varied in Trial) in premenopausal women. At 6 months post terms of design and inclusion criteria, generally surgery, the BSO group had less improvement in show that sexual function, quality of life and body image, sleep problems and mental components body image improve following hysterectomy. of the SF-36. There were no differences in sexual Although some suggested greater improvements functioning between the groups. By 2-year follow- after subtotal hysterectomy, this was not consis- up these differences were no longer evident. Use of tently shown. While BSO may adversely affect hormones was noted in 56% of the BSO group at 6 certain outcomes, even in women who undergo months, which declined to 45% at 24 months. The hormone replacement, the difference may decline authors conclude that while there are some differ- over time. Further research, with attempts to ences in the initial postoperative period for those control for oophorectomy, as well as mode of who undergo BSO, these appear to diminish over surgery, in a prospective, randomized manner time. would be beneficial.

International Journal of Impotence Research Gynecological surgery and female sexual function RN Pauls 109 The literature also suggests that, while medical Post-sterilization regret was the only factor to be management and intrauterine device may be inferior associated with negative impact on sexuality.55 to hysterectomy when discussing sexual function, minimally invasive procedures such as uterine artery embolization and ablation could be a better Surgical treatment for stress incontinence and option, due to reduced pain and preservation of sexual function ovarian function. However, available data in this Urinary incontinence has been associated with aspect of the field are too scant to formulate any firm increased prevalence of sexual dysfunction. Reasons conclusions. include impairment in body image, social isolation, loss of spontaneity and fear of leakage with coitus.56,8 Several authors have therefore assessed Tubal sterilization and sexual function the impact of stress urinary incontinence repair on Few authors have assessed the impact of tubal subsequent sexual function using prospective (Table 1) sterilization on sexual function. Basgul et al.54 and retrospective designs.57–62 conducted a retrospective study of women who The results of most studies suggest that sexual had tubal sterilization over a 5-year period, and symptoms, sexual activity and sexual function queried regarding sexual function by telephone either improve or are unchanged following surgery interview. Tubal ligations were performed both for stress incontinence. Physical improvements of laparoscopically and during cesarean delivery. The coital incontinence, urinary frequency and inter- authors reported that 23% noted changes in their ference with sexual activity may be responsible for sex life, with 13% describing these changes as most benefit. Despite this, some studies do suggest negative. Costello et al. performed an analysis of deterioration, possibly due to decreased genital 4576 women who were enrolled in a prospective, sensation, altered lubrication, mesh extrusion and multicenter cohort study and assessed whether dyspareunia. Sub-urethral sling procedures are interval tubal sterilization lead to change in female anatomically distinct from retropubic suspensions, sexual interest or pleasure. Two questions were used such as the Burch and Marshall–Marchetti–Krantz, to compare sexual function. Most women did not and may lead to different symptoms. Further report any changes; however, in those who did, research is needed to confirm whether surgical positive effects were more common than negative. approaches for incontinence have minor detrimental

Table 1 Studies assessing sexual function after anti-incontinence surgery; prospective

Authors No of pts Follow-up Type of Surgical procedure Results (months) questionnaire

Iosif,65 1988 156 12–24 Non-validated Burch Sexual problems declined from 30 to 10% Berglund,66 1996 45 12 Non-validated MMK and Sexual frequency unchanged, majority satisfied pubococcygeal repair Berglund,67 1996 45 12 Non-validated MMK and Improved desire, pain; increased orgasmic pubococcygeal repair dysfunction Lalos,68 2001 45 60–84 Non-validated MMK and 79% sexually active, majority satisfied despite pubococcygeal repair recurrence of incontinence in 35% Yeni,69 2003 32 6 IFSF TVT Worsening in orgasm, pain and satisfaction scores after surgery; unchanged desire and arousal Mazouni,70 2004 55 6 Non-validated TVT 20% deterioration, 14.5% dyspareunia, may have been due to vaginal scar Ghezzi,71 2005 53 6 Italian TVT Increased sexual frequency, improved coital translation of incontinence, only two patients deteriorated (one PISQ extrusion, one dyspareunia) Pinto,72 2007 64 6 FSFI ‘Sub-urethral support No significant change in overall scores, 52% noted techniques’ improvements, 16% unchanged, 32% worsened Jha,73 2007 54 6 PISQ-31 TVT and TVT-O Improved PISQ scores, no difference between two techniques Pace,74 2008 108 12 FSFI TVT and Monarc TOT Significant improvements in both groups Cayan,75 2008 94 6 þ FSFI Vaginal sling and Deterioration in both groups, worse in Burch Burch Brubaker,76 2009 297 24 PISQ-12 Burch and autologous Improvement in PISQ scores; successful surgery sling associated with better function Jha,77 2009 62 3 EPAQ TVT Improvement in coital incontinence, reduction in lower urinary tract impact on sex

Abbreviations: EPAQ, Electronic Personal Assessment Questionnaire; FSFI, Female Sexual Function Index; IFSF, Index of Female Sexual Function; MMK, Marshall–Marchetti–Krantz; PISQ, Prolapse/Incontinence Sexual Questionnaire; TVT, tension-free vaginal tape (Johnson and Johnson J&J Inc.); TVT-O, tension-free vaginal tape-obturator (Johnson and Johnson J&J Inc.); Monarc TOT, transobturator tape (American Medical Systems AMS Inc.).

International Journal of Impotence Research Gynecological surgery and female sexual function RN Pauls 110 impacts on sexual function, and to assess whether The outcomes of pelvic organ prolapse repair with one technique is more beneficial. respect to subsequent sexual function are the least reassuring of all gynecological surgeries. Many studies suggest improved anatomic outcomes, which correlate with improved prolapse symptoms Surgical treatment for pelvic organ prolapse and on validated questionnaires. However, pain, partic- sexual function ularly related to the posterior colporrhaphy, may Many studies have assessed sexual function after affect sexual function adversely. Use of synthetic pelvic organ support repairs. Oftentimes pelvic graft material is still novel and the available data are organ prolapse and urinary incontinence coexist, conflicting as regards the impact on sexual function. and pelvic organ prolapse may, in its own right, The currently available validated instruments may impact body image or cause discomfort or inter- not be sensitive to the particular symptoms experi- ference with sexual activity.5,9,63,64 However, while enced after mesh placement, such as extrusion, surgical repair may correct the support problems, contraction and partner discomfort, leading to concerns of vaginal narrowing, potential for dyspar- difficulty in describing these. Further research to eunia and anatomic disruption exist (Table 2). better document, in a standardized manner, will be The usage of vaginal grafts, including synthetic helpful to this field. meshes, has become increasingly popular. The premise of reinforcing native tissue to reduce the risk of prolapse recurrence has been the emphasis Conclusion behind these repairs. However, concern for long- term outcomes, especially dyspareunia and extru- Gynecological surgery is an extremely common sion, have lead to hesitance to adopt these intervention for women and may be necessary to techniques (Table 3). treat pathology such as vaginal bleeding, painful

Table 2 Studies assessing sexual function after prolapse repair; prospective

Authors No of pts Follow-up Type of Surgical procedure Results (months) questionnaire

Haase,78 1988 55 6 Non-validated Anterior colporrhaphy, 91% improvement or no change, 9% colpoperineoplasty, deteriorated, attributed to posterior colporrhaphy Burch Holley,79 1996 36 15–79 Non-validated Sacrospinous and Three patients with apareunia due to narrowing, concomitant repairs most often due to concomitant repairs Gungor,80 1997 44 6 Non-validated Anterior colphorrhaphy Majority improved or unchanged; 18% with colpoperineoplasty deteriorated Weber,20 2000 81 6 Non-validated Burch/ sling with Burch with posterior repair was associated with posterior repair dyspareunia thought due to ridge formation in posterior vagina Shah,81 2005 29 7–37 FSFI Anti-incontinence No change in FSFI scores procedure±concurrent prolapse repair Helstrom,82 2005 45 12 McCoy IVS for incontinence; Deterioration in sexual function and frequency, inventory for Manchester for prolapse dyspareunia more common after prolapse repair sexual behavior Jeng,83 2005 158 6 Non-validated TVH versus sacrospinous No difference between groups; decreased uterine suspension frequency of orgasm with both Roovers,84 2005 62 6–12 ‘QSD’ Vaginal and abdominal Most improved; two patients with de novo correction problems Rogers,85 2006 75 3,6 PISQ-31 ‘variety’ PISQ scores improved, felt to be due to improved incontinence Stoutjesdijk,86 2006 67 14 Non-validated Variety of vaginal repairs Improved sexual function, decreased with anti-incontinence dyspareunia Pauls,87 2007 48 6 FSFI Vaginal prolapse repair FSFI scores unchanged, 25% incidence of with and without anti- dyspareunia postoperatively, possibly due to incontinence perineal pain and vaginal narrowing; no differences based on incontinence surgery Handa,88 2007 224 12 PISQ-12 Sacrocolpopexy with and Improvement in pelvic floor symptom without Burch interference with sexual function. Burch did not impact postoperative sexual function Azar,89 2008 67 3–4 FSFI Variety of vaginal Improvement in five FSFI domains; deterioration procedures in symptoms of dyspareunia

Abbreviations: FSFI, Female Sexual Function Index; IVS, intravaginal slingplasty; PISQ, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire; QSD, Questionnaire for Screening Sexual Dysfunctions; TVH, total vaginal hysterectomy.

International Journal of Impotence Research Gynecological surgery and female sexual function RN Pauls 111 Table 3 Studies assessing sexual function after synthetic mesh-augmented prolapse repair

Authors No of pts Follow-up Type of Study design Surgical procedure Results (months) questionnaire

Milani,90 2005 63 17 Two questions Prospective Anterior posterior High dyspareunia (63% with about pain and repair with posterior repair) and erosion activity polypropylene (13%) mesh augmentation Gauruder- 120 12 Validated 105 Prospective Apogee/perigee No change in sexual function Burmester,91 item (AMS Inc.) 2008 Nieminen,92 182 24 Non-validated Prospective Anterior repair Less dyspareunia in mesh group; 2008 with mesh versus mesh exposure 8%; vaginal no mesh, bulge symptom improvement concomitent better with mesh prolapse repair Sentilhes,93 83 12 PISQ-12 and Retrospective Variety of Improved sexual function 2007 Lemack procedures with questionnaire synthetic meshes Altman,94 2009 69 12 PISQ-12 Prospective Prolift (J&J Inc.) Worsening sexual function in behavioral-emotive and partner domains; dyspareunia unchanged Su,95 2009 33 6 PISQ-12 Prospective Prolift (J&J Inc.) Deterioration in sexual function, 73% worse after procedure

Abbreviation: PISQ, Prolapse/Incontinence Sexual Questionnaire. intercourse or pelvic organ prolapse. However, since Conflict of interest many procedures are elective, an understanding of the subsequent impact on sexual function is para- The author declares no conflict of interest. mount to the decision-making process. Despite significant improvements in many symptoms related to the disease pathology, improvements in sexual function are not always guaranteed and References occasionally there may be deteriorations. Sexual function is complex. Multiple factors 1 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the impact this in the context of a woman’s life, United States: prevalence and predictors. JAMA 1999; 281: 537–544. including body image, relationship, social situation, 2 Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muirch- partner sexual function, or availability of a partner, eartaigh CA, Waite LJ. A study of sexuality and health medications, hormonal changes and cultural expec- among older adults in the United States. N Engl J Med 2007; tations. Given this, it is often difficult to predict how 357: 762–774. 3 Pauls RN, Kleeman SD, Segal JL, Silva WA, Goldenhar LM, patients will respond following surgical interven- Karram MM. Practice patterns of physician members of the tion. Nevertheless, it is critical that research seek to American Urogynecologic Society regarding female sexual answer unresolved questions so that we may better dysfunction: results of a national survey. Int Urogynecol counsel patients. The current gaps include predic- J Pelvic Floor Dysfunct 2005; 16: 460–467. tive factors for deterioration of sexual function and 4 Biddle AK, West SL, D’Aloisio AA, Wheeler SB, Borisov NN, Thorp J. Hypoactive sexual desire disorder in postmenopausal comparisons of anatomically distinct techniques. women: Quality of Life and Health Burden. Value Health Improvement in design and selection of validated 2009, Jan 12 [E-pub ahead of print]. tools may reduce challenges for researchers in this 5 Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC. Sexual area, and enhance consistency and generalizability function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 2002; 99: 281–289. of the data. 6 Lowenstein L, Gamble T, Sanses TV, van Raalte H, Carberry C, The findings of this review suggest that following Jakus S et al. Sexual function is related to body image most gynecological surgery, sexual function im- perception in women with pelvic organ prolapse. J Sex Med proves. However, it is vital that physicians remain 2009; 6: 2286–2291. attuned to the potential for negative outcomes. 7 Pauls RN, Segal JL, Silva WA, Kleeman SD, Karram MM. Sexual function in patients presenting to a urogynecology Subjects who experience worsening should undergo practice. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17: thorough evaluation early in the postoperative 576–580. period. Treatment modalities for sexual dysfunction 8 Pauls RN, Karram MM. Sexual function following anti- following surgery should continue to be the focus of incontinence surgery. Minerva Urol Nefrol 2008; 60: 113–122. controlled trials so that we have available tools to 9 Pauls RN, Berman JR. Impact of pelvic floor disorders and mitigate these debilitating symptoms and their prolapse on female sexual function and response. Urol Clin impact on quality of life. North Am 2002; 29: 677–683.

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International Journal of Impotence Research Gynecological surgery and female sexual function RN Pauls 114 after anterior vaginal wall repair with or without polypropy- 94 Altman D, Elmer C, Kiilholma P, Kinne I, Tegerstedt G, lene mesh. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: Falconer C. Sexual dysfunction after trocar-guided transvagi- 1611–1616. nal mesh repair of pelvic organ prolapse. Obstet Gynecol 2009; 93 Sentilhes L, Berthier A, Sergent F, Verspyck E, 113: 127–133. Descamps P, Marpeau L. Sexual function in women 95 Su TH, Lau HH, Huang WC, Chen SS, Lin TY, Hsieh CH et al. before and after transvaginal mesh repair for pelvic organ Short term impact on female sexual function of pelvic floor prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2008; 19: reconstruction with the prolift procedure. J Sex Med 2009, 763–772. Jul 21 [E-pub ahead of print].

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