Aside from simple screening tools, a number of sexual function questionnaires have been developed. Some are generic, and others are condition-specific:
- Generic questionnaires are typically designed to address the function of a range of women. For example, the Female Sexual Function Index comprises 19 questions. Domains include orgasm, desire, arousal, lubrication, pain and satisfaction.14
- Condition-specific questionnaires of sexual function each have been validated in their target population so that they measure nuances in sexual health relevant to that population. The Pelvic Organ Prolapse/Incontinence Sexual Questionnaire—IUGA-Revised includes questions about the domains listed for the generic Index (above) plus questions about the impact of coital incontinence or bulge symptoms on sexual function.12
History-taking. If a woman identifies a problem with sexual function, a thorough history helps elicit whether the condition is lifelong or acquired, situational or general, and, most important, whether or not it is bothersome to her.14,15 It is important not to make assumptions when pursuing this part of the history, and to encourage patients to be candid about how they have sex and with whom.
Physical examination. The patient should undergo a complete physical exam, including 1) a detailed pelvic exam assessing the vulva, vagina, and pelvic-floor musculature, and 2) estrogenization of the tissue.
Partner concerns. For women who have a partner, addressing the concerns of that partner following gynecologic surgery can be useful to the couple: The partner might be concerned about inflicting pain or doing damage during sex after gynecologic surgery.
CASE Informative discussion
While ascertaining her sexual symptoms, your patient reveals to you that she has attempted sexual intercourse on 3 occasions; each time, penetration was too painful to continue. She tells you she did not have this problem before surgery.
The patient says that she has tried water-based lubricants and is using vaginal estrogen 3 times per week, but “nothing helps.” She reports that she is arousable and has been able to achieve orgasm with clitoral stimulation, but would like to have vaginal intercourse. Her husband does have erectile dysfunction, which, she tells you, can make penetration difficult.
On physical examination, you detect mild atrophy. Vaginal length is 9 cm; no narrowing or scarring of the vaginal introitus or canal is seen. No mesh is visible or palpable. The paths of the midurethral sling arms are nontender. However, levator muscles are tender and tense bilaterally.
Given these findings on examination, what steps can you take to relieve your patient’s pain?
What can we offer these patients?
Treating sexual dysfunction after pelvic reconstructive surgery must, as emphasized earlier, be guided by a careful history and physical exam. Doing so is critical to determining the underlying cause. Whenever feasible, offer the least invasive treatment.
The IUGA/ICS terminology report describes several symptoms of postoperative sexual dysfunction12:
- de novo sexual dysfunction
- de novo dyspareunia
- shortened vagina
- tight vagina (introital or vaginal narrowing, or both)
- scarred vagina (including mesh-related problems)
- hispareunia (pain experienced by a male partner after intercourse).
Of course, any one or combination of these symptoms can be present in a given patient. Furthermore, de novo sexual dysfunction, de novo dyspareunia, and hispareunia can have various underlying causes—again, underscoring the importance of the history and exam in determining treatment.
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