Female Sexual Dysfunction Following Radical Cystectomy: A New Outcome Measure Craig D. Zippe, M.D., and Rupesh Raina, M.D. utcome measures follow- validated for assessment of data suggest no significant dif- of the vagina (vs. posterior flap Oing radical cystectomy male sexual dysfunction. Spe- ference between the Indiana rotation) to preserve vaginal (RC) have focused primarily cific domains include vaginal and Studer pouch diversions. depth and maintain pain-free on cure, urethral recurrence lubrication, orgasm, dyspare- Thus, the benefit in preserving intercourse. and continence. However, sex- unia, sexual desire and over- the anterior vaginal wall and its While efforts have been ual dysfunction is a major all sexual satisfaction. neurovascular innervation in made to preserve the vaginal concern in many younger fe- With a mean follow-up of an attempt to preserve sexual neurovasculature, the use of male patients. During RC, the 24.2 months, IFSF score de- function is still unclear. oral therapy has not been ade- neurovascular bundles are creased from 17.4 to 10.6 (p ≤ Sexual dysfunction should quately explored. The success of usually removed or damaged 0.05) [see table]. Decreased sex- be used as an outcome measure oral PDE-5-inhibitor (sildena- due to their location in the ual desire was noted in 37%, following female RC, and urol- fil) therapy in males has anterior vaginal wall. Devas- decreased lubrication in 41%, ogists should be encouraged to prompted its use in females and cularization of the clitoris diminished ability or inability attempt neurovascular preser- may show promise for improv- with removal of the urethra to achieve or- may also affect subsequent gasm in 45%, IFSF Domains: Baseline and After Radical Cystectomy (n=27) sexual arousal and desire. and dyspareu- IFSF Domains Before radical cystectomy After radical cystectomy P-values Cleveland Clinic research- nia in 22%. Degree of vaginal lubrication 3.3 ± 1.90 1.6 ± 2.01* 0.0098 ers were among the first to Only 48% Ability to achieve orgasm 4.0 ± 1.83 2.2 ± 2.09* 0.0306 conduct studies addressing (13/27) of the Free of pain during intercourse 3.5 ± 1.99 2.0 ± 2.22 0.0711 sexual dysfunction in females women were Overall sexual desire 2.9 ± 1.30 2.1 ± 1.25 0.1262 undergoing cystectomy. Sexu- able to have Overall sexual satisfaction 3.7 ± 1.23 2.7 ± 1.53 0.0775 al response was stratified based successful Total mean IFSF Score 17.4 ± 7.23 10.6 ± 6.62* 0.0067 on the type of urinary diver- vaginal inter- *P<0.05 Responses were scored from 0 to 5; 0= no sexual activity, 1= rarely/occasionally, 2 = less than 1/2 the time, 3 = sometimes/1/2 the time, 4 = more than 1/2 the time, 5 = almost always. sion to determine if vaginal course, with and urethral sparing influ- 56% (15/27) enced sexual response. reporting decreased satisfaction vation in appropriate cases. Two ing the sexual quality of life in Baseline and follow-up in overall sex life after RC. Thir- domains in our IFSF question- women. Nitric oxide-mediated data were obtained from 27/34 ty percent of the patients expe- naire had significant declines: stimulation of clitoral caver- sexually active consecutive fe- rienced a decrease in desire for 1) ability to achieve orgasm/ nosal smooth muscle increas- male patients (mean age 54.79 sexual activity due to apprehen- sexual arousal and 2) the degree es clitoral blood flow and + 12.7 years) undergoing non- sion following cancer diagnosis of vaginal lubrication. A third results in genital engorgement nerve preserving RC. Thirteen and treatment. Preliminary domain—pain during inter- important in sexual arousal. patients were premenopausal data suggest no differences in course—dropped from a mean Thus, it is hypothesized that before radical cystectomy. Thir- sexual function between pa- of 3.5 to 2.0 (p=0.07). These sildenafil will subsequently ty seven percent (10/27) had a tients having Studer orthotopic data suggest that the following improve vaginal lubrication Studer orthotopic diversion, diversions vs. Indiana cutane- surgical modifications may be and sexual satisfaction. 26% (7/27) had a cutaneous ous diversions. appropriate in sexually active Our preliminary data es- diversion, and 37% (10/27) had The results demonstrate females: 1) routine preservation tablish a need for more research an ileal conduit diversion. that female sexual dysfunction of the distal urethra in all diver- in the area of FSD following Sexual dysfunction was is prevalent, with 52% of the sions in an effort to preserve the pelvic surgery. Clinical research assessed using a 10-item ver- preoperatively sexually active clitoral neurovasculature 2) is ongoing to analyze both sur- sion of the Index of Female females experiencing problems preservation of the anterior gical modifications and phar- Sexual Function (IFSF) ques- following RC. Whether the vaginal wall when reasonable to macological intervention in an tionnaire, which is patterned type of diversion affects sexu- maintain vaginal lubrication effort to better define the “qual- after the International Index al function remains to be de- and neurovascular innervation ity of life preserving” female of Erectile Function (IIEF) termined, but our preliminary and 3) tubular reconstruction cystectomy. www.clevelandclinic.org/urology | 13.