- To evaluate the impact of laparoscopic sacrocolpopexy on symptoms, health-related quality of life (HRQL) and sexuality among women with symptomatic urogenital prolapse (UGP).
Colorectal-Anal Impact Questionnaire
Defecation Distress Inventory
Pelvic Floor Distress Inventory (questionnaire)
Pelvic Floor Impact Questionnaire
Pelvic organ prolapse urinary Incontinence Sexual Questionnaire
Pelvic Organ Prolapse Impact Questionnaire
Pelvic organ prolapse-Quantification
Pelvic Organ Prolapse Screening Instrument
Urinary Distress Inventory
Urinary Impact Questionnaire
Sexual function of women is influenced by psychological, sociological, physical and environmental factors . Age and the menopause both have a negative impact on sexuality . Urogenital prolapse (UGP) is responsible for pelvic symptoms that might equally lead to decreased sexual function . UGP is a frequent ailment with a prevalence of ≈50% and a lifetime risk of needing surgery of 19% [3, 4].
The most frequent symptoms associated with UGP concern genital symptoms (sensation of having a ball in the vagina, perineal heaviness) as well as urinary symptoms (dysuria, urinary incontinence, UI) or ano-rectal (constipation or faecal incontinence) [5, 6]. Those symptoms affect health-related quality of life (HRQL) but also sexuality . It is very difficult to know what role organic and psychological factors linked to UGP play in the onset of sexual disorders [8, 9]. Currently, the existing data in this area are hard to compare, as the tools used to evaluate sexuality are not standardised. However, all studies agree that patients with UGP experience sexual health inferior to those of the same age without a UGP [10-12].
For patients who are still sexually active, one of the main treatments of UGP is abdominal sacrocolpopexy using non-absorbable prostheses . The laparoscopic route has allowed the technique to be less invasive and to reduce postoperative convalescence . Although the result of the surgery is related to anatomical correction, the main objective must be to correct the symptoms related to the UGP. The preoperative evaluation has to specify through interview and clinical examination, the degree of UGP, the nature of pelvic symptoms and their impact on HRQL and on sexual function. The quality of this evaluation will then allow the outcome of the symptoms to be objectively evaluated .
There is not, to our knowledge, any study evaluating the relationship between the clinical degree of a UGP, the severity of symptoms linked to the UGP and the quality of sexual health. The main objective for practitioners treating such a functional ailment should be to improve the HRQL of patients and to preserve their sexuality. The capacity to undertake daily activities of living and sexual function are therefore at least as important as the improvement of symptoms attributable to the UGP . These functional data can be measured with the help of specific questionnaires, of which many have been validated by the ICS . Their simplified versions (also validated by the ICS) currently make them easily employable in everyday practice.
To date, very few studies have evaluated the effect of surgical treatments of UGP on sexual function using validated tools.
The main objective of the present study was to evaluate the impact of laparoscopic sacrocolpopexy on sexual function and symptoms of patients presenting with a symptomatic UGP. The second objective was to determine if HRQL is improved by the laparoscopic treatment of UGP.
Between February 2009 and January 2012, we conducted a multicentre prospective study. In all, 148 patients were included according to the following criteria: aged ≥18 years, symptomatic UGP stage ≥2 (according to Pelvic organ prolapse-Quantification [POP-Q] classification). The patients received clear information about the objectives of the study and the content of the questionnaires. Their written consent was then obtained. The French National Ethic Committee (CNE) approved the study and data were protected by the French National Committee of Informatic and Liberty (CNIL).
A standardised formula was used to record data such as age, weight, height, previous medical history, surgery, and obstetric history. The results are expressed in medians and percentages.
The POP-Q classification was used to quantify the clinical severity of the UGP. The measurement of the following points were reported: anterior vaginal wall (Ba), posterior vaginal wall (Bp) and cervix (C).
Sexual quality of life was evaluated using the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12). It is a specific self-administered questionnaire that has been validated in French [17, 18].
The Pelvic Floor Distress Inventory (PFDI-20) questionnaire was used to evaluate the severity of symptoms related to the UGP and validated in French .
To evaluate the impact of these symptoms on HRQL, we used the Pelvic Floor Impact Questionnaire (PFIQ-7), both specific and validated in French .
The PFDI-20, PFIQ-7 and PISQ-12 questionnaires were completed at the preoperative consultation. The total mean score and also the mean score for each sub-questionnaire [Urinary Distress Inventory (UDI-6), Pelvic Organ Prolapse Distress Inventory (POPDI-6) and Defecation Distress Inventory (DDI-8)] are reported. For the questionnaire on sexuality (PISQ-12), we report the total mean score as well as the mean score for each of the 12 questions.
All surgeons were considered as expert in the treatment of UGP and all performed traditional laparoscopic surgery. In each case, both anterior and posterior repair was done using Surgimesh prolapse® implant and no hysterectomy or incontinence treatment was undertaken during the surgery.
Patients were followed-up at 3 and 12 months after surgery. Each follow-up appointment consisted of a clinical evaluation (POP-Q) and the patients completed the questionnaires (PFDI-20, PFIQ-7 and PISQ-12). The results are reported as the mean (sd).
For statistical analyses we used the non-parametric test of Spearman to evaluate the correlation between symptom scores (PFDI-20, DDI-8, POPDI-6 and UDI-6) and sexual function (PISQ-12). The Student's t-test was used to compare preoperative data with follow-up results for all symptoms, HRQL and sexuality scores. A P < 0.05 was considered to indicate statistical significance. We defined clinical failure as the existence, after treatment, of a grade ≥2 UGP.
In all, 148 patients were included. The median (range) age was 63.1 (33.7–86.3) years. The patients had between zero and seven children with a median of two. In all, 10 patients (6.8%) had already been operated on for stress UI and 16 (10.8%) had had failed UGP treatment, of whom 12 (8.1%) had been operated on vaginally and four (2.7%) abdominally. In all, 33.8% of patients presented with stress UI and 10.8% with urge UI. Constipation affected 30.4% of patients. Dyspareunia was reported by 27 patients (18.2%) (Table 1).
|Median (range) age, years||63.1 (33.7–86.3)|
|Mean (sd) body mass index, kg/m2||25.03 (3.55)|
|Median (range) parity||2 (0–7)|
|C-section, n (%)||9 (6.1)|
|Hysterectomy, n (%)||19 (12.8)|
|Previous UI surgery, n (%):||10 (6.8)|
|Previous prolapse surgery, n (%):||16 (10.8)|
|Abdominal route||4 (2.7)|
|Vaginal route||12 (8.1)|
|UI, n (%):||66 (44.6)|
|Overactive bladder||16 (10.8)|
|Constipation, n (%)||58 (39.2)|
|Anal incontinence, n (%)||45 (30.4)|
|Dyspareunia, n (%)||27 (18.2)|
At 3 months after surgery, 11.3% of patients reported stress UI and 9.9% had urge UI. De novo urge UI was reported at this time by three patients (2.3%). Eight patients (5.6%) reported persistent dyspareunia and one (0.7%) de novo dyspareunia. All data were significantly lower than preoperatively.
At the 12-month follow-up examination, 10.9% of patients presented with stress UI, 13.3% with urge UI and 2.8% with de novo urge UI. Dyspareunia was persistent in six patients (4.7%) and two reported de novo dypsareunia (1.6%). These percentages were significantly lower than preoperatively. There was no significative difference between the results at 12 months and those at 3 months.
In all, 142 patients (95.9%) were reviewed at 3 months and 128 (90.1%) at 12 months. The anatomical results at 3 months showed a significant correction (P < 0.05), relative to the preoperative values, of the three pelvic floor parameters measured (Table 2). The recurrence rate was 6.3% (nine of 142). Anatomical correction remained significant at 12 months (P < 0.05), relative to the preoperative values. At this time, the recurrence rate was 7% (nine of 128). It is worthy to note that there was no significant difference between the results at 3 months and those at 12 months.
|Anterior vaginal wall (Ba)||Posterior vaginal wall (Bp)||Cervix (C)|
|Preoperative value, cm||+0.7 (1.6)||–1.7 (1.8)||–0.1 (2.5)|
|3-month value, cm||–3 (2.2)*||–2.3 (1.7)*||–5.9 (2.7)*|
|12-month value, cm||–3 (2.1)*||–2.3 (1.7)*||–5.5 (2.8)*|
The response rate to the PFIQ-7 questionnaire was 79.7% (118/148) preoperatively. It was 71.8% (102/142) at 3 months and 75% (96/128) at 12 months. The results showed a significant improvement (P < 0.05) on all scores [Pelvic Organ Prolapse Impact Questionnaire (POPIQ-7), Urinary Impact Questionnaire (UIQ-7) and Colorectal-Anal Impact questionnaire (CRAIQ-7)] at 3 and 12 months (Table 3). There was no significant difference between the scores at 3 months and those at 12 months.
|Mean (sd) score:|
|Preoperative score||3 months||12 months|
|POPIQ-7 (/100)||23.45 (4.85)||4.58 (1.87)*||5.78 (1.39)*|
|UIQ-7 (/100)||30.25 (7.26)||8.07 (1.37)*||8.20 (1.62)*|
|CRAIQ-7 (/100)||13.37 (2.01)||5.17 (1.33)*||5.19 (1.88)*|
|Total score (/300)||64.04 (5.20)||16.61 (4.12)*||18.21 (4.71)*|
In all, 120 patients (81.1%) completed the PFDI-20 questionnaire preoperatively. The response rate was 73.9% at 3 months (105/142) and 78.9% at 12 months (101/128). At 3 months there was a significant improvement (P < 0.05) in the total mean score (32.24 vs 94.31) and also in all the scores of the sub-questionnaires: POPDI-6 (6.67 vs 40.39), UDI-6 (12.66 vs 33.06) and DDI-8 (12.91 vs 20.87) (Table 4). At 12 months, the improvement remained significant (P < 0.05) for all scores compared with the preoperative results. Once again there was no difference between the results at 3 months, and those at 12 months.
|Mean (sd) score:|
|Preoperative||3 months||12 months|
|POPDI-6 (/100)||40.39 (2.28)||6.67 (9.76)*||10.06 (4.10)*|
|UDI-6 (/100)||33.06 (5.16)||12.66 (1.62)*||13.63 (7.74)*|
|DDI-8 (/100)||20.87 (1.89)||12.91 (4.44)*||14.37 (4.51)*|
|PFDI-20 (/300)||94.31 (5.64)||32.24 (3.44)*||38.06 (8.15)*|
In all, 118 patients were sexually active (79.7%) and 83.9% of these patients (99/118) completed the PISQ-12 questionnaire at their preoperative consultation. The total PISQ-12 score was significantly linked to the symptom scores of the PFDI-20, POPDI-6 and UDI-6 (all P < 0.05) but not to the DDI-8 score (P = 0.22). There was no significant link between the POP-Q value and the overall sexuality score PISQ-12 (P = 0.24).
The total mean (sd) score of the PISQ-12 questionnaire was 32.07 (7.36) preoperatively and the mean score for each item varied from 2.1 (sexual desire) to 3.5 (fear of UI during sexual relations) (Table 5).
|PISQ-12 items||Mean (sd) score:|
|Preoperative||3 months||12 months|
|Sexual desire||2.1 (1.1)||2.2 (1.1)||2.3 (1.1)|
|Comparison of orgasmic level between past and present||2.1 (0.9)||2.6 (1.0)||2.7 (1.0)|
|Climax (orgasm)||2.3 (1.3)||2.4 (1.3)||2.5 (1.2)|
|Sexual satisfaction with sexual activities||2.3 (1.3)||2.5 (1.3)||2.7 (1.1)|
|Sexual excitement||2.4 (1.2)||2.5 (1.2)||2.7 (1.1)|
|Avoidance of intercourse due to prolapse||2.7 (1.4)||3.7 (0.8)*||3.8 (0.5)*|
|Pain during intercourse||2.8 (1.2)||3.1 (1.2)||2.9 (1.1)|
|Negative emotional reactions||3.0 (1.3)||3.6 (1.0)*||3.7 (0.8)*|
|Erection problems of partner||3.2 (1.1)||3.1 (1.2)||3.4 (1.2)|
|Premature ejaculation of partner||3.3 (1.1)||3.2 (1.2)||3.5 (1.0)|
|UI during sexual activities||3.5 (0.9)||3.7 (0.8)||3.7 (0.7)|
|Fear of UI during sexual activities||3.5 (1.1)||3.6 (1.0)||3.8 (0.6)|
|Total PISQ-12 score||32.07 (7.36)||35.42 (7.76)*||36.56 (6.50)*|
Among the 99 PISQ-12 questionnaires initially completed, 80 were completed again at 3 months after surgery (80.8%). At 3 months, the total mean score had improved significantly compared with the preoperative score (35.42 vs 32.07, P < 0.05). Analysing the 12 items of the questionnaire separately, we found that only some were significantly increased after surgery; they were: ‘existence of negative emotions during sexual activity’ and ‘the avoidance of sexual activity because of prolapse’ (both P < 0.05) (Table 5).
At 12 months after surgery, 87 PISQ-12 questionnaires were again completed (87.9%). The total mean score remained significantly improved compared with the preoperative score (36.56 vs 32.07, P < 0.05). The two items that had improved at 3 months, remained improved at 12 months.
We also noted a significant improvement in overall sexual satisfaction (P < 0.05), as well as a significant lessening of the fear of UI during sexual activities (P < 0.05) (Table 5). There were no significant differences between the results obtained at 3 months and those obtained at 12 months.
To our knowledge this is the first prospective multicentre trial based on specialised and validated self-questionnaires evaluating the effect of laparoscopic sacrocolpopexy on sexuality, symptoms and HRQL.
The present results show that UGP tends to negatively affect sexual function. Handa et al.  reported that 30% of patients had poorer sexuality due to pelvic or vaginal symptoms. In the same trail, ≈45% of women avoided sex because of bulging in the vagina and 44% because of pain. The average overall preoperative score for the PISQ-12 questionnaire in the present study population was slightly better than the average published scores for women with UGP (32.07 vs 31.01) .
The effect of UGP symptoms on sexuality is still debated and the existing data are contradictory. For some authors there is no correlation between severity of symptoms linked to UGP and altered sexuality . However, we have shown a significant negative effect of urinary and pelvic symptoms on sexual well-being. It has been shown that urinary symptoms and in particular UI negatively affect sexual function, independently of the type of UI . We found that ano-rectal symptoms did not have any effect on overall sexual function, which is in in accordance with published data .
In the present study, the sexual function score and clinical severity of UGP were not statistically linked. One reason might be that sexuality is under the influence of several other factors, e.g. psychological, environmental or social . In fact it is not possible to compare sexuality with only anatomically related function. Moreover, in the present study, anatomical correction of the UGP did not improve every sexual field, supporting the influence of other environmental, social and psychological factors on sexual function .
Overall, these results suggest that the PISQ-12 questionnaire is a useful tool, which allows evaluation of overall sexual function for those women presenting with a UGP.
Komesu et al.  has outlined the basis of an evaluation of sexual function by the total score of the questionnaire PISQ-12. A precise analysis of each response supplied by the patient allows a more precise targeting of the domain affected. However, it is not a tool that allows a fine appreciation of sexuality of the partners of patients with UGP. Yet, it seems that the evaluation of masculine sexuality is a major element in the sexual health of a couple. Thus, it appears necessary to develop reliable and reproducible tools to allow an objective analysis of the sexual function of partners.
In the present study, the relapse rate at follow-up was 6.3% at 3 months and 7% at 12 months, which is consistent with published data [24-28].
On the other hand, we found an important improvement in HRQL from the third postoperative month. The total score was a quarter of that of the preoperative value. Published studies report a significant improvement in HRQL after laparoscopic sacrocolpopexy [29-34]. Sexual function was also significantly improved from the third postoperative month. This increase remained significant 12 months after surgery and there was no significant improvement between the 3- and 12-month follow up.
Thus the present results confirm that the laparoscopic correction of UGP is an effective method for significant improvements in the medium term, both for HRQL and sexuality .
Several recent studies have shown an improvement in sexual health after laparoscopic sacrocolpopexy [28, 36, 37]. However, there has been no study, to our knowledge, which has suggested a postoperative delay beyond which there will be no further improvement in sexuality. The present results show that this improvement mainly happens in the first 3 months after surgery.
These successful results of laparoscopic sacrocolpopexy should be considered when compared with the results for the different therapeutic options, especially for their impact on sexual health.
Amongst these, the use of a pessary constitutes a non-invasive and low morbidity treatment. Its efficiency on urinary and digestive symptoms has already been shown. They can be used as a therapeutic trial before surgery [38, 39]. However, for anatomical reasons, sexual health may limit this option especially in younger women.
Surgery by the vaginal route presents undeniable advantages particularly for operative morbidity. Its weak point remains vaginal scarring and sensory changes caused by prosthetic surgery. Results on sexual health are contradictory depending on the study. Some authors have shown that they are able to use techniques allowing preservation of sexuality . But most studies, to date, have shown a deleterious effect of vaginal surgery on sexual health [28, 41]. A recent Cochrane review  reported that abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse (relative risk 0.23, 95% CI 0.07–0.77) and dyspareunia (relative risk 0.39, 95% CI 0.18–0.86) than with vaginal sacrospinous colpopexy. The vaginal route was quicker and cheaper to perform. Moreover, it allowed an earlier return to activities of daily living and a shorter length of stay.
Finally, studies are necessary to evaluate the benefit of robot-assisted surgery in the management of UGP. Results from such studies should allow us to report a net benefit despite the significant cost of the procedures.
UGP surgery seems to be beneficial for male partner's sexuality. It seems that the perception that men have of their sexuality is improved by surgical treatment of their partner's UGP . However, in the present study, items concerning sexuality of the partner, which are part of PISQ-12 questionnaire, were not significantly improved. Specific analysis should be done to more clearly evaluate this parameter.
When surgically managing a UGP, the physician will have to respond to a complex problem: to propose an anatomical correction of the UGP and its symptoms without altering sexual function. The use of prosthetic materials has allowed an improvement in UGP surgery results: clinically, functionally and sexually.
However, patients should be informed of the inherent complications that result from the use of prostheses . The choice of operating technique should not be dictated by surgical habits but by the functional and sexual complaints of the patient. Counselling on the expected benefits of the surgery on sexual health is mandatory.
All patients should be classified in the context of an overall evaluation of the type of UGP, associated functional symptoms but also on the sexuality of both the woman and ‘the couple’.
In conclusion, laparoscopic sacrocolpopexy resulted in an early and persistent (in the medium-term) improvement of symptoms, HRQL and sexuality. This improvement occurred primarily in the first 3months after surgery.
Anatomical improvement was not related to an improvement of all fields of sexuality. Thus confirming the existence of several factors, notably environmental, social and psychological, influencing the sexual wellbeing of a woman.
The present study underlines the importance of preoperative evaluation of sexual health. At the time of the therapeutic decision, patients as well as their partners should be informed of the expected benefits in these domains.