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Some women choose to undergo posterior colporrhaphy (PC) concurrently with procedures for SUI to regain sexual confidence and improve sexual function. We determine the effect of PC on sexual function in women requiring a midurethral sling for SUI.
A total of 119 women were retrospectively reviewed 81 women had the midurethral sling alone (Group A), and 38 women voluntarily had PC concurrently with the midurethral sling (Group B). Sexual function was evaluated using the FSFI before and after surgery.
The postoperative composite scores were significantly increased in both groups (Group A: p=0.02; Group B: p=0.04), and significant increases were observed in 'desire,' 'arousal' and 'satisfaction'. However, there were no significant differences in the composite score or six domainscores between the two groups.
PC performed concurrently with midurethral sling for treatment of SUI does not provide any additional benefits towards improving the sexual function.
Sexual function in women is multifactorial and is affected by psychological, sociological, environmental, and physical factors. Sexual dysfunction is difficult to define, but the prevalence of sexual dysfunction among women has been estimated to be as high as 50% [1,2]. Disorders of arousal, desire, and lubrication, as well as anorgasmia and dyspareunia, are typical complaints reported on sexual function questionnaires. Aging and the presence of certain comorbid conditions (i.e., cervical cancer or multiple sclerosis) place additional constraints on the quality of female sexual function . Other factors, such as hormonal status and hysterectomy, have also been implicated, although much less clearly so, in the development of sexual dysfunction [4-7].
Urinary incontinence and pelvic organ prolapse are common and exist in 41% to 65% of women [8-10]. Stress urinary incontinence (SUI) has major impacts on quality of life and is reported to have especially negative impacts on female sexual function [11-13]. SUI patients report avoiding sexual intercourse because of wetness at night, leakage during intercourse, embarrassment, and depression .
Some female patients believe that good sexual function is facilitated by preservation of vaginal length and caliber adequate for sexual intercourse. These patients often request posterior colporrhaphy (PC) to be performed along with procedures for SUI to regain confidence as well as to improve sexual function. However, very few studies on the efficacy of such combined procedures have been reported.
We evaluated changes in the sexual function of patients who underwent a midurethral sling operation alone for treatment of SUI and compared the results of these patients with those of patients who underwent a midurethral sling operation and concurrent PC procedure.
Our study included 160 patients who underwent midurethral sling operations for SUI between January 2006 and December 2007. Forty-one patients who reported no sexual intercourse before or after the operation were excluded. Inclusion criteria were women with SUI whose conditions did not respond to pelvic floor exercises and were therefore undergoing surgery. The preoperative data collected included age, menopausal state, Urodynic parameters, symptoms, and quality of life scores. After exclusions, 119 patients were divided into two groups: 81 women who underwent the midurethral sling operation alone (Group A), and 38 women who voluntarily underwent PC concurrently with the midurethral sling operation (Group B). No patients in Group B had a rectocele. The anti-incontinence procedures implemented included Tension-Free Vaginal Tape (TVT) Tension-Free Vaginal Tape-Obturator, inside out (TVT-O)and Tension-Free Vaginal Tape-Obturator, outside in (TOT). PC was performed via conventional procedures. Female sexual function was evaluated according to the Female Sexual Function Index (FSFI, Korean version), which assesses sexual desire, arousal, lubrication, orgasm, satisfaction, and pain; higher scores reflect better sexual function (maximum score 36). A Korean translation of the FSFI has been validated for linguistic accuracy. The total score and the six individual domain scores were compared before and after the operation.
The patients were evaluated for 3 months postoperatively for changes in their medical histories, physical examination findings, and FSFI scores. Groups A and B were compared for disparities in preoperative and postoperative FSFI scores and for preoperative and postoperative FSFI score differences by use of Student's t-test. A p value less than 0.05 was considered significant.
The two groups were similar in mean age, urinary symptoms, quality of life, preoperative physical examination, Urodynic studies, and preoperative FSFI score (table 1). Among the 119 patients, 57.1% (68/119) underwent a TOT, 31.1% (37/119) a TVT, and 11.8% (14/119) a TVT-O. Twenty-nine patients (24.4%) previously had hysterectomies and 44 patients (37.0%) were postmenopausal. The postoperative total FSFI scores were significantly increased in both groups (Group A: p=0.02 and Group B: p=0.04) and particularly significant increases were observed in the 'desire,' 'arousal,' and 'satisfaction'domains. In Group A, however, the 'pain' domain scores were significantly lower, showing that postoperative pain had a detrimental effect on subjective sexual function (table 2). However, there were no significant differences in total FSFI scores or the six individual domain scores between the two groups after surgery (table 3).
Improvement in the quality of life following treatment for SUI can be assessed by a variety of measures. Several studies have assessed sexual function following surgery for SUI and have found both positive and negative effects [14-17]. Improvements in sexual function following vaginal surgery are believed to be due to the cessation of incontinence during intercourse, whereas worsening sexual function is believed to be caused by dyspareunia following perineorrhaphy . Other possible sources must be considered. Thereis a constant concern regarding the possibility of interfering with vaginal sensitivity resulting from the fact that the principal site of innervation is the location for the incision in the midurethral sling procedure . Psychological changes due to the fear of dyspareunia, altered sensation, diminished lubrication, and orgasmic dysfunction have been suggested as potential contributors to postoperative sexual dysfunction . In our study, both surgical groupshad a significant postoperative improvement in FSFI scores, and particularly significant improvements were observed in 'desire,' 'arousal,' and 'satisfaction.' Improvements in sexual function after surgery for SUI were primarily attributed to the relief of coital leakage of urine .
Colpoperineorrhaphy can result in dyspareunia due to narrowing of the vagina . However, vaginal narrowing may not be entirely responsible for altered sexualfunctioning and sexual dissatisfaction after vaginal surgery. Porter et al reported that PC alone or concurrent with other vaginal surgery does not adversely affect sexual function and in fact may aid in the resumption of sexual activity, significantly improving quality of life and social relationships . Previous studies described varying results regarding the association of dyspareunia and PC that were believed, in part, to be due to the effects of levatorplasty [22,23]. In our study, the postoperative 'pain' scores decreased in both groups. This result was likely related to the fact that our patients underwent levatorplasty during their PC procedures.
Posterior compartment defects are known to arise from abnormalities in the rectovaginal connective tissue and its attachments within the pelvis. Repairs of these defects include traditional PC, which is performed by repairing the patient's native rectovaginal connective tissue in the midline, or site-specific PC, which is performed by repairing individual breaks in the rectovaginal tissue . Controversy exists over whether posterior repair is associated with diminished sexual function or dyspareunia. Some authors have reported increased rates of dyspareunia after PC, whereas others have not [18,21-23,25]. Some female patients believe that maintenance of good sexual function is accomplished by preservation of vaginal length and caliber adequate for sexual intercourse. These patients ask for PC with procedures for SUI to regain sexual confidence and improve sexual function. Weber et al reported that vaginal dimensions of introital caliber and vaginal length did not correlate with a patient's sexual symptoms, so they were not able to identify the ideal vaginal dimensions to use as a goal for vaginal reconstructive surgery .
Our findings suggest that the midurethral sling procedure for urinary incontinence has overall positive effects on sexual function. However, PC performed concurrently with the midurethral sling operation does not provide any additional benefits for improving the sexual function of women.
The authors have nothing to disclose.