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Review Article *Corresponding author Melissa L. Dawson, Department of Obstetrics and Gynecology, Drexel University College of Medicine, The Impact of Pelvic Fellow, Female Pelvic Medicine and Reconstructive , 207 North Broad St, 4th floor, Philadelphia, PA Reconstructive Surgery for Pelvic 19107, USA, Tel: 215-863-8100; Fax: 215-587-6251; Email: Submitted: 10 April 2017 Organ and Urinary Accepted: 09 May 2017 Published: 11 May 2017 Copyright Incontinence on Female Sexual © 2017 Dawson et al. Dysfunction: A Review OPEN ACCESS Keywords 1* 1 1 Melissa L. Dawson , Rebecca C. Rinko , Nima M. Shah , and • Female Kristene E. Whitmore2 • Pelvic reconstructive surgery 1Department of Obstetrics and Gynecology, Drexel University College of Medicine, USA 2Department of , Drexel University College of Medicine, USA

Abstract Symptoms of sexual dysfunction are defined as a departure from normal sensations and/or function experienced by a woman during sexual activity. The diagnosis of urinary incontinence and/or along with their treatments can have a psychological impact. Surgical procedures may help resolve the symptoms of the diagnosis however can contribute to worsening sexual dysfunction. There is not much literature evaluating female sexual function pre or post-operatively on women undergoing these procedures. This review will discuss how surgical treatments for pelvic organ prolapse and/or urinary incontinence affect sexual function.

INTRODUCTION Definitions SUI and/or UUI that may impact sexual behavior. Women that undergo native tissue repair for POP may develop a shortened from wound healing or scarring leading to . The DSM-IV TR [1] classification system has been used for All pelvic surgical procedures have the potential to cause FSD many years to define female sexual dysfunction (FSD). The DSM- or acutely worsen persistent symptoms through a variety of 5 classification of FSD has now been published and definitions are proposedEvaluation mechanisms not well described in the literature. listed in (Table 1). The DSM-5 classification system is relatively new and no studies are available for evidence-based evaluation [2].Symptoms Signs of FSD include any abnormality indicative of disease or a health problem discoverable on examination [3]. Pelvic evaluation may display vaginal shortening and scarring which Symptoms of sexual dysfunction are defined as a departure may be the cause of a woman’s symptoms. Table (2) describes from normal sensations and/or function experienced by a woman the various signs encountered during vaginal examination that during sexual activity [3]. The type of sexual dysfunction depends may attribute to FSD. The procedure and the indication, position on procedure and indication. Sexual behavior and partner and mobility of the bladder neck, placement of meshes, tapes, and relationship must first be evaluated pre and post-operatively. implantsOutcome may measures impact FSD [3]. One must understand the psychological impact of the diagnoses of urinary incontinence and pelvic organ prolapse (POP) on an individual. After surgery, de novo symptoms may occur including A minimum demographic data set is recommended when coital incontinence (urinary and fecal), urge urinary incontinence documenting surgical outcomes to ensure more consistent (UUI), sexual dysfunction, dyspareunia, and partner dyspareunia. reporting including age, parity, BMI, hormone replacement Symptoms may vary as each preoperative diagnosis indicates a therapy (HRT), prior , prior POP surgery, prior specific treatment plan. For example, women that undergo a mid continence surgery, chronic cough, chronic constipation, and urethral sling for stress urinary incontinence (SUI) may develop smoking history [3]. Composite outcome measures for the mesh extrusion into the vagina, mesh contracture, worsening correction of POP include pelvic organ prolapse quantification Cite this article: Dawson ML, Rinko RC, Shah NM, Whitmore KE (2017) The Impact of Pelvic Reconstructive Surgery for Pelvic Organ Prolapse and Urinary Incontinence on Female Sexual Dysfunction: A Review. JSM Sexual Med 2(1): 1006. Dawson et al. (2017) Email:

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Table 1:

DSM 5 Female Sexual Dysfunction Definitions modified from Association, A.P., Sexual Dysfunction, in Diagnostic and statistical manual of mental disorders. 2013: Washington, D.C. Female Sexual Interest/Arousal Disorder Lack of, or significantly reduced, sexual interest or arousal, as manifested by at least 3 of the following: 1. Absent or decreased interest in sexual activity. 2. Absent or decreased sexual/erotic thoughts or fantasies. 3. Absent or decreased initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate. 4. Absent or decreased sexual excitement or pleasure during sexual activity in almost all (approximately 75%–100%) sexual encounters. 5. Absent or decreased sexual interest or arousal in response to any internal or external sexual and erotic cues (e.g., written, verbal, visual). 6. Absent or decreased genital or nongenital sensations during sexual activity in almost all (approximately 75%–100%) sexual encounters. Persistent or recurrent difficulties with 1 or more of the following: 1. Vaginal penetration during intercourse. 2. Marked vulvovaginal or pelvic during vaginal intercourse or penetration attempts. Genito-/Penetration Disorder 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. 4. Marked tensing or tightening of the muscles during attempted vaginal penetration. Presence of either of the following on all or almost all (75-100%) occasions of sexual activity: Female Orgasmic Disorder 1. Marked delay in, marked infrequency of, or absence of orgasm. 2. Markedly reduced intensity of orgasmic sensations. Table 2:

Physical Exam Signs That May Attribute to FSD, modified from Haylen, B.T., et al., An International Urogynecological Association (IUGA)/ Sign Definition International Continence Society (ICS) joint report on the terminology for female . Neurourol Urodyn. 2010; 29: 4-20.

Exam for urinary incontinence best performed with comfortably full bladder Urinary incontinence Observation of involuntary loss of urine Exam for POP performed with empty bladder and in lithotomy position Descent of one or more compartments of vaginal walls including apex described Pelvic organ prolapse using POP Q Staging system Exam for urethral pathology best with empty bladder Urethral caruncle Eversion of the urethral urothelium Lump or tenderness along urethral or external urethral discharge during Urethral diverticulum urethral massage

Exam for vagina includes length and mobility, presence of scarring and/or pain and estrogenization Vaginal dermatoses Apparent skin changes, biopsy confirms diagnosis in most instances Vaginal atrophy Distinct skin changes including paleness and loss of physiologic discharge Vaginal cysts (Gardners or Bartholins) Observation of mass in appropriate location Includes, but not limited to, vaginal mesh, menstrual tampon, devices, Vaginal foreign body etc Exam of pelvic floor muscles Overactive pelvic floor muscles Muscles which do not relax Underactive pelvic floor muscles Muscles which cannot voluntarily contract Non-functioning pelvic floor muscles Muscles where there is no action palpable Perineal descent Seen on valsalva; vulva, perineum and anus move outward Anal sphincter laceration Drooping or gap seen in the anal sphincter on digital exam Neurologic Exam Normal perineal sensation, normal levatorani and anal sphincter squeeze Pelvic plexus injury strength, normal bulbocavernosus and anal wink reflexes, anal sphincter resting tone may be decreased Parkinsons disease Bowel and bladder dysfunction Lower extremity hyperreflexia, sensory loss, weakness consistent with location Spinal cord lesions of injury JSM Sexual Med 2(1): 1006 (2017) 2/8 Dawson et al. (2017) Email:

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(POP-Q) to the hymen, bulge symptoms, and re-operation rate. independent of diagnosis or therapy for urinary incontinence Sexual data are usually secondary outcomes. The onset, duration, or prolapse [6,20,21]. The effect of surgery on sexual function is severity, level of personal distress, improvement after surgery, of significant interest as demonstrated by an increased number frequency of sexual activity, and de novo sexual dysfunction and of abstracts reporting with female sexual function over the past dyspareunia should be recorded. In these cases, sexual function 15 years. There is a need for focused research regarding sexual remains the same post-operatively or improves in most cases. function and dysfunction [5,22]. Providers should use the tool that is most appropriate for the Overall, there is a lack of randomized controlled trials (RCTs). patient’s specific situation and assess sexual function before and Outcome measures vary among the current literature [23]. There after surgery. is a lack of reporting per DSM-IV/ DSM-5 and lack of long-term The Female Sexual Function Index (FSFI-19) and Pelvic Organ follow-up. In many studies the Level of Evidence (LOE) is poor Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ) are andUrinary sexual incontinence dysfunction is often a secondary outcome measure. most commonly used to assess sexual function [4-6] although Stress urinary incontinence and midurethral slings: there are other options to assess sexual function. The FSFI-19 includes 19 questions in 5 domains which include desire, arousal, orgasm, pain, and satisfaction [7]. The Hoda et al., utilized the validated FSFI-19 as a primary outcome zero category was suggested as non-applicable in scoring [8]. to prospectively follow 96 sexually active women for 2 years The cut-off score for female sexual dysfunction is 26.55 and is not after undergoing a transobturator mesh implant. The FSFI- condition-specific [9]. The PISQ is a validated condition specific 19 scores initially decreased in the first 3 months, followed by questionnaire of 31 questions for pelvic floor disorders [10]. reported improvement in sexual function thereafter (p=0.023). There are abbreviated versions of these questionnaires such The positive outcomes in this study may have been influenced as PISQ [11] and PFDI and PFIQ [12]. In 2013, the PISQ-IUGA by the inclusion of only sexually active women, young age (mean Revised (PISQ-IR) was validated for sexually active (21 items) and age 51.4 years), and peri-operative use of topical estrogen [24]. non-sexually active patients (12 items), as well as patients with In a retrospective cohort evaluating sling revision surgery, 64% anal incontinence. Patients with pelvic pain were excluded. This of women were satisfied with surgery and had an improvement questionnaire provides information on the impact of pelvic floor in pain (p=0.04), dyspareunia (p< 0.001) and Patient Global disorders on sexual function, especially sexual inactivity. The Impression of Improvement questionnaire scores (p< 0.0001) Female Sexual Distress Score (FSDS) questionnaire measures the [25]. Pastore et al., conducted a prospective trial including 42 personal distress component of female sexual dysfunction. This is women randomized to tension-free transobturator suburethral assessed in a 12 item self- report questionnaire with 6 subscales tape or single incision sling. The FSFI-19 score increased [13]. The FSDS and FSFI-19 discriminates between women with significantly in all 6 domains in both treatment groups [26]. Sixty- and without sexual problems [14]. The FSDS-Revised increased three women who had a tension-free vaginal tape performed the sensitivity for patients with hypoactive sexual desire disorder for SUI completed PISQ-12 questionnaires pre-operatively and [15]. The Lemack questionnaire is an invalidated sexual function 6 months following surgery. PISQ-12 scores were significantly questionnaire including a question on coital incontinence [16]. improved (p< 0.05) and virtually cured coital incontinence post The McCoy sexual inventory for sexual behavior involves 9 operatively. The improvement in sexual function may be due to Coital urinary incontinence and midurethral slings: questions, regarding appreciation of the present extent of sexual the resolution of incontinence [27]. activity, sexual interest, enjoyment, excitement, orgasm, vaginal dryness, dyspareunia, ad partner relationship [17]. Finally, the Coital incontinence is present in 23-56% of incontinent women Male Sexual Health Questionnaire (MSHQ) is a 25 items survey and associated with decreased frequency of sexual intercourse with 4 domains; erection, ejaculation, satisfaction, and desire [28]. Improvement in coital incontinence after SUI surgery led with a higher score indicating better sexual function and may be to the greatest improvement in sexual function on the Lemack beneficialSurgical in treatment a complete evaluation and non-conservative for FSD [18]. minimally questionnaire [16] and was considered a prognostic factor in invasive treatment the success of incontinence surgery in a retrospective study of 136 sexually active women undergoing SUI surgery [29]. Coital incontinence decreased significantly following SUI surgery with Surgical procedures that may result in FSD include no significant improvement in sexual function in a metanalysis treatment of incontinence and pelvic organ prolapse. Other non- including 21 studies following tension-free vaginal tape (TVT), conservative, minimally invasive treatment procedures that tension-free vaginal tape-obturator (TVOT), tension-free may result in FSD include sacral neuromodulation, intravesical obturator tape (TOT), Burch, and autologous fascial sling (AFS) onabotulinumtoxinA injection, and percutaneous tibial nerve [23]. Several prospective studies utilizing the validated FSFI stimulationSurgical outcomes (PTNS). showed an improvement in sexual function and a significant decrease in coital incontinence following SUI surgery [23,30- 33]. TVT and single incision sling (SIS) improved FSFI scores Sexual function traditionally has not been mentioned in 6 months post-operatively in 150 patients [34]. The PISQ-12 surgical outcomes. Patients with urinary incontinence can was significantly decreased in 48% of 68 patients after TVOT report impairment in sexual function [19]. Prolapse is more procedure at 8 months follow-up [35]. PISQ-12 scores and coital likely to result in sexual inactivity and perceived to affect sexual incontinence improved in 78% of 53 patients with 6 months relations than urinary incontinence (UI). Sexual satisfaction is follow-up following TVT surgery for SUI. Absence of fear of JSM Sexual Med 2(1): 1006 (2017) 3/8 Dawson et al. (2017) Email:

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incontinence during sexual activity was significantly decreased between groups in coital frequency, satisfaction, ability to in womenStress undergoing urinary incontinence prolapse surgery and [27]. prolapse repai reach orgasm, or dyspareunia pre and post-operatively [46]. Alternatively, Altman et al., compared transvaginal mesh repair r: In a with anterior colporrhapphy showed the mesh to have higher prospective study of women undergoing SUI and POP surgery, success but also higher rates of surgical complications and post- 81 of 165 patients (49%) were sexually active pre and post- operative adverse events at 12 months follow-up. The PISQ-12 operatively. Post-operative introital caliber and length were scores at baseline were similar among both groups at baseline significantly decreased in women after surgery (p<0.001) and moderately improved and partner satisfaction at one year. however, were not correlated with sexual function measured De novo dyspareunia was found in 2% of the colporrhaphy group by dyspareunia, frequency of intercourse, vaginal dryness and andPosterior 7.3% in the repair mesh group (P = 0.07) [47]. satisfaction [5]. Celik et al., studied 116 women who underwent procedures for incontinence and/or pelvic organ prolapse and : Traditional fascial plication has been grouped patients into POP, UI, and UI + POP procedures. PISQ-12 described with and without levatorani plication to correct scores did not worsen among any of the groups, however there posterior defects. According to Paraiso et al., posterior wasPelvic a significant organ prolapse improvement in the UI and UI + POP groups [36]. colporrhaphy has a lower anatomic failure rate than site-specific fascial defect repair. The rate of dyspareunia was 20% in the posterior colporrhaphy group compared to 14% in the site- A third of sexually active women with POP complain that specific group [48]. Due to the increased risk of dyspareunia, prolapse interferes with sexual function [37]. The resolution levatorani plication should be rarely used in patients undergoing of POP symptoms after treatment can improve female sexual native tissue repair. There is insufficient evidence to support the function [38]. Multiple studies have shown that total and supra- use of specific surgical techniques base on defect [49]. Schimpf cervical hysterectomy have an equivocal impact on sexual et al., reviewed the use of graft and mesh use for posterior function [39-41]. Some have argued that rhythmic uterine defect repair and found there is no difference in anatomic and contractions at time of orgasm are pleasurable and are adamant quality-of-life outcomes when using synthetic absorbable mesh, about keeping their and [39]. Helstrom et al., synthetic nonabsorbable mesh, or biologic graft compared with evaluated 118 sexually active women who underwent surgery native tissue. Furthermore, data on sexual function outcomes do for UI or POP, of whom 88 had deterioration in sexual activity on not show a significant improvement with mesh or graft use [50]. the McCoy inventory for sexual behavior and a decreased sexual The most recent literature does not support the use of biologic frequency at 1 year follow-up. Dyspareunia was not significantly grafts in the posterior compartment [48,51]. In sexually active increased postoperatively but quality of life was improved [42]. women undergoing surgery for urinary incontinence and/or POP repair, a study found that 30 out of 73 women who underwent Jelovsek et al., evaluated the association between the posterior repair reported a higher dyspareunia rate compared modified body image scale (MBIS) and the PFDI demonstrating to women who did not have a posterior repair (57% vs 28%, that worse body image and the feeling of less sexually attractive respectively)Apical repair [52]. was correlated with POP [37]. Two hundred thirty-five women who had pessary treatment or POP reconstructive surgery : Apical repairs can be approached vaginally were followed 6 months after treatment. The surgical group or abdominally using open or laparoscopic/robotic techniques. had improved MBIS, PFDI, and PISQ scores as compared to the The gold standard approach is the abdominal sacrocolpopexy pessary group demonstrating an improvement in POP symptoms, in which polypropylene mesh is attached to the vagina. Mesh sexual function, and body image perception [38]. Women with a extrusion into the vagina is a known complication of the total vaginal length of less than 7cm post-operatively appear to sacrocolpopexy procedure and can occur up to 11%. The mesh have a negative impact on sexual function, so shortening of the extrusion rate depends on graft material, operator technique and vagina should be avoided [39]. Patients undergoing native tissue length of follow up [53]. Newer reviews report mesh extrusion as repair for POP had an improvement in the PISQ-12-SF of 72% 6 low as 2% [54]. Anterior repair: months post-operatively [27]. A metaanalysis of sexual function following uterosacral In a recent Cochrane review, there were ligament suspension was lacking in comprehensiveness [55]. no differences in de novo dyspareunia among native tissue and Silva f reported that of the 34 (47.2%) women that were sexually mesh augmented repairs for anterior prolapse [43]. Nguyen et active pre and postoperatively following uterosacral ligament al., found de novo dyspareunia was less in the anterior mesh suspension, 7 (20.6%) complained of dyspareunia preoperatively group than in the native tissue group post operatively, 9% that were cured after surgery. Seven patients described denovo vs 16% respectively after one year [44]. To further support dyspareunia after surgery that was associated with vaginal this finding, Weber et al., evaluated 16 patients after vaginal atrophy, tight introitus and decreased libido. Of the 31 who mesh placement at 6 month follow up and found mesh did not responded to the satisfaction domain on the FSFI, 29 (94%) decrease vaginal vasocongestion or vaginal wall sensibility under reported normal satisfaction [56]. erotic conditions. Sexual function was unchanged using various In the 2004 Cochrane review, Maher et al., found that validated questionnaires [45]. An RCT comparing anterior repair abdominal sacrocolpopexy was found to have less postoperative with and without mesh showed 100 of 202 patients (50%) were dyspareunia compared to vaginal colpopexies [57]. A prospective sexually active preoperatively with no significant deterioration randomized study with 95 women undergoing sacrocolpopexy at 3 years follow-up in both groups. There was no difference or sacrospinouscolpopexy showed 40% with pre-operative JSM Sexual Med 2(1): 1006 (2017) 4/8 Dawson et al. (2017) Email:

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dyspareunia had post-operative resolution of dyspareunia and In a small prospective pilot study, 43% (7 patients) had a de novo dyspareunia occurred in 5-7% of cases regardless of the significant increase in the FSFI score from 20.74 to 30.22 at 5.7 surgical approach [58]. months follow-up [67]. A significant improvement in FSFI and FSDS with a follow-up of up to 23 months was seen in 4 of 11 Maher’s follow up review in 2011 comparing abdominal neurogenics and 2 of 8 idiopathics with permanent SNS in sexually sacrocolpopexy to sacrospinous fixation shows similar active patients [68]. A prospective observational study of 167 results to the 2004 review. There was less dyspareunia in the women with voiding dysfunction showed a significant increase in sacrocolpopexy group than the sacrospinous group (RR 0.39, CI FSFI score at 12 months following SNS [69]. Another prospective 0.18 - 0.86) [43]. observational study of 23 sexually active women followed at least Newer studies such as Geller et al., reported 160 women 4 months after SNS showed a significant increase in the total FSFI undergoing pelvic surgery with mesh including abdominal and score (p=0.011) and the desire and orgasm component scores laparoscopic sacrocolpopexies, midurethral slings, transvaginal (p=0.014 and p=0.035, respectively). There was no correlation placement and concomitant mesh implants for POP and between FSFI scores and quality of life [70]. incontinence. Of the 54% that reported sexual activity, 19% Nine of 16 sexually active women undergoing SNS for fecal reported dyspareunia postoperatively. Pelvic pain at one year incontinence completed a non-validated Sex Life Questionnaire. after surgery was 15.8% however women with pain were All had a significant reduction in from 12 younger, with fibromyalgia, worse physical health and less to 1.5 episodes per week (p=0.008). Seven of the 9 sexually successful surgical outcomes (p< 0.5) [59]. active patients reported a median improvement of 40% in their Laparoscopic sacrocolpopexy procedures have limited data sexualityPercutaneous up to 36 months tibial nervefollow-up stimulation: [71]. especially reporting the rate of dyspareunia. In a small prospective Percutaneustibial study with 22 women undergoing laparoscopic sacrocolpopexy, nerve stimulation (PTNS) has been shown to be effective in no new onset dyspareunia was reported at 2 years [60]. Fewer treating overactive bladder (OAB), chronic pelvic pain (CPP), studies have reported sexual function outcomes following robotic and non-obstructive urinary retention. One hundred twenty sacrocolpopexy. Culligan et al., reported out of 64 patients that one patients with lower urinary tract dysfunction underwent were sexually active without dyspareunia preoperatively, 3 12 weeks of PTNS therapy prospectively. Men and women (3.7%)Mesh complications reported de novo dyspareunia at 12 months [61]. completed a validated sexual questionnaire, Sexual Functioning, and Dutch language version (NSF-9) in which sexual frequency and satisfaction were significantly improved in men however Pelvic organ prolapse recurrence after surgery led surgeons greater response was seen in women [72]. More recently, Musco to seek more durable interventions through the use of synthetic et al., conducted a prospective study for women with dry OAB mesh. In 2010, the Food and Drug Administration in the United receiving PTNS. All patients completed an FSFI, OAB-short States (U.S. FDA) placed a public health notification highlighting form questionnaire, and 24-hour bladder diary at baseline and the increase in reported complications associated with the use at 3 months. All FSFI domains showed statistically significant of vaginal mesh [62]. The prevalence of vaginal mesh exposure/ improvement in women with FSD. This study may show extrusion averages 10.3%, dyspareunia 9.1% and wound the improvement in urinary function did not correlate with granulation 7.8% [63]. The use of polytrafluroethylene and improvement in sexual function and possibly related to PTNS tobacco use was found to be a significant contributor to mesh treatmentChemodenervation rather than the with improvement Onabotulinumtoxin in OAB [73]. A erosion in a study evaluating risk factors following abdominal sacrocolpopexy [64].

Brubaker in 2006 coined the term “hispareunia” identifying OnabotulinumtoxinA has been used more recently to help partner dyspareunia in women with vaginal mesh exposure. treat symptoms of high-tone pelvic floor dysfunction (HTPFD) Partners have reported penile laceration and bleeding after associated with CPP. OnabotulinumtoxinA is a neurotoxin intercourse [65]. The specific effect of mesh complications on that acts on the presynaptic motor neuron and inhibits sexual function using validated questionnaires remains to be release of acetylcholine thus inducing muscle paralysis. A pilot determined.Non-conservative minimally invasive treatment study was conducted evaluating electromyographic guided Sacral neuromodulation: onabotulinumtoxinA injections into trigger points of patients with refractory high tone pelvic floor dysfunction. At 24 weeks Sacral nerve stimulation (SNS) after injection, 15 of 18 sexually active patients reported a was approved by the FDA for three indications; refractory urinary significant decrease in dyspareunia on visual analog scale for urgency/frequency, non-obstructive urinary retention, and fecal pain (7.8 to 5.4). The FSDS improved from 33.5 at baseline to incontinence. A lead with 4 electrodes is placed in the S3 foramen 22.6 at 24 weeks follow-up (p ≤ 0.001) [74]. In a randomized and tested for 1 to 3 weeks. If urinary/bowel symptoms are controlled trial in women with evidence of pelvic floor muscle more than 50% improved, an impulse generator is placed lateral spasm that received 80u of onabotulinumtoxinA or saline, to the sacrum. Neuromodulation of the pudendal, pelvic, and the VAS for dyspareunia decreased from 6.6 to 1.2 after intra- lateral femoral cutaneous nerves provide therapeutic decrease muscular injection of onabotulinumtoxinA with a follow-up of 6 in incontinence, urinary frequency, post void residuals [66]. The months [75]. level of evidence for sacral nerve stimulation and female sexual function is weak. OnabotulinumtoxinA intravesical injection is now JSM Sexual Med 2(1): 1006 (2017) 5/8 Dawson et al. (2017) Email:

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recommended as a third-line treatment of urinary urgency/ 8. Meyer-Bahlburg HF, C Dolezal. The female sexual function index: frequency. In a systematic review including a total of 11 studies a methodological critique and suggestions for improvement. J Sex Marital Ther. 2007; 33: 217-224. and 2149 patients, intravesical injections of 100 U compared to placebo showed a significant improvement in the treatment of 9. Wiegel M, Meston C, Rosen R. The female sexual function index (FSFI): urinary urgency/frequency at 12 weeks after injection. Adverse cross-validation and development of clinical cutoff scores. J Sex Marital Ther. 2005; 31: 1-20. events associated with onabotulinumtoxinA include urinary retention and urinary tract . There is no significant 10. Rogers RG, Kammerer-Doak D, Villarreal A, Coates K, Qualls C. A difference in rates between patients being treated with new instrument to measure sexual function in women with urinary 100SUMMARY U and those receiving higher doses [76]. incontinence or pelvic organ prolapse. Am J Obstet Gynecol. 2001; 184: 552-558. 11. Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C. A short Further metanalyses, prospective studies and RCTs are form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct. needed that address sexual function with the utilization of 2003; 14: 164-168. validated questionnaires. The recording of vaginal dimensions and their relevance are sparse in the current literature. The 12. Barber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric following are recommendations that should be collected with the evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet appropriate patient candidates to help assess sexual function and Gynecol. 2001; 185: 1388-1395. dysfunction: 13. Derogatis LR, Rosen R, Leiblum S, Burnett A, Heiman J. The Female • A standard minimum demographic data set should be Sexual Distress Scale (FSDS): initial validation of a standardized scale included. for assessment of sexually related personal distress in women. J Sex Marital Ther. 2002; 28: 317-330. • Validated questionnaires should be routinely included. 14. ter Kuile MM, Brauer M, Laan E. The Female Sexual Function Index • Study cohorts should be standardized in terms of (FSFI) and the Female Sexual Distress Scale (FSDS): psychometric compartment, procedures performed, and outcome data. properties within a Dutch population. J Sex Marital Ther. 2006; 32: 289-304. • Procedures should be standardized. 15. Derogatis L, Clayton A, Lewis-D’Agostino D, Wunderlich G, Fu Y. • Longer follow-up should be encouraged. 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Cite this article Dawson ML, Rinko RC, Shah NM, Whitmore KE (2017) The Impact of Pelvic Reconstructive Surgery for Pelvic Organ Prolapse and Urinary Incontinence on Fe- male Sexual Dysfunction: A Review. JSM Sexual Med 2(1): 1006.

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