Vaginal mesh. Mesh has been used in various surgical procedures to correct pelvic floor disorders. Numerous randomized trials have comparatively evaluated the use of transvaginal polypropylene mesh and native tissue for POP repair, and many of these studies have assessed postoperative sexual function. In a 2013 systematic review on sexual function after POP repair, the authors found no significant difference in postoperative sexual function scores or the dyspareunia rate after vaginal mesh repair (14%) and after native-tissue repair (12%).6
Key touchpoints in managing sexual dysfunction after pelvic reconstructive surgery
Ask; then ask again
· Talk about sexual function before and after surgery
Remember the basics
· A thorough history and physical exam are paramount
Ask in a different way
· Any of several validated questionnaires can be a valuable adjunct to the history and physical exam
Individualize treatment
· Many patients respond to nonsurgical treatment, but surgical management is necessary in some cases
Studies of postsurgical sexual function are lacking
Important aspects of sexual function—orgasm, arousal, desire, lubrication, sexual satisfaction, effects on the partner—lack studies. A study of 71 sexually active couples assessed sexual function with questionnaires before and after vaginal native-tissue repair and found that, except for orgasm, all domains improved in female questionnaires. In male partners, interest, sexual drive, and overall satisfaction improved, whereas erection, ejaculation, and orgasm remained unchanged.7
Urinary incontinence during sexual intercourse affects approximately 30% of women with overactive bladder or stress incontinence.8 Several reviews have analyzed data on overall sexual function following urinary incontinence surgery:
- After stress incontinence surgery, the rate of coital incontinence was found to be significantly lower (odds ratio, 0.11).9 In this review, 18 studies, comprising more than 1,500 women, were analyzed, with most participants having undergone insertion of a midurethral mesh sling. Most women (55%) reported no change in overall sexual function, based on validated sexual questionnaire scores; 32% reported improvement; and 13% had deterioration in sexual function.
- As for type of midurethral sling, 2 reviews concluded that there is no difference in sexual function outcomes between retropubic and trans‑obturator sling routes.9,10
Although most studies that have looked at POP and incontinence surgeries show either improvement or no change in sexual function, we stress that sexual function is a secondary outcome in most of those studies, which might not be appropriately powered to detect differences in outcomes. Furthermore, although studies describe dyspareunia and overall sexual function in validated questionnaire scores, most do not evaluate other specific domains of sexual function. It remains unclear, therefore, how POP and incontinence surgeries affect orgasm, desire, arousal, satisfaction, and partner sexual domains; more studies are needed to focus on these areas of female sexual function.
How do we assess these patients?
We do know that sexual function is important to women undergoing gynecologic surgery: In a recent qualitative study of women undergoing pelvic reconstruction, patients rated lack of improvement in sexual function following surgery a “very severe” adverse event.11 Unfortunately, however, sexual activity and function is not always measured before gynecologic surgery. Although specific reporting guidelines do not exist for routine gynecologic surgery, a terminology report from the International Urogynecologic Association/International Continence Society (IUGA/ICS) recommends that sexual activity and partner status be evaluated prior to and following surgical treatment as essential outcomes.12 In addition, the report recommends that sexual pain be assessed prior to and following surgical procedures.12
Ascertain sexual health. First, asking your patients simple questions about sexual function, pain, and bother before and after surgery opens the door to dialogue that allows them, and their partner, to express concerns to you in a safe environment. It also allows you to better understand the significant impact of your surgical interventions on their sexual health.
Questionnaires. Objective measures of vaginal blood flow and engorgement exist, but assessment of sexual activity in the clinical setting is largely limited to self-assessment with questionnaires. Incorporating simple questions, such as “Are you sexually active?,” “Do you have any problems with sexual activity?,” and “Do you have pain with activity?” are likely to be as effective as a more detailed interview and can identify women with sexual concerns.13 Many clinicians are put at a disadvantage, however, because they are faced with the difficult situation of addressing postoperative sexual problems without knowing whether the patient had such reports prior to surgery.
Continue to: Aside from simple screening tools...