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Purpose: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including
decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve
orgasm. In this review we addressee the etiologies and incidence, evaluation and treatment of female sexual dysfunction
following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior
colporrhaphy, perineoplasty and vaginal vault prolapse.
Materials and Methods: Literature on the mechanisms by which vaginal surgery affects female sexual function are
discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and
introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular
damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunc-
tion following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal
fistula repair were also discussed.
Results: Current literature does not support an association between vaginal length following vaginal surgery and sexual
function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery
for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual
function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience
improved overall sexual function due to complete relief from coital incontinence
Conclusions: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall
sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect
specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible
etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.
Key Words: vagina, sexuality, bladder, urethra, reproductive and urinary physiology
he female sexual response cycle is a 3 phase model, lower urinary tract dysfunction and sexual difficulties.
Mean age 52 41 49 50
% Sexually active:
Preop Not given 100 100 91
Postop 68 95 100 86
% Sexual dysfunction:
Preop Not given 42 (dyspareunia) 33 (dyspareunia) 33 (dyspareunia), 39
(orgasm dysfunction),
55 (decreased
lubrication), 27
(decreased desire)
Postop 22 (deteriorated) 20 (deteriorated) 9 (dyspareunia) 28 (dyspareunia), 48
(orgasm dysfunction),
48 (decreased
lubrication), 20
(decreased desire)
Followup (mos) Mean 12 12–24 Mean 6 Mean 12
Adapted from Lemack and Zimmern10
study is required to determine how many women may have blood flow can cause vaginal smooth muscle fibrosis, result-
stopped sexual activity because of symptoms. ing in vaginal dryness and dyspareunia.11 In addition, any
surgical disruption of the iliohypogastric and/or pudendal
POST-PELVIC FLOOR arterial bed may result in compromised blood flow and sex-
SURGERY SEXUAL FUNCTION ual complaints. Compared to the emotional etiology the psy-
chological causes of sexual dysfunction include the entire
The maintenance of sexual function requires preservation of gamut of life stressors, past sexuality, mental health prob-
a vaginal length and caliber adequate for sexual intercourse. lems (eg anxiety, depression and other psychopathology re-
The surgical procedure and psychosocial issues may contrib- sulting in sexual dysfunction) and contextual factors, among
ute to altered sexual function following vaginal surgery. others.
Improvements in sexual function following vaginal surgery Colpoperineorrhaphy can result in dyspareunia due to
were believed to be due to the cessation of incontinence narrowing of the vagina.8 However, vaginal narrowing may
during intercourse, whereas worsening sexual function was not be entirely responsible for altered sexual functioning
believed to be caused by dyspareunia following perineorrha- and sexual dissatisfaction after vaginal surgery. Vaginal
phy. innervation is concentrated on the anterior and distal as-
pects of the vaginal wall.12 It may be affected by operations
Incidence and prevalence. Haase and Skibsted reported for SUI and paravaginal repair of cystocele that are typically
that 91% of 55 women who underwent anteroposterior re- directed toward this region. Others believe that altered sex-
pair or anteroposterior repair with colposuspension experi- ual functioning (dysfunction during the orgasm phase)
enced improvement or no change in sexual life following might be attributable to other causes, such as unreasonable
surgery for incontinence.8 Black et al noted that 78% of 355 expectations following surgery in women with SUI, of whom
women, of whom most had undergone colposuspension or many had preexisting sexual dysfunction.13
AC, considered that their sex life had improved or was same Vaginal narrowing/shortening following posterior repair
as their preoperative condition.9 has been reported to result in sexual dysfunction in 17% of
Lemack and Zimmern reported that 20% of women noticed the women surveyed.12 Lemack and Zimmern reported that
pain during intercourse following anterior vaginal wall sus- women on hormone replacement therapy are more than
pension for SUI, which was slightly lower than the preoper- twice as likely to be sexually active as those who are not.10
ative incidence of 29% (table 1).10 Of the patients 18% If not medically contraindicated, they recommended hor-
reported that intercourse was worse following surgery. The mone replacement therapy to optimize the likelihood of re-
investigators found that premenopausal and postmeno- maining sexually active or resuming sexual activity
pausal women on hormone replacement therapy were more following vaginal surgery for SUI. Strauss et al reported
likely to be sexually active following surgery than those not that sexual dysfunction following vaginal hysterectomy is
on hormone replacement (46% vs 17%). more likely to be related to preoperative psychological traits
than to the surgery.14
ETIOLOGY OF FSD
FOLLOWING VAGINAL SURGERY
ASSESSMENT OF SEXUAL FUNCTION
Sexual dysfunction may be affected positively or negatively
by surgical treatment for SUI. The causes of sexual dysfunc- The limitations of current methods of sexual function eval-
tion following vaginal surgery may be classified as organic, uation are their retrospective nature, that is mostly nonvali-
emotional and psychological. Organic causes are anatomical, dated questionnaires and assessment by telephone contact,
physiological, vascular, neural and hormonal factors. Clito- and inadequate followup (maximum up to 6 months). Only
ral and vaginal vascular insufficiency syndrome may result few methods, eg PISQ and IIQ-7 as used by Rogers et al,15
in decreased genital blood flow and in turn decreased pelvic are prospective and validated. PISQ assesses the effect of
442 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
TABLE 4. Sexual symptoms and conditions before and after defect specific rectocele repair
No/Total No. (%)
Preop Postop Improvement/Cure p Value
TABLE 5. Cure rates, and effects on bowel and sexual function in other studies
% Difficulty % Pelvic
Emptying Pressure % Vaginal % Fecal % Anatomical
References % Constipation Bowels Pain Lump % Splinting Incontinence % Dyspareunia Cure
Cundiff et al:*,46
Preop 46 39 13 29
Postop 13 16 15 25 8 19
Kahn and Stanton:23
Preop 22 27 64 18
Postop 33 38 22 36 33 27 76
Francis and Jeffcoate:22 30
Murthy et al:47
Preop 40 9 25 29
Postop 12 8 12 8
Mellgren et al:48
Preop 100 13 8 6
Postop 88 8 8 19
Janssen and van Dijke:49
Preop 37 30
Postop 54 33 82
Arnold et al:25
Preop 75 23 20
Postop transanal 54 4 38 21 80
Postop transvaginal 54 32 36 23 80
Adapted from Porter et al.17
* Site specific repair.
444 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
nold et al found no functional difference between a SPARCTM sling and they recommended abstinence from
transvaginal and transanal rectocele repair in terms of the sexual intercourse until spontaneous epithelialization over
incidence of vaginal tightness/sexual dysfunction, which was the mesh.27 On the other hand, Sweat et al suggested that
22% in each group.25 polypropylene tape erosion should be treated with complete
removal of the mesh.28
SUBURETHRAL SYNTHETIC VAGINAL TAPES
HYSTERECTOMY
The major vessels in the retropubic space and anterior ab-
dominal wall lay 0.9 to 6.7 cm lateral to tension-free vaginal Many women are concerned that hysterectomy may affect
tape needles. Mesh exposure can create dyspareunia and their sexual well-being or sexual attractiveness.29 Hysterec-
vaginal bleeding. At times the sexual partner complains of tomy has been reported as having adverse as well as bene-
penile pain or scratches after vaginal penetration. If the ficial effects on sexual well-being.21,30 –34
tension-free vaginal tape needle is too laterally aimed or Because hysterectomy disrupts the local nerve supply
rotated, major vascular injury can occur. Maaita et al re- and anatomical relationships of the pelvic organs, it has
ported no significant change in sexual function/activity after been thought that the function of these organs may be ad-
a TVT procedure in 67 women 6 to 36 months following versely affected. The idea that sexual well-being may differ
surgery.26 On the other hand, Yeni et al noted a statistically according to the type of hysterectomy is based on the hy-
insignificant decrease in the mean domain scores of the pothesis that the techniques damage the innervation and
Index of Female Sexual Function, namely desire, arousal, supportive structures of the pelvic floor differently. During
orgasm, pain and overall satisfaction, 6 months following a hysterectomy the pelvic plexus may be damaged in 4 ways.
TVT procedure.16 However, compared to controls all pa- 1) The main branches of the plexus passing beneath the
tients had a significant decrease in all scores except desire uterine arteries may be damaged during the division of the
and arousal following the TVT operation. Overall the sur- cardinal ligaments.35 2) The major part of the vesical inner-
gery negatively affected sexual function. The investigators vation, which enters the bladder base before spreading
believed that the TVT decreases genital sensation and vag- throughout the detrusor muscle, may be damaged during
inal lubrication or wetness, which may result in painful blunt dissection of the bladder from the uterus and cervix.35
intercourse and inevitably inhibit orgasm. 3) The extensive dissection of the paravaginal tissue may
disrupt the pelvic nerves passing from the lateral aspect of
the vagina.36 4) The removal of the cervix may result in the
POST-VAGINAL SURGERY FEMALE
loss of a large segment of intimately related plexus.36 Auto-
SEXUAL DYSFUNCTION: PROSPECTIVE DATA
nomic and somatic neural disruption of the upper vagina
In a multicenter, prospective study of sexual function follow- may interfere with lubrication and orgasm. However, Gutl
ing surgery for stress incontinence and/or POP Rogers et al et al reported that sexual desire and activity increased pro-
reported mixed results with improved sexual function in gressively during a 2-year postoperative period, accompa-
21% of women and worsened function in 22% using 2 vali- nied by decreases in dyspareunia, vaginismus and
dated, condition specific questionnaires (PISQ and IIQ-7) anorgasmia.37 Rhodes et al found increased sexual activity
preoperatively, and 3 and 6 months after surgery in 102 with more women experiencing orgasm following surgery
women with a mean age of 47 years.15 They brought forth than preoperatively.21 Kilkku et al observed that supracervi-
the caveat of postoperative anatomical measures as indica- cal hysterectomy can have a limited impact on sexual function
tors of sexual function. Of the women 4% had normal compared with abdominal hysterectomy.32 Berman reported
arousal after surgery compared to 83% preoperatively. The that nerve sparing hysterectomy (sparing the autonomic pelvic
incidence of women reporting weekly sexual desire de- nerves) may prevent sexual and bladder function.38
creased from 63% to 11%, arousal with sexual activity de- Dragisic and Milad reported no change in sexual desire,
creased from 83% to 4% and the frequency of orgasm orgasm frequency or orgasm intensity in 75 patients follow-
universally decreased, although reportedly the intensity did ing hysterectomy.39 Cosson et al noted that many long-term
not change. Positive changes included an improved rate of complications following hysterectomy, including the worsen-
coital incontinence (from 60% to 25%) and no dyspareunia. ing of all urinary problems, digestive problems and sexual
Decreased postoperative sexual function scores are signifi- intercourse, cannot be attributable to the intervention.40
cant in view of the younger age of the study population and They believed that vaginal hysterectomy should not be con-
the fact that patients did not report more pain with sexual sidered responsible for major complications appearing dur-
activity after surgery. The investigators hypothesized that ing the first 4 years of followup. Strauss et al noted that the
the change in the perception of genital health of the women sexual consequences of hysterectomy are more likely to be
due to surgical alteration of the genitalia and the fear of predicted based on psychological traits that existed before
harming themselves by engaging in sexual activity after surgery.14
surgery were the contributing factors, coupled with the part-
ner fear of harming the women following vaginal surgery. VAGINAL VAULT SUSPENSION
Vaginal erosion of slingplasty and FSD. Vaginal ero- Vaginal repair of vault prolapse may result in a narrowed
sion of various synthetic slings, which occurs in 1% to 12% of and shortened vagina with decreased function. Abdominal
cases, can mechanically contribute to sexual dysfunction. sacral colpopexy attaches the vaginal apex to the sacral
Often the male partner feels the tape first during penile- promontory and restores the physiological position of the
vaginal penetration. In a recent article Kobashi and Govier vagina. Geomini et al noted that only 10 of 27 patients (37%)
reported nonoperative management of vaginal erosion using were symptom-free at followup of those with a combination
FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY 445
of preoperative symptoms of vaginal protrusion, sexual dys- inal stenosis. Many clinicians argue that posterior
function, urinary incontinence and defecation problems com- colpoperineorrhaphy may be unnecessary for low grade pos-
pared to success in 13 of 14 (93%) with only vaginal terior compartment POP. Some data indicate that defect
protrusion as the presenting symptom.41 specific posterior colporrhaphy with the avoidance of levator
Holley et al reported that SSLF did not predispose to ani plication may improve sexual function.
dyspareunia unless vaginal narrowing due to repair of asso- A perception of genital health change due to surgical
ciated defects was present.12 Paraiso et al noted that ap- alteration of the genitalia and fear of harming themselves by
proximately 20% of 243 women who underwent SSLF had engaging in sexual activity after surgery are the contribut-
sexual dysfunction before surgery.42 Long-term (74 months) ing factors, coupled with the partner fear of causing harm
followup in patients following surgery revealed worsening following vaginal surgery. Counseling might have a crucial
sexual function.43 The inconsistency in data reporting may role in returning these women to their preoperative level of
have resulted in variations in outcome data and prospective sexual function.
studies with validated questionnaires are indicated. The relationship between dyspareunia, vaginal dryness
and sexual function in postmenopausal women and the in-
MARTIUS FLAP HARVEST fluence of hormone replacement therapy need further re-
search. Future prospective long-term studies should focus on
Petrou et al reported that Martius flap harvest in women is postoperative vaginal changes associated with aging,
not associated with a significant perceived cosmetic disfig- changes in sexual activity and estrogen use with respect to
urement of the labium majus and it has little effect on sexual symptoms and sexual dysfunction.
relations despite associated numbness and decreased sensa-
tion at the harvest site in 62% of their patients.19 Only 1 of ACKNOWLEDGMENT
8 women reported interference with coital relations due to
associated pain. They believed that concomitant transvagi- Lianne Krueger Sullivan provided the illustrations.
nal urethrolysis rather than Martius flap harvest was the
culprit.
A Martius flap is also used for transvaginal (vesicovagi-
Abbreviations and Acronyms
nal and rectovaginal) fistula repairs. Elkins et al reported a
25% incidence of dyspareunia over the Martius flap harvest AC ⫽ anterior colporrhaphy
site following fistula repair.44 They noted a dual blood sup- FSD ⫽ female sexual dysfunction
IIQ-7 ⫽ Incontinence Impact Questionnaire-7
ply for the Martius graft, posterior labial branches of the
nNOS ⫽ neuronal nitric oxide synthase
internal pudendal artery and vein posteroinferior, and PISQ ⫽ Pelvic Organ Prolapse Urinary
branches of the external pudendal vessels anterosuperior. Incontinence Sexual Questionnaire
Webster et al reported decreased sensation at the labial POP ⫽ pelvic organ prolapse
harvest site in 17% of cases when a Martius flap was used for SSLF ⫽ sacrospinous ligament fixation
post-urethrolysis interposition.43 SUI ⫽ stress urinary incontinence
TVT ⫽ tension-free vaginal tape
CONCLUSIONS
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