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Sexual function and pelvic floor disorders

https://doi.org/10.1016/j.bpobgyn.2005.08.012Get rights and content

Sexual wellbeing is an important aspect of women's health. Female sexual dysfunction is multifactorial and involves physical, social and psychological dimensions. Dysfunction may result from lack of sexual desire, sexual pain or arousal, and orgasmic problems. Sexual dysfunction is common and increases with age and pelvic floor disorders such as urinary incontinence and pelvic organ prolapse. Surgical treatment of pelvic floor disorders has been poorly studied but has the potential to improve sexual satisfaction or to cause sexual difficulties. New instruments such as condition-specific sexual questionnaires have recently been developed and will help us to better evaluate the results of incontinence and prolapse surgery on sexual function.

Section snippets

Classification of sexual dysfunction

Female sexual dysfunction is multifactorial and involves physical, social and psychological dimensions. One classification developed at an international consensus workshop described a sequence of four separate phases: sexual desire (libido), arousal (excitement), orgasm and satisfaction.4 Dysfunction can affect any of these areas and be organic, psychological, mixed, or of uncertain aetiology. It can be primary or secondary to other physical or emotional disorders.

Sexual desire disorders

Evaluation of sexual function

Two types of questionnaire are in current use to evaluate sexual function. Generic questionnaires have been designed to screen large populations but may not detect fine changes within a specific population. Disease-specific questionnaires are used to evaluate patients suffering from specific medical conditions and are, therefore, more sensitive to specific aspects of the disease. The King's Health Questionnaire (KHQ) is a condition-specific survey designed to measure quality of life in women

Sexual function in women with POP and/or USI

Urinary incontinence affects quality of life and may progressively lead to loss of confidence and self-esteem, isolation, frustration, and depression. Psychological aspects play an important role in sexual health in women, so UI would be expected to have a significant impact on sexual function. Women with UI may avoid sexual intercourse because of fear of leakage during intercourse; this has been reported to occur in 11–45% of patients with UI.14, 15, 16, 17, 18 Moran et al found that 11% of

Neuroanatomy of the pelvic floor

The somatic nerve supply to the pelvic floor muscles is provided through direct branches issued from S3 to S5.26 The pudendal nerve originates from S2 to S4 and includes sensory and motor fibres. It has three main branches (Figure 1). The inferior rectal nerve arises at the beginning of the pudendal canal and penetrates the ischiorectal fossa, where it gives motor branches to the lower rectum and the external anal sphincter, and sensory branches to the skin anterior and lateral to the anus. The

Sexual function before and after pelvic floor surgery

Pelvic organ prolapse can affect different compartments separately or in combination. Anterior vaginal wall prolapse occurs because of defective support laterally by the endopelvic fascia that attaches the middle third of the vagina to the arcus tendineus fascia pelvis and centrally through weakness of its intimate connection at the anterior vaginal wall. The vaginal apex (vault±uterine cervix) is attached to the pelvic sidewall through the uterosacral and lateral cervical ligamentous complex

Stress incontinence surgery

There are many different procedures described for correcting USI. The Burch colposuspension is one of the most commonly performed operations for USI and involves the suspension of the bladder neck to the iliopectineal ligament (Cooper's ligament). Fascia lata or rectus sheath sling inserted at the bladder neck is also a very effective operation, although more obstructive than the Burch colposuspension. This operation is preferred by many surgeons for treatment of USI associated with low

Anterior repair

Anterior vaginal wall prolapse (cystocele) can be caused by a relaxation or tear in either the fibromuscular vaginal wall supporting the bladder centrally or a defect in the lateral attachment of the paracolpium to the arcus tendineus fascia pelvis resulting in a sagging of the lateral vaginal sulci. Loss of apical support is also a common and frequently neglected cause of anterior vaginal wall prolapse. Therefore, surgical correction of cystocele can be either by the midline plication of

Posterior repair

Rectocele is a protrusion of the rectum secondary to overdistension or fascial tears in the posterior vaginal or perineal body. These defects can be repaired either by a plication of the fascia along the midline or by repairing the breaks in the fascia (site-specific repair).44 Richardson described the tears occurring in the rectovaginal fascia most frequently as a transverse detachment from the perineal body and as vertical midline and lateral defects.44 Reconstruction of the perineal body is

Vault prolapse

Vault prolapse can be corrected either by an abdominal (abdominal sacrocolpopexy) or a vaginal (sacrospinous, uterosacral, iliococcygeal suspension) approach. Vault prolapse is often associated with other compartment defects and, therefore, may require concomitant repair of the anterior and/or posterior vaginal wall. Several studies have evaluated sexual function after vaginal vault repair. Sacrospinous fixation is the most popular vaginal procedure and involves the dissection of the pararectal

Vaginal repair with synthetic mesh

Synthetic and donor grafts are being increasingly used to reinforce vaginal repair to improve the long-term results and prevent prolapse recurrence. There is little information to date on the effects of these grafts on the functional results of surgery, particularly sexual function. Dwyer and O'Reilly reported their results using polypropylene mesh to reinforce anterior and posterior compartment repair in 97 women with recurrent or large vaginal prolapse.63 Dyspareunia decreased significantly

Hysterectomy (Table 3)

Hysterectomy is frequently performed in conjunction with other pelvic floor reconstructive procedures either for uterine prolapse or other benign gynaecological conditions. Hysterectomy is mostly performed for benign conditions without pelvic floor repair. Vaginal hysterectomy is performed for uterocervical prolapse to remove the prolapsed uterus and hypertrophic cervix and allow ready access to the laterocervical/uterosacral complex for the McCall procedure (Table 3).

There has been controversy

Summary

This article reviews the impact of pelvic floor disorders and their surgical treatments on sexual function. Functional results are as important an outcome measure as anatomical results in the assessment of pelvic floor surgery. In particular, sexual function following pelvic floor surgery has been overlooked and superficially assessed in the past. Several condition-specific questionnaires such as PISQ have been developed to evaluate sexual function.

Sexual function seems to be improved after

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