Female Sexual Dysfunction in Urogenital Prolapse Surgery: Colposacropexy vs. Hysterocolposacropexy

Authors


Alessandro Zucchi, MD, Urology and Andrology Department, University of Perugia, 06100 Perugia, Italy. Tel: 00390755783979; Fax: 00390755726123; E-mail: azucchi@unipg.it

ABSTRACT

Introduction.  Colposacropexy (CSP), with or without hysterectomy, is a valid technique for the repair of severe urogenital prolapse. For many years, uterine prolapse has represented an indication for hysterectomy, apart from the presence or absence of uterine disease and the patient's desires. Nevertheless, sparing the uterus is essential to women not only to have normal sexual functioning but to maintain physical and anatomical integrity as well.

Aim.  To assess sexual function in a group of patients who underwent CSP or hysterocolposacropexy (HSP).

Materials and Methods.  We enrolled 37 patients who underwent surgery for urogenital prolapse (15 HSP, mean age 53 years; 22 CSP, mean age 56 years). Based on a preliminary sexual history and sexual questionnaire, all patients were sexually active before surgery. At a mean follow-up of 39 months, we reassessed the patients using the Female Sexual Function Index (FSFI).

Main Outcome Measure.  We considered sexual activity with a score of 30 = good, 23–29 = intermediate, and <23 = poor.

Results.  In patients who underwent CSP and HSP, sexual activity was good in 13% and 26%, intermediate in 33% and 21%, and poor in 54% and 53%, respectively; considering also five patients who no longer had sexual activity postoperatively. Nevertheless, the statistical analysis, performed based on the data obtained from the FSFI questionnaire, showed that there were no significant differences between the two groups of points in terms of total score—CSP 21.1 (1.2–33.5) vs. HSP 22.8 (3.6–34.5)—and single domains (desire, arousal, lubrication, orgasm, satisfaction, and pain) (P = not significant).

Conclusions.  Our data demonstrated no substantial differences regarding sexual activity in patients in which the uterus has been spared as opposed to those in whom it has been removed. Furthermore, in a small percentage of cases, surgery actually reduced regular sexual activity. Zucchi A, Costantini E, Mearini L, Fioretti F, Bini V, and Porena M. Female sexual dysfunction in urogenital prolapse surgery: Colposacropexy vs. hysterocolposacropexy. J Sex Med 2008;5:139–145.

Introduction

For many years, uterine prolapse has represented an indication for hysterectomy, apart from the presence or the absence of any uterine disease and independently of the patients’ desires [1]. Hysterectomy is still considered the standard procedure for correcting prolapse, even if uterine descensus is a consequence rather than the cause of prolapse [2]. Sparing of the uterus during prolapse surgery is a known technique [2,3]. However, only a few studies have been published to date on this subject. Moreover, based on the most recent literature, the indications for sparing or removing this organ in both open and transvaginal surgery are unclear.

In this regard, it is important to observe that women's lifestyles and expectations have changed profoundly in recent years, and that many patients with urogenital prolapse prefer to avoid ahysterectomy because they consider it extremely important not only to have a normal sex life but also to maintain physical integrity [3,4].

In the past, little or no consideration has been given to the problem of sexuality among patients who undergo pelvic surgery for urogenital prolapse, and validated questionnaires on sexual activity of these patients have been introduced into common clinical practice only recently [5,6].

Therefore, the aim of our study was to assess sexual function in a group of women who underwent open surgery for urogenital prolapse, comparing hysterectomy with sacropexy to hysterocolposacropexy (HSP) from the standpoint of functional and surgical outcomes [7].

Materials and Methods

Thirty-seven patients with symptomatic grade III–IV uterovaginal prolapse [8,9] were enrolled in this study between January 1999 and December 2004: 22 patients underwent hysterectomy and sacropexy, and 15 underwent HSP.

Table 1 resumes preoperative assessment of the two groups of patients.

Table 1.  Preoperative characteristics of the two groups of patients
 Colposacropexy (N = 22)Hysterocolposacropexy (N = 15)P
  • *

    Mean ± SD;

  • **

    **median and range.

  • NS = not significant; SD = standard deviation.

Age (year)*56.3 ± 6.352.9 ± 10NS
Parity** 2 (1–4) 2 (1–4)NS
Body mass index (Kg/m2)**25 (20–35.1)24.7 (20.1–29.2)NS
Menopause (%)14 (63%)8 (54%)NS

The patients were not randomized as they were free to decide whether or not they wanted their uterus retained (exclusion criteria: postmenopausal bleeding, previous cervical CIN, abnormal cervical smears, uterine enlargement, or cervical ulceration).

We clearly outlined the surgical procedure, the risks associated with uterine preservation, and the need for long-term checkups. We also acquainted fertile patients with pregnancy-related risks.

Before providing an informed consent, the patients understood that the surgeon reserved the right to perform hysterectomy during surgery if necessary or advisable.

Before surgery, all patients completed a detailed case history and sexual interview, as well as a nonvalidated sexual health questionnaire (validated questionnaire like Female Sexual Function Index [FSFI] have only recently been incorporated into clinical practice).

Preoperatively, all patients reported experiencing regular sexual activity and a satisfying sexual life. The patients also underwent a clinical urogynecological exam [8] using the Halfway as well as the Pelvic Organ Prolapse-Quantifization (POP-Q) system to quantitatively measure the degree of pelvic organ prolapse [9]. In addition, a pelvic ultrasound was performed to exclude uterine or ovarian disease, and a vaginal inspection in the lithotomy and standing positions were performed at rest and under maximum straining with full bladder; to measure preoperative vaginal length. Transrectal dynamic ultrasounds and urodynamic tests were performed in all patients (complying with the International Continence Society standards).

Surgical Technique

The surgeries were performed by the same team using consistent surgical techniques and procedures.

During HSP, the uterus was held with uterine forceps while the visceral peritoneum was incised over the isthmus. After emptying the bladder, the anterior vaginal wall was bluntly dissected from the bladder in order to reach the posterior bladder neck. The procedure was repeated for the posterior vaginal wall. When colposacropexy (CSP) followed a standard hysterectomy, the anterior and posterior vaginal walls were dissected off of the bladder and rectum respectively, as described in HSP. Careful preparation of the vagina made it possible to remove the uterus, sparing the vagina and thus leaving a long vaginal stump. Four or five reabsorbable sutures were placed on the anterior and posterior vaginal walls. Two meshes (Marlex, Cousin Biotech, Wervicq-Sud, France) were fixed on the anterior and posterior vaginal wall, and the length of the anterior and posterior meshes were adjusted avoiding traction.

The sacral promontory surface was prepared by opening the posterior peritoneum, and a nonabsorbable suture was placed in the sacral periostium about 2 cm below the promontory to fix the two meshes. The peritoneum is then closed over the meshes.

At a mean follow-up of 39 months (r. 16–84), all patients were reassessed by FSFI and sexual interview; clinical examination and ultrasound examinations were performed in order to know the real length of vagina after surgery.

We considered good sexual function as a score ≥30, intermediate between 23 and 29, and poor as ≤23.

Objective success was defined as the cervix and/or vaginal apex remaining well supported <6 cm above the hymenal plane, and no vaginal prolapse greater or equal to grade 2 at any site during Valsalva's maneuver.

Subjective success was determined by the absence of symptoms related to prolapse or incontinence.

Patient satisfaction was determined by replies to the question on whether the patient was satisfied about surgical outcome and would repeat the operation.

Statistical analyses were performed using the nonparametric Mann–Whitney test.

Results

Preoperative assessment of our patients, based on sexual history and our questionnaire, showed that all patients were sexually active before surgery with a satisfying sexual life. Postoperatively (FSFI results), in patients who underwent CSP and HSP, respectively, sexual activity was good in 13% and 26%, intermediate in 33% and 21%, and poor in 54% and 53%. In addition, only three patients (8%) experienced worsening dyspareunia postoperatively. Two patients reported relational issues as they no longer had a sexual partner for intercourse.

Statistical analysis performed on the data obtained from the FSFI questionnaire demonstrated that there were no significant differences between the two groups in terms of both total score—CSP 21.1 (1.2–33.5) vs. HSP 22.8 (3.6–34.5)—and in the individual domains examined (desire, arousal, lubrication, orgasm, satisfaction, and pain) (P = N.S.).

Table 2 and Figure 1 list the detailed results of statistical analysis conducted based on the data obtained through the FSFI questionnaire.

Table 2.  Different scores in different domains between the two groups of patients expressed in median value (range)
DomainColposacropexy (N = 22)Hysterocolposacropexy (N = 15)P
  1. NS = not significant.

Desire2.4 (1.2–5.4)3.0 (1.2–4.8)NS
Arousal3.3 (0–5)3.0 (0–6)NS
Lubrication4.0 (0–6)3.6 (0–6)NS
Orgasm3.4 (0–6)4.0 (0–5.6)NS
Satisfaction4.4 (0–6)4.8 (0–6)NS
Pain3.6 (0–6)4.4 (0–7)NS
Total21.1 (1.2–33.5)22.8 (3.6–34.5)NS
Figure 1.

Box-and-whiskers plots of Female Sexual Function Index scores. The middle box covers the middle 50% of data, between lower (25th) and upper quartile (75th); the “whiskers” extend out to the 10th and 90th percentiles, while the central line is at the median.

Total vaginal length was similar in both groups as no significant intergroup difference was found between postoperative measurements (Table 3).

Table 3.  Pre- and postoperative vaginal length in CSP and HSP
 CSP (N = 22)HSP (N = 15)
  1. CSP = colposacropexy; HSP = hysterocolposacropexy; NS = not significant.

Total vaginal length (cm)7 (6, 10)6.5 (6, 10)P = N.S.8 (6, 11)8 (6, 11)P = NS

The patients’ overall satisfaction level, as well as objective and subjective results, are briefly reported in Table 4.

Table 4.  Overall results
 Colposacropexy (N = 22)Hysterocolposacropexy (N = 15)P
  1. NS = not significant.

Objective results20 (90%)14 (93%)NS
Subjective results18 (82%)13 (86%)NS
Satisfaction20 (90%)14 (93%)NS

Discussion

In the patients affected by urogenital prolapse, the goals of pelvic floor and reconstructive genital surgery are to maintain the natural vaginal axis and correctly suspend the top of the vagina. Abdominal sacropexy corrects uterovaginal prolapse, leaving a functional and anatomical vagina without painful or rigid scarring. In addition, the uterus can be preserved using this technique. In our previous study, published in European Urology [7], there were no differences in outcomes in terms of subjective, objective, and patient satisfaction assessment after HSP or hysterectomy with CSP. The advantages of HSP include maintaining pelvic anatomy integrity, which is crucial in prolapse resolution, and significantly reducing blood loss, operating times, and hospital stays. The main disadvantage is the continuous surveillance required for cervical or uterine cancer.

Sexual well-being is an important aspect of women's health, and dysfunction can lead to a decrease in quality of life and can affect marital relations. Although female sexual dysfunction is a common problem among the general population [10] and especially in urogynaecological patients, it has been poorly studied and reported in the literature.

Several recent studies clearly show that there are no differences in sexual function between patients with and without pelvic floor dysfunction, with over 81% of sexually active women with prolapse defining their sexual relations as “very satisfactory”[11–15].

The only parameter that can be related to reduced sexual activity is represented by age: increasing age is related to reduced sexual activity and no available partners [14].

Moreover, there are few specific studies that investigate sexual function following reconstructive surgery such as CSP and HSP. Recent reports, comparing vaginal and abdominal approaches, show extremely conflicting results concerning postoperative sexual activity [16].

Concerning uterine removal, the percentage of sexual dysfunction among patients who have undergone hysterectomy varies from 13% to 37% [17,18]. If we analyze the data reported in the literature, however, it is clear that there is a significant divergence of opinions on this subject [19].

While some authors report normal or even improved sexual activity following hysterectomy, other authors report worsening in sexual function: in fact, some authors suggest that uterine contractions play an important role in the perception of orgasm [20], whereas others sustain that hysterectomy can shorten the vagina or damage the autonomic nerve endings in the cervicovaginal area [21]. Hysterectomy could have also psychological effects with loss of self-esteem in these patients [16].

Recent studies have focused on the possibility that anatomic modifications induced by uterine surgery can damage sexuality; damage to the innervation of the uterine cervix and the upper vagina, following hysterectomy, could interfere with the mechanisms involved in lubrication and orgasm [20]: internal orgasm is essentially a cervical orgasm provoked by stimulation of the nervous fiber endings of the uterovaginal plexus that surround the cervix and the upper vagina. Therefore, the loss of most of the uterovaginal plexus could have adverse effects on the sexuality in women who had this type of orgasm preoperatively [20]. Inversely, women who only had clitoral orgasm do not have this type of problem, as the clitoral nerve fibers are not affected by removal of the uterus [20].

In contrast, longitudinal studies demonstrate a positive effect of hysterectomy on sexual function. A recent study involving 1,132 patients, using a sexual questionnaire (sexual functioning outcomes of the Maryland Women's Health Study), demonstrated that following hysterectomy there is an improvement in sexual arousal of 70.5% vs. 76.7% after 24 months, reduction in dypareunia (18.6% vs. 3.6%), improved libido (35.3% vs. 45.2% desiring sex >1 day/week), and a decrease in vaginal dryness. Surgical approach did not alter any of the sexual outcomes [22].

Moreover, it has been demonstrated that there are no differences between total and subtotal hysterectomy in terms of dyspareunia, quality of orgasm, or sexual satisfaction, with an improvement in sexual function in both groups [23,24].

Therefore, damage to autonomic nervous fibers could play a primary role at the onset of sexual dysfunction. It is important to note, however, that this depends on the type of hysterectomy performed, and whether or not a hysterectomy is required. For instance, in patients with cervical or uterine cancer, a radical hysterectomy is usually performed resulting in easier potential damage to nerve fibers. In our study, we considered only patients without any uterine pathology other than descensus, limiting debulking surgery. Blunt dissection of the vagina makes it possible to remove the uterus, sparing contiguous structures as much as possible [25].

Our statistical analysis shows that there are no differences, in terms of sexual function, between the patients in whom the uterus was spared and those in whom it was removed.

We did not use a validated questionnaire preoperatively, which certainly introduces bias. Nevertheless, by using sexual history and our sexual health questionnaire, as supported by recent literature [11–15], we can affirm that 87% of the patients postoperatively did not experience any alteration of any parameters evaluated in the FSFI questionnaire. We must, however, carefully interpret these results given our limitations in small sample size and low statistical power.

Of the five patients (13%) who reported deteriorated sexual activity, only three (8%) had real sexual problems (dyspareunia) and two reported only relational problems (no partner), but they would have had sexual intercourse.

The clinical exams and ultrasound performed pre- and postoperatively also allowed us to establish, with a great degree of accuracy, the length of the vagina before and after surgery. Careful preservation of a large vaginal stump, which can technically be performed due to the fact that these cases were benign, made it possible to maintain a vaginal length that was fully adequate for sexual relations.

Conclusions

As a result of changing attitudes in Western society toward sexuality and the psychological and emotional value of the sexual organs, surgeons must consider the wishes and feelings of the patient who wants to preserve vaginal function and the uterus.

CSP with or without hysterectomy provides secure proximal and distal anchorage, without tension, maintaining normal vaginal axis and a good vaginal length.

HSP can be safely offered to women with symptomatic descensus who request uterine preservation. Although women who retained their uterus were satisfied with maintaining their bodily integrity, and they were fully informed of the need for ongoing, long-term follow-up to prevent malignant disease.

Statistical analysis of our data, on a small series of patients, reveals that there are no substantial differences in sexual activity in patients in which the uterus has been spared or removed. Furthermore, in a small percentage of cases, surgery actually reduced regular sexual activity.

Conflict of Interest: None declared.

Statement of Authorship

Category 1

  • (a)Conception and Design
  • Alessandro Zucchi; Elisabetta Costantini

  • (b)Acquisition of Data
  • Luigi Mearini; Fabrizio Fioretti

  • (c)Analysis and Interpretation of Data
  • Vittorio Bini; Massimo Porena

Category 2

  • (a)Drafting the Article
  • Alessandro Zucchi; Elisabetta Costantini

  • (b)Revising It for Intellectual Content
  • Massimo Porena

Category 3

  • (a)Final Approval of the Completed Article
  • Alessandro Zucchi; Massimo Porena

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