Best Practice & Research Clinical Obstetrics & Gynaecology
12Sexual function and pelvic floor disorders
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
References (83)
- et al.
Sexuality in sexagenarian women
Maturitas
(1991) - et al.
Report of the international consensus development conference on female sexual dysfunction: definitions and classifications
Journal of Urology
(2000) - et al.
Safety and efficacy of sildenafil in postmenopausal women with sexual dysfunction
Urology
(1999) - et al.
Sexual function after vaginal surgery for stress incontinence: results of a mailed questionnaire
Urology
(2000) - et al.
A new instrument to measure sexual function in women with urinary incontinence or pelvic organ prolapse
American Journal of Obstetrics and Gynecology
(2001) - et al.
Mechanisms of urine loss during sexual activity
European Journal of Obstetrics, Gynecology and Reproductive Biology
(1993) - et al.
Sexual function in women with uterovaginal prolapse and urinary incontinence
Obstetrics & Gynecology
(1995) - et al.
Urinary incontinence during orgasm
Urology
(1988) - et al.
Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study
Eur Urol
(2004) - et al.
The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function
American Journal of Obstetrics and Gynecology
(2003)
Sexual function among women with urinary incontinence and pelvic organ prolapse
American Journal of Obstetrics and Gynecology
Sexual function in women with urinary incontinence and pelvic organ prolapse
Obstetrics & Gynecology
Innervation of the female levator ani muscles
American Journal of Obstetrics and Gynecology
Attachment of the rectovaginal septum to the pelvic sidewall
American Journal of Obstetrics and Gynecology
Structural anatomy of the posterior pelvic compartment as it relates to rectocele
American Journal of Obstetrics and Gynecology
Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence
Obstetrics & Gynecology
Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out
European Urology
Sexual function after surgery for stress urinary incontinence and/or pelvic organ prolapse: a multicenter prospective study
American Journal of Obstetrics and Gynecology
A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up
American Journal of Obstetrics and Gynecology
Posterior colpoperineorrhaphy
American Journal of Obstetrics and Gynecology
Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation
Obstetrics & Gynecology
Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse
American Journal of Obstetrics and Gynecology
Iliococcygeus or sacrospinous fixation for vaginal vault prolapse
Obstetrics & Gynecology
Posthysterectomy vaginal vault prolapse: primary repair in 693 patients
Obstetrics & Gynecology
Abdominal sacrocolpopexy and anatomy and function of the posterior compartment
Obstetrics & Gynecology
Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study
American Journal of Obstetrics and Gynecology
A post-hysterectomy syndrome
Lancet
Respective consequences of abdominal, vaginal, and laparoscopic hysterectomies on women's sexuality
European Journal of Obstetrics, Gynecology and Reproductive Biology
Functional outcomes and satisfaction after abdominal hysterectomy
American Journal of Obstetrics and Gynecology
Sexual dysfunction in the United States: prevalence and predictors
Journal of the American Medical Association
Sexual function in the elderly
Archives of Internal Medicine
The prevalence of dyspareunia
Obstetrics & Gynecology
A new questionnaire to assess the quality of life of urinary incontinent women
British Journal of Obstetrics and Gynaecology
Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory
Neurourology and Urodynamics
The measurement of marital quality
Journal of Sex and Marital Therapy
The DSFI: a multidimensional measure of sexual functioning
Journal of Sex and Marital Therapy
A short form of the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12)
International Urogynecology Journal and Pelvic Floor Dysfunction
Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom
British Journal of Obstetrics and Gynaecology
Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse
International Urogynecology Journal and Pelvic Floor Dysfunction
Urinary laekage during coitus in women
J Obstet Gynaecol
Sexual function in women attending a urogynecology clinic
International Urogynecology Journal and Pelvic Floor Dysfunction
Cited by (75)
Sexual dysfunction in patients after cystocele surgery. Is the g-spot a myth or reality?
2023, European Journal of Obstetrics and Gynecology and Reproductive BiologyPelvic Floor Muscle Training Effect in Sexual Function in Postmenopausal Women: A Randomized Controlled Trial
2021, Journal of Sexual MedicineDirective clinique de consensus sur la santé sexuelle de la femme
2016, Journal of Obstetrics and Gynaecology CanadaFemale Sexual Function following Pelvic Organ Prolapse Reconstruction: A Case Serial Study
2024, Current Women's Health Reviews