The impact of pelvic floor surgery on female sexual function: a mixed quantitative and qualitative study

Authors


Abstract

Objective

To assess whether the current condition-specific sexual function questionnaire provides full insight into sexual function following pelvic floor surgery.

Design

Prospective, mixed quantitative and qualitative study.

Setting

Urogynaecology clinic in a large university hospital.

Population

Thirty-seven women undergoing surgery for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI).

Methods

Women were seen before surgery and 3 months postoperatively. At both visits the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) was completed and a qualitative face-to-face semi-structured interview was conducted. PISQ total and domain scores, as well as the change in the preoperative and postoperative score, were calculated and analysed using Wilcoxon signed rank test and one-sample t-test. The qualitative data were systematically analysed using data-matrices.

Main outcome measures

The impact of pelvic floor surgery on female sexual function.

Results

Significant improvement was seen for PISQ total score (= 0.003) as well as Physical (P < 0.001) and Partner-related (= 0.002) domains, but not for the Behavioural/Emotive domain (= 0.220). Analysis of qualitative data showed that improvement in sexual function was a result of cure of POP and SUI symptoms. Deterioration of sexual function was due to dyspareunia, fear of causing damage to the surgical result, new symptoms and a disappointing result of surgery.

Conclusions

Our qualitative data show that PISQ is limited in the assessment of sexual function after pelvic floor surgery as it does not assess most surgery-specific negative effects on sexual function.

Introduction

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) form a major health burden to women. In the USA, 11.8% of women undergo at least one surgery for these conditions by the age of 80 years.[1] Women with POP and SUI are at a higher risk of sexual dysfunction.[2, 3] However, studies following POP and anti-incontinence surgery show conflicting results regarding the impact on sexual function, ranging from overall improvement,[4-6] via no change,[7, 8] to even deterioration.[9] These variable results may be a reflection of differences in population characteristics, differences in treatment or differences in the measurement of outcome.

In urogynaecology, female sexual function has been evaluated using various questionnaires. Questionnaires measure ‘subjective’ information in an ‘objective’ fashion and as such they provide a reproducible method for evaluating female sexual function. Early studies mostly used nonvalidated sexual function questionnaires. Recently, validated sexual function questionnaires have been developed, subdivided into general or condition-specific types. Condition-specific sexual function questionnaires are designed to assess changes in sexual health specifically caused by POP and SUI. Currently, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ)[10] (including its short-form PISQ-12[11]) is the only validated condition-specific female sexual function questionnaire available. Other validated condition-specific questionnaires that have been used to assess sexual function following pelvic floor surgery, including The King's Health Questionnaire[12] and International Consultation on Incontinence Questionnaire—Vaginal Symptoms (ICIQ-VS),[13] are quality of life questionnaires or symptom severity questionnaires. Although these questionnaires include a few questions addressing sexual function, they really deal with the overall impact of POP or SUI on the patient's quality of life or measure the presence and severity of symptoms.

The PISQ[10] is optimised to discriminate between women with and without sexual dysfunction, within the group of women with POP and SUI. However, such a questionnaire may not be optimal to detect sexual dysfunction following treatment. This is particularly the case if only selective aspects of sexual function improve, or new aspects due to the treatment become relevant. Our study's objective was to establish whether PISQ[10] provides full insight in, and covers all relevant aspects of, sexual function following pelvic floor surgery. For this, a mixed quantitative and qualitative study was performed. In comparison to a quantitative study, a qualitative study is able to provide the woman's view as well as the context of problems, which are necessary to understand the surgery-specific impact on sexual function.

Methods

Women were recruited from two urogynaecology outpatient clinics, led by two consultant urogynaecologists (RT/AHS), in a large university hospital (Croydon University Hospital, Croydon, UK). Study inclusion criteria included the following: (1) having consented to undergo corrective surgery for POP or SUI; (2) being over 18 years of age; (3) having good comprehension of verbal and written English; (4) having a partner; and (5) being sexually active. Exclusion criteria included malignancy or terminal illness.

Women were selected by the consultant urogynaecologist running the clinic, who tried to select those women who were considered to be ‘good’ informants, i.e. articulate, reflective and likely to share as much information with the interviewer as possible.[14] The idea behind qualitative research is to purposefully select participants that will best help the researcher understand the problem and the research question. This does not necessarily suggest random sampling of participants as is typically found in quantitative research.[15] The selection of participants was unrelated to whether the woman expressed any concerns regarding her sexual function before surgery.

The indication for having surgery would be the presence of subjective complaints, including feeling of bulge, obstructive defecation or urinary incontinence, explained by an objective indication of disease, such as descent of one or more vaginal compartments (POP) or SUI. Surgery would be indicated when conservative treatment, including pelvic floor exercises and vaginal pessary, was unsuccessful or not wanted (in case of vaginal pessary).

Recruitment occurred over a period of 17 months, from April 2008 to August 2009, until the cohort of women had reached maximum variation with regards to types of surgery and combinations of procedures performed. Over this time period, 220 women were operated on and 37 women were included (17%).

Outcome measures

All participating women were seen before and 3 months after surgery. For quantitative assessment women were asked to complete the PISQ.[10] The PISQ is a condition-specific questionnaire validated to evaluate sexual function in sexually active women with POP or SUI. The questionnaire consists of 31 questions that are divided into three domains including: ‘Behavioural/Emotive’ (15 questions), ‘Physical’ (ten questions), and ‘Partner-related’ (six questions). The Behavioural/Emotive domain covers sexual desire, frequency of sexual activity, arousal and orgasmic capabilities, whereas the Physical domain assesses more directly the effect of POP and SUI on sexual function. The Partner-related domain assesses the woman's perception of her partner's response to the effect of POP and SUI on their sexual functioning, as well as her partner's own sexual functioning. Questions are scored on a Likert-type scale from 0 (always) to 4 (never). Summary scores, for the entire questionnaire as well as for the different domains, are obtained by unweighted summation of the score for each question. The PISQ total score ranges from 0 to 125 with higher scores reflecting better sexual functioning.

Qualitative assessment consisted of a semi-structured face-to-face interview. All face-to-face interviews were conducted by the first author (AMR), who had been trained in qualitative research methods and interviewing techniques. The interviewer was a female medical doctor working as a research fellow and was introduced as such. The interviewer was not involved in the treatment of the women and was not present during their clinic visits. Although not a native speaker, she was fluent in the English language. Participants were interviewed within the hospital premises in the privacy of a consulting room without the presence of their partner. At the start of the interview, the interviewer explained the purpose of the study and assured the confidentiality of the collected data to the participant. An interview guide was developed before the start of the study with the help of a clinical psychologist with expertise on the evaluation of sexual function. The interview guide included open-ended questions addressing different topic areas from which both the interviewer or the interviewee could diverge to pursue an idea in more detail. The template of questions used after surgery is shown in Table 1. The wordings used were not standardised to reflect the women's own vocabulary while framing the questions. The interview process was audio-taped and each interview was transcribed verbatim.

Table 1. Template for semi-structured interview
Aim of questionExample of question
To introduce the topic and to ascertain the baseline health after surgery.‘As you know we are interested in knowing how conditions like leaking of urine and or sagging of womb, bladder and bowel affects sexual life and also how surgical treatment for these conditions affects sexual life. Could you therefore please tell me how you are presently?’
To find out participant's sexual function after surgery and reasons, if any, for inactivity.‘Could you please tell me if you have resumed sexual activity at present and how your present sexual experience is?’
 ‘In case you haven't resumed sexual activity could you tell me why you are not comfortable with sexual activity as of now?’
To explore the domains of sexual function after surgery further as well as the severity of any problems.‘You mentioned this ……….. please tell me a bit more about by what you mean by this?’
To explore body image and the impact, if any, of the pelvic floor.‘How do you feel presently physically and sexually? Is it any different than before?’
To explore the impact of surgery on sexual function further.‘Could you please describe how it feels the same or how it feels different than before?’
To ascertain the level of intimacy, comfort and satisfaction in sexual relations.‘Could you please describe how it is, to have sex with your partner at present?’
To explore the impact of surgery on sexual relations, as well as any change in partner's sexual needs and function.‘Could you please tell me if you feel your sexual relations with your partner are the same or not quite the same as before and why you think they feel the same or not the same as before?’
To find anything else relevant to the study once the participant is at ease.‘Is there anything else that you think might be helpful for me to know at this stage?’

Data analysis

Quantitative data analysis was done using the statistical spss program (SPSS version 16, SPSS Inc, Chicago, IL, USA). First, descriptive analyses of baseline characteristics were compared between women who did and did not return for follow-up using chi-square or Fisher's exact test for proportions and Student's t test or Mann–Whitney U test for continuous variables. Total PISQ and domain scores were calculated and preoperative and postoperative values were compared using Wilcoxon signed rank test. The change in total PISQ and domain scores (delta score) was calculated for each participant by subtracting the preoperative score from the postoperative score. This delta score was normally distributed and a one sample t test was used to analyse whether the delta scores were significantly different from 0. A P-value <0.05 was considered significant.

For analysis of the qualitative data we made use of data matrices.[16] First, a list of 11 broad categories was developed to cluster the data. Categories were either introduced into the interviews by the questions in the interview guide or as issues raised by the participants themselves. The 11 categories were: ‘resuming sexual activity’, ‘evaluation of sex life after surgery’, ‘desire’, subdivided into ‘drive’ (spontaneous sexual interest) and ‘motivation’ (willingness to engage in sexual activity), ‘arousal’, ‘orgasm’, ‘dyspareunia’, ‘symptoms’, ‘body image’, ‘overall feelings regarding surgery’, ‘partner domain’, ‘relationship’ and ‘others’. All interviews were subsequently coded and the data from the interviews were coupled to the corresponding categories. In the next step, subcategories were created within each category and each ‘verbal unit’ of the interview was assigned to a subcategory. Structured as spreadsheet data, the columns were respondents, the rows the detailed subcategories, which were only filled if such a response had been given. All interviews were coded by the first author (AMR). A second researcher (AP) went through 25% of the transcripts independently to check for agreement in coding categories. Any discrepancies in coding were discussed between the two researchers and consensus on coding was always reached. There were two main reasons for discrepancy between the researchers. The first cause for discrepancy was a result of overlap between the ‘symptoms’ and ‘resuming sexual activity’ categories. Physical complaints were often a cause for delay in resuming sexual activity in which case it was coded both as ‘symptoms’ and ‘resuming sexual activity’. The second cause was the unclear definition of the ‘dyspareunia’ category. After discussion it was agreed that duration, evaluation and cure of dyspareunia would be coded in the ‘dyspareunia’ category.

Results

Thirty-seven women were included and 30 (81%) came for follow up after surgery. The interquartile ranges of follow up were: 12–13, 14–15, 16–19 and 20–54 weeks after surgery. One woman had cancelled her surgery because of personal circumstances and the other six were lost to follow up. The participants demographic data as well as that of the seven women not attending follow up are included in Table 2.

Table 2. Demographics of women who did and did not return for follow up
 Included women(n = 30)Women not attending follow up (= 7)P-value
  1. a

    Represented as median (range).

Agea49 (36–64)47 (32–63)0.830
Body mass indexa28 (20–36)29 (24–36)0.260
Ethnicity
Caucasian28 (93%)7 (100%)1.000
Other2 (7%)0
Parity a 2 (0–5)2 (1–3)0.671
Vaginal parity a 2 (0–5)2 (1–3)0.791
Menopausal
Postmenopausal14 (47%)4 (57%)0.651
Premenopausal13 (43%)3 (43%)
Unsure, post-hysterectomy3 (10%)0
Hormone replacement therapy 6 (20%)00.569
Hypertension 9 (30%)2 (29%)1.000
Diabetes 01 (14%)0.184
Previous hysterectomy 11 (37%)00.084
Previous incontinence surgery 6 (20%)00.569
Previous prolapse repair 7 (23%)00.309
Surgery performed
POP surgery16 (53%)2 (29%)0.644
UI surgery6 (20%)1 (14%)
POP and UI surgery8 (27%)3 (43%)
Surgery cancelled1 (14%)

The types of POP surgery performed included: vaginal hysterectomy, anterior repair, posterior repair, sacrocolpopexy, stapled transanal resection of the rectum and vaginal excision of cervical stump either as sole or combined procedures. The types of anti-incontinence surgery performed included: tension-free vaginal tape and transobturator tape. Additionally one woman had a salpingo-oophorectomy, one a laparoscopic aspiration of ovarian cyst and one underwent adhesiolysis.

Quantitative results

Of the 30 included women, four had not resumed sexual intercourse at follow up. For the 26 women who were sexually active both before surgery and at follow up, total PISQ scores had significantly improved after surgery (Table 3). When analysed by domain, improvement was seen in the Physical domain, which measures the direct effect of POP and SUI on sexual function, as well as in the Partner-related domain, which includes the woman's perception of her partner's response to the effect of POP and SUI on their sexual functioning. There was no change seen in the Behavioural/Emotive domain, which evaluates sexual desire, frequency of sexual activity, arousal and orgasmic capabilities (Table 3).

Table 3. PISQ results for 26 sexually active women
 Group analysisIndividual analysis
PreoperativeaPostoperativeaP-valuebDelta scorecP-valued
  1. a

    Represented as median (range).

  2. b

    Using Wilcoxon signed-rank test.

  3. c

    Delta score: change in score per participant, represented as mean (standard deviation).

  4. d

    Using one-sample t-test, test value = 0.

PISQ total 85 (49–105)98.5 (56–112)0.0039.77 (14.66)0.002
Domain score
Behavioural/Emotive39 (15–46)42.5 (16–52)0.2201.77 (9.24)0.338
Physical29 (14–40)36.5 (23–40)<0.0016.35 (6.42)<0.001
Partner-related18 (12–22)20 (14–24)0.0021.65 (2.24)0.001

Qualitative results

Of the 30 included women the median duration of the interviews before surgery was 21 minutes (range 8–72 minutes) and after surgery was 24 minutes (range 10–43.5 minutes). One woman's interview before surgery was missing because of a technical recording error. The qualitative results are described around the two main categories: ‘resuming sexual activity’ and ‘evaluation of sex life after surgery’.

Resuming sexual activity

At the time of interview four women had not resumed sexual intercourse. Three of these four women had not resumed sexual intercourse out of fear to undo the effect of surgery, and one woman had separated from her partner. All three women who had not resumed sexual activity out of fear of doing damage, had had previous surgery for the same complaint for which they were currently operated on, i.e. POP or SUI. Women were afraid the transobturator tape sling could be damaged ‘when you've got your legs open’ (n = 1), or the mesh used for sacrocolpopexy (n = 2) could dislodge during penetrative sex. Additional factors relating to the failure to resume sexual activity in these three women were: partner's physical difficulties and partner's fear of causing pain.

I suppose it's just this fear that because the mesh is in there and full penetration might sort of… I'm sure it won't do any harm or dislodge anything but I've just got that fear of… that something might happen and I might sort of be back to square one again. (participant 19)

Of the 26 women who had resumed sexual activity at the time of follow up, nine (34%) had started sexual intercourse around 6 weeks after surgery, and 15 (58%) were sexually active by 10 weeks after surgery. For two women (8%) the resumption of sexual activity was delayed to 3–4 months after surgery. The reason why sexual activity had been delayed by 3–4 months was that women wanted to make sure everything was healed completely so as to avoid dyspareunia and doing damage.

Eleven of the 26 women who had resumed sexual activity had had sex only once or twice at the time of their follow-up visit. Two of these eleven women had delayed resuming sexual activity by 3–4 months and therefore had not had sex regularly yet. The other women mentioned one or more reasons for this low frequency, either related or unrelated to the surgery. Reasons related to the surgery included: dyspareunia, not being well after surgery, new symptoms such as faecal urgency, used to not having sex (because of avoiding sex when incontinent), and partner afraid of causing pain. Reasons unrelated to the surgery included: no time together, tired and partner's physical restrictions.

Evaluation of sex life

Twenty women (67%) expressed overall improvement of their sex lives, although 15 of these 20 women also mentioned some factors affecting their sex life negatively. Two women (7%) were negative about their sex lives. Four women (13%) were positive as their sex lives were unchanged and another four women (13%) were not able to comment on their sex lives, because they were not sexually active yet. Both the reasons for improvement, as well as the negative factors, are described in more detail below.

Positive effects on sexual function

Cure of prolapse symptoms

A positive effect on the evaluation of women's sexual lives was seen from the cure of prolapse symptoms for four main reasons. The first reason was an improvement in body image. Following surgery, women described their vagina as ‘normal’ again, which made them feel more confident and more attractive. This improved the evaluation of their sex life, because they no longer had to worry about the presence of POP during sexual activity. Furthermore, worries about their partner's sexual experience, because he might feel or see the prolapse or because of lack of tightness, were resolved.

It was just awkward before, because there was like this lump there and it was, it was, it wasn't very nice, it was awkward with that like, it's like a growth there. You know, now I haven't got that, it's much better, much, much better. (participant 1)

It's just a relief really that it's not there. I can't say that it, it's just that is all really; it's just, it's gone. And uhm… It was funny because it felt as if it was, you know, an intrusion and because it has gone everything is a lot more relaxed. (participant 8)

The second reason was an improvement in genital sensations following POP surgery: women felt more sensitive and tighter.

Oh yeah, because obviously you can't feel a lot you know, when everything's collapsed inside. You can't, can you, really, because you know, there's loss of sensation, simply because everything's you know, well, floppy really, you know. I mean, you know, it obviously does make a difference. (participant 17)

The last two reasons were related either to relief of discomfort from POP during sexual activity or relief of fear of doing damage to POP during sexual activity.

It's a lot better, because obviously I had that, whatever it was, hanging down. That was quite painful, that was quite uncomfortable. Of course now I haven't got that and it's a lot better. (participant 1)

And, I just felt that if there was going to be any penetration then it would… And I didn't know looking back, I didn't know whether penetration could damage it, you know, or whether there would be, make a hole in it or, you know, and what that side effect would be. And I was really worried that it could do damage and then that would cause more damage, and that was in my mind all the time. (participant 8)

As a result of these four reasons women were less worried about having sex, were more relaxed to let things happen, and were not avoiding sexual activity anymore. A less profound effect was mentioned on arousal and orgasm. Only a few women described improvement in their ability to arouse as they did not have to worry about the presence of POP during sexual activity or the possibility of doing damage. For some women orgasm had improved, because of the improvement in genital sensations.

Cure of incontinence

A second positive effect on the evaluation of sex life was as a result of the cure of incontinence, either urinary or anal incontinence. With the cure of coital incontinence women were more confident and more relaxed during sexual activity, because they no longer feared incontinence during intercourse. Furthermore, without the need to empty their bladder or wash before sexual activity (because they had been afraid of smelling of urine or faeces), sex was more spontaneous.

So maybe let myself go a bit more, and you know not, because you're not worrying about [incontinence] in the back of your mind, you're just enjoying it, rather than, you know maybe holding back a bit because of that. (participant 38)

I knew I passed urine and I hated that. It made me feel very dirty and very uncomfortable and tense, you know, uhm and so to be able to not do that is great. (participant 9)

As women did not have to worry about the possibility of coital incontinence their drive, motivation, arousal and orgasm improved. Women were more relaxed and more confident regarding being sexually active and initiating sex and they were more confident during sexual activity. Furthermore, arousal improved as there was no need to void during sexual activity. A further improvement in orgasm occurred, because women did not have to prevent climaxing, which they would have done to prevent coital incontinence.

Well it makes me feel more confident about orgasm, if that makes sense. That when you kind of, you know, whereas before I was almost like not wanting to orgasm, because, you know, I know that if, when that happens I'm going to pass urine and then that, then that spoils the moment, because you then feel immediately dirty, you know. (participant 9)

Other positive effects of surgery

Two women described positive effects specifically following hysterectomy: they were no longer afraid of becoming pregnant during sexual activity, there was no need for contraception and no menstrual periods interrupting sexual activity anymore. Furthermore, having a new partner improved one woman's sexual activity, especially as he complimented her on her vaginal tightness.

Negative effects on sexual function

Dyspareunia

The most common factor negatively influencing the evaluation of sex life after surgery was the presence of dyspareunia. A total of 13 women complained of dyspareunia after surgery. Nine of these women also suffered with dyspareunia before surgery. However, before surgery dyspareunia was caused by the presence of prolapse, whereas after surgery the healing and scar tissue were causing the complaint. In eight of the 13 women postoperative dyspareunia affected their evaluation of their sex life; six women who had had POP surgery as a sole procedure and two who had had POP surgery combined with anti-incontinence surgery. For one woman full penetrative sex was impossible because of dyspareunia. None of the women who had had anti-incontinence surgery as a sole procedure had experienced dyspareunia after surgery.

Due to dyspareunia sex was not enjoyable, which affected drive and motivation, resulting in avoidance of sex. Dyspareunia also had an impact on arousal and consequently orgasm, because women were tense because of (fear of) pain, and were more focused on the discomfort than on enjoying sexual stimulation.

Worried about doing damage

For three women their sex life was affected by their worries regarding doing damage to the surgical repair. All three had had POP surgery only. Two of these three women felt their vagina was shorter, which also caused dyspareunia.

It seems that there is an ending, whereas before there didn't seem to be. You seem to hit something. (…) And the feeling that it was going to break, does that make sense? It feels as if it was, it was stretching. (participant 27)

Because of worrying about doing damage with penetrative sex, drive and motivation could be affected and women found it more difficult to become aroused.

I just imagine in my head that blood is coming out and you know. You can imagine you're having sex: “Oh my god blood's coming out.” If it comes out what am I going to do? And this and that. It's so many things going through my mind that I don't, I'm not thinking about what I'm doing. That's the reason that I'm not enjoying sex at all. (participant 32)

New symptoms

Sex life could also be affected by the presence of new physical symptoms, including faecal urgency, prolapse feeling, rectal bleeding and discomfort and swelling of labia. Faecal urgency as a new symptom following combined POP and anti-incontinence surgery was affecting the sex life of one woman, because this symptom required her to plan having sex, rather than it being spontaneous.

It is horrible to have to plan sort of sex, but we sort of do have to now. I mean we have got to know how my body is working and what time is sort of really bad for me. Like if I eat, within half an hour of eating I'm going to the toilet. (participant 5)

Of the 30 included women, five mentioned a feeling of prolapse following surgery and for two it affected their sex life. Physical examination showed POP in a different compartment after combined POP and anti-incontinence surgery in one of these women, but no POP was objectified in the other woman. Although both women felt less confident during sex because of it, due to the concomitant cure of SUI for one woman it did not affect her drive, motivation, arousal or orgasm. The second woman with POP symptoms, that were not objectified, did feel less motivated to be sexually active because of discomfort and because she was afraid to do damage to the prolapse. However, there was no impact on arousal and orgasm.

Sometimes it makes you not want to do it. If you, if you can feel that it's prolapsed any way during the course of the day, and if I can feel that it's hanging right down, yeah you do feel that you don't want to do it sometimes, you just can't be bothered, because you know that it's already uncomfortable, so all that's going do is make it worse. (participant 10)

For one woman drive and motivation were low because she was still suffering with rectal bleeding and pain associated with rectal granulation tissue following a stapled transanal resection of the rectum procedure. Her arousal was low because mentally she was distracted focusing on the discomfort. Furthermore, she was not completely confident regarding her bladder/bowel function, therefore it was difficult to reach orgasm. Another woman felt that her left labia had swollen, and because she was mentally focused on this the intensity of her orgasm was affected.

Unsatisfactory result of surgery

Two women specifically hoped surgery would improve vaginal tightness and genital sensations. After surgery they were dissatisfied with the result, because they had hoped for more tightness, and this negatively affected the evaluation of their sex life.

Because, you know, I was told that it would be quite tight to start with. Why don't I feel that it is? (…) I suppose I was expecting things to be a bit tighter than they are. (participant 17)

Other factors with negative effect

Other factors with a negative effect on the evaluation of sex life postoperatively were: partner's physical restrictions, relationship problems, partner worried about causing pain, low sexual drive related to long recovery from surgery or depression and anti-depressant use, which consequently affected arousal and orgasm.

Discussion

Main findings

The objective of this study was to assess whether assessment of sexual function using the PISQ[10] provides full insight into female sexual function following pelvic floor surgery. We showed that although PISQ is complete in representing the positive effects of surgery, most negative effects are not included. Following surgery improvement was seen in PISQ's Physical and Partner-related domains, which measure the impact of POP and SUI on sexual functioning and the woman's perception of her partner's response to this. With the cure of POP and/or SUI as a result of surgery it seems logical that questions such as ‘Do you avoid sexual intercourse because of bulging in the vagina?’, ‘Are you incontinent of urine with sexual activity?’, and ‘Does fear of incontinence restrict your sexual activity?’ show improvement. The results from the qualitative interviews confirmed that the improvement in sexual function following surgery was as a result of the cure of prolapse and incontinence symptoms. Furthermore, the qualitative results gave context and insight as to why the cure of prolapse and incontinence symptoms improve sexual function, including improvement in body image, improvement in genital sensations and the relief of fear of being incontinent during sexual activity. After surgery, there was no significant change in PISQ's Behavioural/Emotive domain, which evaluates sexual desire, arousal and orgasmic capabilities. Questions such as ‘Do you feel sexually excited (turned on) when having sexual activity with your partner?’, ‘Do you feel your vagina is so “dry” that sexual intercourse cannot occur?’, and ‘How often are you able to achieve orgasm (climax)?’, did not show any change after surgery. In the qualitative interviews women indicated that although there was a positive effect of the cure of prolapse and incontinence symptoms, there was a negative effect on desire, arousal and orgasm from postoperative dyspareunia, new symptoms, a disappointing result of surgery, or being worried about doing damage to the surgical repair. Other than dyspareunia, these negative aspects are not specifically part of the PISQ. Furthermore, the included questions on dyspareunia form only a small part of PISQ's Physical and Partner-related domain scores. Therefore, a deterioration in pain may be neutralised by simultaneous improvement in POP- and SUI-related factors.

Strengths and limitations

Our findings should be interpreted in light of the study limitations. First, our study had a relatively short follow-up time of a median of 17 weeks. Some women had not resumed sexual intercourse and others had not had sex regularly yet. The reason for us to choose this follow-up time was that women were generally allowed to resume sexual activity 6 weeks postoperatively and with longer follow-up time, changes unrelated to surgery might impact on sexual function as well. An added advantage is that we now obtained an insight into the reasons why women were reluctant to resume sexual activity. Nevertheless, we acknowledge that our follow-up time might not have allowed for full physical recovery from surgery especially when complications occurred. With full physical recovery, issues such as confidence and trust might be regained as well. Future qualitative studies should therefore be conducted at a longer follow-up time to study these issues further.

A second limitation is in our patient selection. We chose to use a sample with a large variation of surgical procedures performed in our hospital, so we would be able to comment on common themes associated with pelvic floor surgery. However, we cannot make any conclusions regarding the impact of specific surgeries on the sexual function of women. Furthermore, we did not include any women with vaginal mesh surgery because this type of surgery is not part of our routine practice. The impact of synthetic mesh augmentation at the time of vaginal prolapse repair has been debated in the current literature, as some studies showed increased rates of dyspareunia[4, 17, 18] compared with native tissue repair. Therefore, results from our study might not be representative for this group of women.

A third limitation is in selecting the ‘good’ informants. Experiences and feelings regarding sexual function might have been different in women unwilling to discuss their concerns with their consultant. However, the idea behind selecting participants in qualitative research is to select those women who best help the researcher understand the research question. This does not necessarily involve random sampling of participants as typically found in quantitative research.[15] In fact three good descriptions can be better than 12 poor ones. Furthermore, as the women were selected before surgery, we were not able to select participants based on their sexual experiences after surgery, so eliminating bias.

Interpretation

The PISQ[10] was validated to discriminate women with sexual dysfunction from those without, within the group of women suffering with POP and SUI. Although the PISQ has shown its responsiveness to change after pelvic floor surgery,[4, 5] it might not be optimal to detect sexual dysfunction following surgery as new aspects due to the treatment become relevant. By neglecting the negative impact of pelvic floor surgery, PISQ's evaluation of sexual function following surgery might be too positive. Future studies should therefore be conducted to either confirm or reject this questionnaire as a validated tool for diagnosing sexual dysfunction after pelvic floor surgery. This is important, because when counselling women for pelvic floor surgery, information regarding the impact of surgery on sexual function is mandatory. Without a validated tool, research carried out to study the impact of surgery on sexual function is not reliable.

Before resuming sexual activity after surgery women commonly need reassurance about healing from their doctor as well as reassurance that sexual activity is ‘allowed’. As a result of this, sexual problems will not occur until after the postoperative review by the consultant. As women are commonly reluctant to seek help for their sexual concerns,[19-21] it is possible that sexual problems as a result of surgery will go unnoticed. It is therefore important to specifically address the possibility of dyspareunia and other sexual problems following surgery at the early postoperative review and give women the opportunity to return to clinic when sexual problems occur. Furthermore, our qualitative results showed that sexual inactivity can last up to 3 months postoperatively as a result of the fear of doing damage to the surgical repair. Early postoperative counselling should also in part be directed at reassuring women that tapes and meshes are unlikely to dislodge during penetrative sex.

We are not aware of another study that has used a mixed qualitative and quantitative approach to study sexual function following pelvic floor surgery. By comparing qualitative interviews to the results of the PISQ[10] we were able to show both confirmation and disconfirmation between the two. Compared to quantitative research, the qualitative interviews gave a deeper explanation of changes in sexual function and it helped us to understand the context and associations.

Conclusions

Our study has shown that the current condition-specific sexual function questionnaire for assessment of sexual function in women with POP and SUI (PISQ[10]) does not measure most surgery-specific deteriorating effects on sexual function. This questionnaire might therefore not be able to discriminate between women with and without sexual dysfunction following pelvic floor surgery. Future studies should therefore be conducted to either confirm or reject this questionnaire as a validated questionnaire for diagnosing sexual dysfunction after pelvic floor surgery.

Disclosure of interest

None.

Contribution to authorship

AMR conducted and analysed all the interviews and wrote the first draft of the paper, which was then revised by the co-authors. ATGP analysed 25% of the interviews and contributed substantially in the writing of the paper. RT and AHS co-designed the study and contributed intellectually to the paper. JWL contributed to the interpretation of the data in addition to revising the paper for intellectual content. All authors approved the final version of the paper for publication.

Details of ethics approval

Ethics approval was granted by the Outer South East London Research Ethics Committee (Lewisham Local Research Ethics Committee) (07/Q0701/2), and all participants signed informed consent before entering in the study.

Funding

Part of the research was funded by the Mayday Childbirth Charity Fund.

Acknowledgements

The authors would like to thank all the women who participated in the study.

Commentary on ‘Sex after surgery—what should we tell our patients?’

Pelvic floor disorders (PFDs) frequently affect sexual function and so, for sexually active women, it is important to consider sexual outcomes when treating PFDs. Some studies show disproportionately poorer sexual function in women with symptomatic PFDs, (Handa et al., Obstet Gynecol 2008;111:1045–52) whereas others show similar rates of sexual function and activity in women with and without PFDs (Fashokun et al., Int Urogynecol J 2013;24:91–7). These discrepant results lead to questions of which populations are being studied and how sexual function is being assessed.

In this article, Roos et al. highlight the use of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), a condition-specific questionnaire evaluating sexual function. As discussed by the authors, condition-specific questionnaires are preferred over general sexual function questionnaires when trying to understand changes in sexual health related to a physical condition, like PFDs. Hence, the PISQ may be more useful when assessing the impact of PFD treatment on sexual function. Furthermore, because of its ease of use, validity and responsiveness to change (Rogers et al., AJOG 2006;195:e1–e4) the PISQ has been adopted broadly in pelvic floor outcomes research.

In this study, the authors pose some interesting questions; (1) how often does a questionnaire tell the whole picture? and (2) how much of the picture do we want to capture? For those who use the PISQ in clinical or research settings, there have always been some notable shortcomings, mainly that it is only applicable in sexually active women and does not address reasons for sexual inactivity. After pelvic surgery, there are a myriad of physical, emotional and partner-related factors that may affect the timing of when and how couples choose to resume sexual activity. Hence, using the PISQ within the first 6 months after surgery is challenging, as highlighted by the findings of this study. As clinicians, we are interested in the ‘whole picture’ of our patients, which is not likely to be captured by any questionnaire. We probably need to be sensitive to postoperative concerns regarding new physical symptoms and fear of damage when resuming intercourse. However, when gathering data in questionnaire form, it is uncertain whether the immediate postoperative period is really the important part of the picture to capture. Most women make treatment decisions based on their desires for long-term results and so, for sexual function, it is probably more important to understand how women are doing 6, 12 and 24 months after surgery.

The authors feel that a better tool may be needed that further addresses postoperative issues. In their population, a particular postoperative issue was the lack of sexual activity at the time point when the participants were assessed. Hence, in the postoperative period, a questionnaire that can be applied to sexually active or non-sexually active women would serve as a better tool. The Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) has recently been developed and rigorously validated in the USA and UK (Rogers et al., Int Urogynecol J 2013 Apr 30 [Epub ahead of print]). This updated version of the PISQ is unique in that it can be administered to sexually inactive women and addresses reasons for sexual inactivity. Perhaps the PISQ-IR will be a suitable alternative to understand postoperative sexual function after pelvic surgery.

Disclosure of interests

I do not have any relevant disclosures or conflicts of interest.

  • NY Siddiqui

  • Obstetrics and Gynecology, Urogynecology, Duke University, Durham, NC, USA

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