Sexual dysfunction is challenging for patients and clinicians. Just as sexual function is multidimensional—with physical and psychosocial elements—sexual dysfunction can likewise have multiple contributing factors, and is often divided into dysfunction of desire, arousal, orgasm, and sex-related pain. Addressing each of these dimensions of sexual dysfunction in relationship to pelvic reconstructive surgery is beyond the scope of this article. Here, we focus on aspects of sexual dysfunction most likely to be reported by patients after surgery for pelvic organ prolapse (POP) or urinary incontinence, or for both. We discuss what is known about why sexual dysfunction develops after these procedures; how to assess symptoms when sexual dysfunction occurs; and how best to treat these difficult problems.
CASE Postoperative sexual concerns
Your 62-year-old patient presents 2 weeks after vaginal hysterectomy, uterosacral vault suspension, anterior and posterior colporrhaphy, and retropubic midurethral polypropylene sling placement. She reports feeling tired but otherwise doing well.
The patient returns 8 weeks postoperatively, having just resumed her customary exercise routine, and reports that she is feeling well. Upon questioning, she says that she has not yet attempted to have sexual intercourse with her 70-year-old husband.
The patient returns 6 months later and reports that, although she is doing well overall, she is unable to have sexual intercourse.
How can you help this patient? What next steps in evaluation are indicated? Then, with an understanding of her problem in hand, what treatment options can you offer to her?
Surgery for pelvic-floor disorders and sexual function
The impact of surgery on sexual function is important to discuss with patients preoperatively and postoperatively. Because patients with POP and urinary incontinence have a higher rate of sexual dysfunction at baseline, it is important to know how surgery to correct these conditions can affect sexual function.1 Regrettably, many studies of surgical procedures for POP and urinary incontinence either do not include sexual function outcomes or are not powered to detect differences in these outcomes.
Native-tissue repair. A 2015 systematic review looked at studies of women undergoing native-tissue repair for POP without mesh placement of any kind, including a midurethral sling.2 Based on 9 studies that reported validated sexual function questionnaire scores, investigators determined that sexual function scores generally improved following surgery. Collectively, for studies included in this review that specifically reported the rate of dyspareunia before and after surgery, 47% of women reported improvement in dyspareunia; 39% reported no change; 18% reported deterioration in dyspareunia; and only 4% had de novo dyspareunia.
Colporrhaphy. Posterior colporrhaphy, commonly performed to correct posterior vaginal prolapse, can narrow vaginal caliber and the introitus, potentially causing dyspareunia. Early description of posterior colporrhaphy technique included plication of the levator ani muscles, which was associated with significant risk of dyspareunia postoperatively.3 However, posterior colporrhaphy that involves standard plication of the rectovaginal muscularis or site-specific repair has been reported to have a dyspareunia rate from 7% to 20%.4,5 It is generally recommended, therefore, that levator muscle plication during colporrhaphy be avoided in sexually active women.
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