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Sexual Function In Women with Pelvic Floor Disorders

Posted Sep 13 2008 4:20am
Urinary incontinence and/or pelvic organ prolapse affects nearly a third of premenopausal women and as many as 45% of postmenopausal women. The problems associated with incontinence and prolapse impacts the social, psychological, occupational, domestic, physical and sexual well-being of women. Studies of sexual function in women with incontinence and/or pelvic organ prolapse fall into two groups: those that concentrate on vaginal anatomy and those that evaluate sexual function. Just because the surgery is considered successful in repairing vaginal damage does not mean that the surgery has �cured� any sexual dysfunction. Much of the literature on sexual function in women with pelvic floor disorders is limited by its retrospective design, small numbers, and the bias of physicians who evaluate the outcome of their own operations. Until recently, evaluation of sexual function in women with pelvic floor disorders was also limited by the lack of a condition-specific validated questionnaire. Use of non-validated or general questionnaires to evaluate quality of life outcomes may have led to understatements of the effect on sexual function because of the questionnaires� insensitivity to differences within a specific group of women. Yet as interest in the impact of pelvic floor disorders on quality of life has grown, research into sexual function of patients with such disorders has expanded.


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The traditional model of sexual function for men and women is linear and includes four phases: desire, arousal, climax and resolution. Newer models describe a more circular relationship between satisfaction and intimacy. Although rates of sexual activity decline with age, population based studies indicate continued sexual activity in 47% of married women aged 66 �71 and a third of women over 78. The incidence of incontinence and prolapse are increased in these age groups. Factors which negatively influence sexual activity in elderly women include lack of a partner, erectile dysfunction of a partner, medical illness, and lack of a libido. Sexual dysfunction occurs in up to 35 percent of American women with lack of libido being the most common form Actual data on the sexual function of women with urinary incontinence is scarce. An evaluation of 103 female patients of an incontinence clinic found that 46% admitted urinary symptoms affected their sexual life. Women with overactive bladder problems (detrusor instability) were more likely to complain of vaginal pain (dyspareunia) than women with stress incontinence. Another evaluation of 400 incontinent women found many patients were reluctant to raise questions regarding sexual function with their providers, although urinary incontinence with sexual penetration or with orgasm was common. Recent studies comparing women with stress incontinence and overactive bladder found that women with overactive bladder report poorer sexual functioning than women with stress urinary incontinence. However, none of these studies used validated or reliable questionnaires and most were limited by small numbers of patients involved. A recent comparison of women with and without urinary incontinence and/or pelvic organ prolapse found that those with incontinence or prolapse reported less frequent sexual activity and a higher incidence of dyspareunia, although measurements of satisfaction with sexual activity were similar between groups. This study was the first to use a condition-specific validated and reliable questionnaire, but was limited by the lack of objective evaluation of prolapse or incontinence symptoms. In summary, incontinent women report incontinence with sexual activity and their incontinence may affect their sexual lives. Additionally, women with bladder control problems may have poorer sexual function than women with stress incontinence.

How does surgery for stress urinary incontinence affect sexual function? A prospective cohort study followed 55 patients after surgery for urinary incontinence. Of these patients, 24 % reported that their sexual function improved, 67% found their sex life unchanged, and 9% complained of deterioration of their sex life. Women who underwent posterior surgery were found to have more complaints of dysfunction than patients without posterior repairs. More recently, 45 women were followed prospectively after surgery for stress urinary incontinence. Both the partners�and the patients� attitudes following surgery were evaluated. Approximately one-third of women reported increased sexual desire following surgery for incontinence, while greater than 50% of men reported an increase in desire following their partner�s surgery. A large multicenter trial evaluated 360 women prior to and at three, six, and 12 months following surgery for stress urinary incontinence. The majority of women reported no change in their sex life following surgery, while 13% reported that their sex life improved and 22% reported that it deteriorated. Overall, prospective studies evaluating sexual function have revealed conflicting results regarding change in sexual function that does not seem to be linked to resolution of the patient�s incontinence.

Study of sexual function in women with prolapse has focused on postoperative measurement of vaginal length and caliber or on mechanical obstruction resulting from excessive narrowing following surgical repair. Comparison of vaginal anatomy and sexual dysfunction using a validated non-specific questionnaire found that vaginal anatomy did not correlate with sexual function scores, sexual satisfaction or complaints of vaginal pain. Although 14% of the women complained that prolapse or incontinence interfered with sexual activity, and increasing grade of prolapse predicted interference with sexual activity, women with prolapse or incontinence continued to be �satisfied� with their sexual relationship and did not change their frequency of intercourse.

Measurement of vaginal lengths following three different vault suspensions (abdominal sacrocolpopexy, sacrospinous ligament suspension or posterior culdeplasties) as well as the vaginal length of pre and postmenopausal women found that in all three operations several patients complained of vaginal �tightness�. In this series, vaginal lengths operated groups were not significantly different than those in a cohort of women who did not undergo surgery. Another retrospective series following women for up to 13 years found 19% of women reported sexual dysfunction preoperatively and 21% reported sexual dysfunction postoperatively. No measurable differences in vaginal length and caliber existed between women who complained of vaginal pain and those who did not, although 17% of patients had a constricted or shortened vagina on physical exam.


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Repair of the posterior compartment has received more attention than other prolapse surgeries for its negative effect on sexual functioning. A retrospective review of 100 surgeries including anterior and posterior repair found that, postoperatively, 61% of patients enjoyed �regular� intercourse, and 30% had stopped having sex. After posterior repair, a significant number of women had vaginas so narrowed that it precluded the ability to have intercourse and challenged the necessity of �routinely� performing a posterior repair. Another retrospective review compared women who underwent posterior repair with those who did not and found that excessive narrowing of the vagina was uncommon in the later group. Aparunea and dysparunea were common after prolapse surgery and up to 50% of women ceased intercourse after surgery. More recent studies have corroborated these findings.

The occurrence of vaginal narrowing following repair is not restricted to posterior repair. Approximately 14% of 69 women undergoing sacrospinous ligament suspension were afraid to have intercourse because the vagina was too narrow. Another report of 30 women undergoing abdominal sacrocolpopexy found that 22 % complained of new onset dysparunea, and 41% complained of decreased libido and intercourse.

In one of the few prospective studies in this literature, 81 women were followed for up to one year after surgery for urinary incontinence and or pelvic organ prolapse. This study found that posterior repair, especially in conjunction with the burch retropubic urethropexy method of surgery placed women at risk for postoperative dysparunea rates of up to 38%, despite no differences in vaginal anatomy between women with posterior repair and those without. In another prospective series of 23 women who underwent enterocele (hernia) repair, the majority reported no change in sexual functioning, including frequency of sexual activity, dyspareunia or satisfaction with their sexual relationship.

In summary, the literature on sexual function and prolapse is dominated by retrospective studies that describe surgical outcomes. From these, we can tentatively conclude that posterior may place patients at higher risk for dyspareunia than patients who do not have a posterior repair as part of a prolapse surgery. The negative effect of a posterior colporraphy may be compounded by the performance of a retropubic urethropexy. These findings are consistent with studies which described routinely performing a levatorplasty as part of the posterior repair as well as those that did not.

Suggestions for treatment of sexual dysfunction in women with pelvic floor disorders range from admonishments to �use it or lose it�, advice to abstain from sexual activity or assumption that the treatment of incontinence or prolapse will result in better sexual function. Assumption that the restoration of anatomy will improve function is shortsighted. So far, the literature has been unable to prove a link between sexual function and vaginal anatomy within broad ranges of normal length and caliber. Additionally, measures of satisfaction may inadequately represent patient�s sexual function in term of libido, arousal and orgasmic ability. Finally treatment of sexual function beyond restoration of anatomy in women with pelvic floor disorders has not been researched. The effect of using testosterone supplementation, of devices such as the clitoral stimulator, or of behavioral interventions is unknown.

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