Int Urogynecol J (2010) 21:13131319 DOI 10.

1007/s00192-010-1198-x

ORIGINAL ARTICLE

Can sex survive pelvic floor surgery?

Sushma Srikrishna & Dudley Robinson & Linda Cardozo & Juan Gonzalez

Received: 23 February 2010 / Accepted: 29 May 2010 / Published online: 25 June 2010 # The International Urogynecological Association 2010

Abstract Introduction/hypothesis Sexual function in women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) is adversely affected, but data reporting sexual function following surgery are limited. We aimed to determine effect of pelvic reconstructive surgery on sexual function and to evaluate effect of additional continence procedures. Methods Women with POP or SUI were assessed using pelvic organ prolapse quantification (POP-Q) or videocystourethrography. Sexual function was assessed with Golombok Rust Inventory of Sexual Satisfaction (GRISS) and sexual domains on prolapse quality of life (P-QoL) questionnaire and King's Health questionnaire. Women were reviewed over 2 years using all these objective and subjective assessments. Results In total, 52 patients were followed up over 2 years. Sexual function measured using GRISS scores and sexual function domain scores of KHQ and P-QoL improved following surgery. A better supported pelvic floor (POP-Q) was associated with significantly improved GRISS scores. Conclusions These findings aid in pre-operative counselling of women with POP and SUI about potential improvement in sexual function post-operatively. Keywords Urogenital prolapse . Urinary incontinence . Quality of life . Sexual function . Surgery

Introduction Urogenital prolapse and urinary incontinence are common distressing conditions with a significant impact on quality of life (QoL)[1, 2]. As there is no standard validated definition of urogenital prolapse, it is difficult to determine prevalence in the female population. However large population studies suggest that the prevalence of stage three to four prolapse is in the range of 211% [3, 4]. Urinary incontinence can affect up to 41% of women, in epidemiological studies [5]. Sexual function in this population of women has been shown to be adversely affected in a number of studies [6, 7] although data reporting sexual function following surgical repair are limited and conflicting. Some studies have shown an improvement [8, 9] whilst others have suggested a deterioration in sexual function [10, 11]. Previous work has tended to concentrate on treatments for either urogenital prolapse or stress incontinence alone [1214], and has also been limited in the past, by lack of validated instruments to assess sexual function. Interestingly, a recent study evaluating both male and female sexual function before and after surgery for pelvic organ prolapse found that surgery improved female desire, arousal, lubrication, dyspareunia and overall satisfaction, although orgasms remained unchanged. In men, interest, sexual drive and overall satisfaction improved significantly. Erection, ejaculatory function and orgasm remained unchanged [15]. Similar improvements in desire, arousal, lubrication, orgasm and satisfaction and dyspareunia have been confirmed by other studies [16]. The primary aim of this study was to determine the effect of surgery for prolapse or incontinence on sexual function using the sexual function domain of the King's Health Questionnaire (KHQ). Our secondary aim was to

S. Srikrishna (*) : D. Robinson : L. Cardozo : J. Gonzalez Department of Urogynaecology, Kings College Hospital, Denmark Hill, London SE5 9RS, UK e-mail: sushmasrikrishna@hotmail.com

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evaluate the effect of surgery using two other validated questionnaires, the sexual function domain of the prolapse quality of life questionnaire (P-QoL) and the Golombok Rust Inventory of Sexual Satisfaction (GRISS), and to compare sexual function in subjects undergoing prolapse repair alone with prolapse repair combined with continence surgery.

Materials and methods This was part of a prospective longitudinal observational study. Women complaining of symptomatic urogenital prolapse or stress urinary incontinence (SUI) and who were on the waiting list for pelvic floor surgery were recruited from a tertiary referral urogynaecology centre. All the patients fully understood the nature and purpose of the study and a written informed consent was obtained prior to study entry. Ethical approval for this study was obtained from the King's College Hospital Ethics committee. Inclusion criteria included women who were currently sexually active and on the waiting list for planned urogenital prolapse repair with or without a concomitant continence procedure. Women were excluded if less than 18-years old and if their surgery included removal of previously inserted synthetic mesh as a result of mesh complications. The surgeries for prolapse included vaginal hysterectomy, pelvic floor repair with or without vaginal vault suspension. Specifically, no synthetic mesh augmentation was used for any vaginal repairs. All repairs, anterior colporrhaphy or posterior colpoperineorrhaphy, were done by recruiting native fascial tissue for repair. All posterior repairs included perineorrhaphy in addition to fascial repair of the posterior compartment. The vault suspension procedures comprised either of vaginal sacrospinous ligament fixation using delayed absorbable polydioxone sutures or open abdominal sacrocolpopexy using monofilament macroporous polypropylene mesh (Ethicon). The surgeries for incontinence included tension-free vaginal tape (TVT), TVT-obturator (TVT-O) (Gynecare Inc, Johnson and Johnson,Somerville, NJ) and open Burch colposuspension (with four delayed absorbable polydioxone sutures on each side, no simultaneous paravaginal repairs were performed). The surgical procedures were carried out either by one of the two urogynaecogy consultants or the subspecialty trainee. Women with urogenital prolapse were pre-operatively assessed objectively by clinical examination using the pelvic organ prolapse quantification system (POP-Q)[17] All women with SUI underwent pre-operative videocystourethrography (VCU) to confirm the presence of urodynamic stress incontinence (USI) and exclude underlying detrusor overactivity and voiding dysfunction.

The impact of urogenital prolapse and urinary incontinence on women's QoL was assessed with the P-QoL and KHQ, respectively. The P-QoL and KHQ are reliable and validated disease specific questionnaires which assess both the severity of symptoms of prolapse or urinary incontinence and their impact on the QoL of affected women. Each of these questionnaires has a domain on sexual function. The scoring system of these questionnaires has been previously reported [1, 2]. In addition, all sexually active women were also asked to complete the female scale of the GRISS [18]. The GRISS is a short 28-item questionnaire for assessing the existence and severity of sexual problems. The GRISS is used by sexual dysfunction clinics and relationship counsellors to monitor the state of their patient's sexual function. It has also been used in clinical trials of new treatment approaches and pharmacological products designed for treatment of sexual dysfunction. It is particularly useful in identifying the extent of any change in sexual function as a result of therapy. The female version of the GRISS produces a total score as well as subscales of: & & & & & & & Infrequency: number of times a week (or less) on which sexual intercourse takes place. Avoidance: extent to which a female partner is actively avoiding having sex. Anorgasmia: extent to which a woman is able to attain orgasm. Non-communication: extent to which a couple are able to talk about any sexual problems. Non-sensuality: extent to which a female partner gains pleasure from touching and caressing. Dissatisfaction: extent to which a woman is dissatisfied with her sexual partner. Vaginismus: extent of any tightness around the vagina that interferes with sex.

Although there are other validated indices for sexual function, some validated for use in subjects with prolapse and incontinence (PIS-Q) [19], the GRISS was selected because it was believed that post-operatively the majority of subjects should be cured of their prolapse or incontinence symptoms; hence, a general index for sexual function may be more appropriate. In addition, sexual function is complex and multifactorial, therefore it may be affected by other pre-existing factors besides urogenital prolapse and urinary incontinence. Women were followed up at 6 weeks, 3 months, 6 months, 1 year and 2 years following surgery. Postoperative VCU was repeated at the 6-months review for all women who had undergone continence surgery. At each follow up visit, prolapse was objectively assessed with POP-Q. At each post-operative review, women also completed a KHQ, P-QoL and GRISS questionnaire.

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A single investigator carried out all the post-operative assessment. Statistical analysis was performed using SPSS 17.0 for Windows (SPSS Inc, Chicago, IL). Comparison between preand post-operative data was performed using paired t test. QoL and GRISS scores were assessed using Wilcoxon's signed rank test. Associations between independent variables and GRISS scores were determined using Spearman's rho correlations. The study was sized to give an 80% power to detect a difference of 20 units on the change between preand post-treatment domain scores of the KHQ sexual function domain score at the 5% significant level. This gave us a sample size of 24 patients per group. This level indicates a change that is meaningful to patients and is indicative of a clinically meaningful improvement in health-related quality of life after treatment [20].

Results In total, 201 women were recruited into the study. Complete data were available for 112 women at the 2-years review. Fifty-two patients (46%) were sexually active and these data were used for analysis. All women in this cohort had been sexually active pre-operatively and continued to be so in the post-operative period. None discontinued intercourse after their surgery. Of these women, 29 had prolapse surgery alone whilst 23 had an

additional continence procedure. Mean age of our patients was 64 (Range 4598) and mean parity was 2 (Range 04). There were no significant demographic differences between the groups who did and did not have additional continence surgery [Table 1]. Objective assessment showed statistically significant improvement in POP-Q scores (p <0.05). All measurements made on the specific points on the anterior vaginal wall (Aa, Ba), apex (C,D), as well as on the posterior vaginal wall (Ba, Bp) were significantly improved, whilst maintaining the total vaginal length, increasing the size of the perineal body and decreasing the size of the genital hiatus (Figure 1). The objective cure rate of USI on postoperative VCU was 88.8%. The QoL questionnaires showed an overall significant improvement from pre-operative scores to the 2-year review (p <0.01) [Fig. 2]. In addition, sexual function domain scores on KHQ and P-QoL were significantly improved at 2 years (p <0.01) [Fig. 3]. Analysis of the GRISS showed a significant improvement in the total score from pre-operative scores to the 2-year review (p <0.05). Detailed analysis showed an improvement in all subscales, although this only reached significance in four of seven subscales, i.e. there was a significant improvement in reduction of avoidance of sexual intercourse, improved communication, reduced dissatisfaction and a decrease in female non-sensuality. However surgery did not show a significant change in frequency of sexual

Table 1 Demographic information Variable Mean age Mean parity Previous prolapse surgery Previous continence surgery Pre-operative POP-Q ordinal score Sample (n =52) 64 2 17 5 2=36 (69%) 3=13 (25% 4=3 (5%) 0=26 (50%) 1=23 (44%) 2=3 (5%) 43 32 39 3 4 17 (74%) 2 (0.46%) 4 (17%) Prolapse surgery only (n =29) 65 2.7 1.2 10 2 17 8 3 18 13 3 29 19 22 3 4 Prolapse and continence surgery (n =23) 64 2.8 1.3 7 3 19 5 0 18 10 0 14 13 17 0 0 p value 0.67 0.8 0.70 0.68

Post-operative POP-Q ordinal

Surgery performed: VH Anterior repair Posterior repair Sacrocolpopexy Sacrospinous ligament fixation TVT TVT-O Colposuspension

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intercourse, achieving orgasms or in reducing dyspareunia, despite of there being a trend towards improvement even in these subscales [Fig. 4]. On comparison of women who underwent continence surgery with prolapse repair and those who had prolapse repair alone, there were no differences in the stage of prolapse, KHQ or P-QoL scores. In addition, there was no significant difference in the GRISS scores between these groups (p =0.26). However post-operative GRISS scores correlated significantly with POP-Q ordinal scores (r=0.34, p =0.05). In other words, women with objectively better supported pelvic floors post-operatively were less likely to have sexual dysfunction.

Discussion Sexual function as measured using the GRISS scores in addition to the sexual function domain on the KHQ and P-QoL is improved following surgery for urogenital prolapse with or without concomitant continence procedures. In addition a better supported pelvic floor, as measured on the POP-Q, appears to be associated with significantly improved GRISS scores. Strengths of our study include the prospective design and excellent follow-up rates even at extended follow-up of 2 years. This was despite the fact that it only included those women who had attended every post-operative visit and completed all questionnaires. All patients in this study completed multiple validated indices of bladder prolapse and sexual function. All objective assessments were also performed using the POP-Q system.

Fig. 2 QoL scores: decreasing scores denote improving QoL

We acknowledge that our study has some limitations. Less than half of all women were sexually active, which reduced our numbers. Although we had three surgeons performing the procedures, only a single investigator, the urogynaecology subspecialty trainee, carried out all the post-operative reviews, which might be a potential source of bias. Another debatable issue is that we chose to use the GRISS as our sexual function questionnaire in addition to the sexual domain questions of the KHQ and P-QoL, rather than the PIS-Q, which is a condition-specific, selfadministered, reliable and validated questionnaire. Our justification for this choice was that post-operatively the majority of subjects should be cured of their prolapse or incontinence symptoms; hence, a general index for sexual function may be more appropriate. In addition, as sexual function is complex and multifactorial, it may be affected by other pre-existing factors besides urogenital prolapse and urinary incontinence. GRISS has been validated in a population of sex therapy clients with sexual dysfunction and found to detect therapy-induced changes in global levels of sexual function [21]. However, we acknowledge that using the PIS-Q would have made comparisons between our results and those of other authors easier. Sexual function in patients with urogenital prolapse and urinary incontinence has been studied by several authors in the past. Most literature would suggest that sexual dysfunction is more common in this population [79]. In a recent large prospective study, nearly half of all patients reported pre-operative sexual dysfunction [22]. Our study suggests similar outcomes with regards to reported preoperative sexual dysfunction. There has been a previous work which suggests that changes in sexual function after treatment for prolapse are related to the improvement in body image perception [23]. Whilst there is good evidence that resolution of pelvic organ prolapse (POP) symptoms after treatment improves women's self-perceived body image and sexual function it is difficult to judge whether this works in isolation or in conjunction with the actual absence of a bulge in the vagina which by its presence causes sexual dysfunction. Although some authors would argue that sexual function is related to a woman's self-perceived body image and degree

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Fig. 3 Sexual function domains on KHQ and P-QoL: decreasing scores denote improving sexual function

of bother from POP regardless of vaginal anatomy, the findings in our study show post-operative GRISS scores correlated significantly with POP-Q ordinal scores. In other words, women with objectively better supported pelvic floors post-operatively were less likely to have sexual dysfunction. Dyspareunia in particular following vaginal surgery has been well documented by other studies [10, 14, 24, 25]. In the past, this has been often attributed to the posterior colporrhaphy, with levator plication leading to worsening of this symptom [26]. The use of synthetic mesh augmentation at the time of repair has also been a subject of debate with some studies suggesting increased levels of persistent dyspareunia in 50% of sexually active women when compared to native tissue repair [27].However, a recent randomised controlled trial comparing vaginal repair augmented by mesh with traditional colporrhaphy for the treatment of pelvic organ prolapse found similar rates of de novo dyspareunia in both groups, 16.7% in the mesh group and 15.2% in the no mesh group at 12 months [28].
7 6 5 4 3 2 1 0 Preop 6 weeks 3 months 6 months

Interestingly, even studies in centres where site-specific fascial repair is performed as routine practice, dyspareunia rates of up to 42% have been cited [25]. However, in our study, which also only involved fascial repairs, there was a trend towards improvement in GRISS subscale of vaginismus (which in the context of this paper was taken to represent dyspareunia), although this did not reach significance. This was in keeping with previous work at our institute [26]. There are numerous studies reporting on the outcome of continence surgery, but the reports on the response of sexual function to treatment of urinary incontinence are limited and conflicting [12, 15, 25]. Whilst restoration of continence, especially in the case of coital incontinence has an obvious beneficial effect on sexual function, other factors such as an improvement in negative emotions, body image, and confidence also play an important role [29]. On the other hand, worsening sexual dysfunction may occur as a result of surgical denervation, with detrimental effects on lubrication and orgasm. As cited in previous studies [25], use of synthetic graft material such as polypropylene during

Infrequency Avoidance Anorgasmia Noncommunication Nonsensuality Dissatisfaction Vaginismus Total

1 year

2 years

Fig. 4 GRISS scores: decreasing scores denote improving sexual function

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Int Urogynecol J (2010) 21:13131319 5. Jolleys JV (1988) Reported prevalence of urinary incontinence in women in a general practice. Br Med J (Clin Res Ed) 296:1300 1302 6. Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC (2002) Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol 99:281289 7. Pauls RN, Segal JL, Silva WA, Kleeman SD, Karram MM (2006) Sexual function in patients presenting to a urogynecology practice. Int Urogynecol J Pelvic Floor Dysfunct 17:576 580 8. Rogers RG, Kammerer-Doak D, Darrow A et al (2006) Does sexual function change after surgery for stress urinary incontinence and/or pelvic organ prolapse? A multicenter prospective study. Am J Obstet Gynecol 195:e1e4 9. Ghezzi F, Serati M, Cromi A, Uccella S, Triacca P, Bolis P (2005) Impact of tension-free vaginal tape on sexual function: results of a prospective study. Int Urogynecol J Pelvic Floor Dysfunct 17:54 59 10. Mazouni C, Karsenty G, Bretelle F, Bladou F, Gamerre M, Serment G (2004) Urinary complications and sexual function after the tension-free vaginal tape procedure. Acta Obstet Gynecol Scand 83:955961 11. Helstrom L, Nilsson B (2005) Impact of vaginal surgery on sexuality and quality of life in women with urinary incontinence or genital descensus. Acta Obstet Gynecol Scand 84:7984 12. Jha S, Radley S, Farkas A, Jones G (2009) The impact of TVT on sexual function. Int Urogynecol J Pelvic Floor Dysfunct 20 (2):165169 13. Pace G, Vicentini C (2008) Female sexual function evaluation of the tension-free vaginal tape (TVT) and transobturator suburethral tape (TOT) incontinence surgery: results of a prospective study. J Sex Med 5(2):387393 14. Elzevier HW, Putter H, Delaere KP, Venema PL, Lycklama Nijeholt AA, Pelger RC (2008) Female sexual function after surgery for stress urinary incontinence: transobturator suburethral tape vs. tension-free vaginal tape obturator. J Sex Med 5(2):400 406 15. Kuhn A, Brunnmayr G, Stadlmayr W, Kuhn P, Mueller MD (2009) Male and female sexual function after surgical repair of female organ prolapse. J Sex Med 6(5):13241334 16. Azar M, Noohi S, Radfar S, Radfar MH (2008) Sexual function in women after surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 19(1):5357 17. Bump RC, Mattiasson A, Bo K et al (1996) The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 175:1017 18. Rust J, Golombok S (1986) The GRISS: a psychometric instrument for the assessment of sexual dysfunction. Arch Sex Behav 15(2):157165 19. Rogers RG, Kammerer-Doak D, Villarreal A, Coates K, Qualls C (2001) A new instrument to measure sexual function in women with urinary incontinence or pelvic organ prolapse. Am J Obstet Gynecol 188:552558 20. Kelleher CJ, Pleil AM, Reese PR, Burgess SM, Brodish PH (2004) How much is enough and who says so? BJOG 111(6):605612 21. Meston CM, Derogatis LR (2002) Validated instruments for assessing female sexual function. J Sex Marital Ther 28(Suppl 1):155164 22. Pauls RN, Silva WA, Rooney CM et al (2007) Sexual function after vaginal surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 197:622.e1622.e7 23. Lowenstein L, Gamble T, Sanses TV, van Raalte H, Carberry C, Jakus S, Pham T, Nguyen A, Hoskey K, Kenton K (2009) Changes in sexual function after treatment for prolapse are related to the improvement in body image perception. J Sex Med 7:1023 1028. doi:10.1111/j.1743-6109.2009.01586.x

retropubic or transobturator sling procedures may have an impact on the pliability of the vagina, lead to dyspareunia or even affect sexual function of the partner if the mesh becomes exposed. However, in our study, we did not notice any difference in sexual function scores between groups that did and did not have additional continence procedures. There was a similar improvement in sexual function in both groups. Finally, it is well known that the physiology of sexual function is very complex and is associated with multiple factors in addition to normal functional anatomy. Sexual desire and orgasmic capabilities have been shown to have an inverse relationship with anxiety states [30]. This may have been one of the contributing factors why the domains to show least improvement on the GRISS scales were those affecting frequency of intercourse and the ability to achieve orgasms. In conclusion, the findings of this study suggest that sexually active women who undergo prolapse or continence surgery are able to continue to enjoy active penetrative sexual intercourse at 2 years. At this time, there is an improvement in sexual function domains of KHQ and PQoL as well as all domains of the GRISS. We believe that these findings may aid in counselling women with urogenital prolapse and urinary incontinence prior to surgery about potential improvement in sexual function post-operatively. In particular, it also provides information on the aspects of sexual function which is more likely to improve after surgery.

Conflicts of interest Sushma Srikrishna, Speaker Honorarium: Recordati, Astellas, SEP, Advisory board; Astellas. Dudley Robinson, Consultant: Astellas, Ferring, Gynaecare, Uroplasty, Pfizer, Recordati, Novo-Nordisk, Speaker Honorarium: Astellas, Ferring, Gynaecare, Uroplasty, Pfizer, Recordati, Trial participation: Astellas, Pfizer. Linda Cardozo, Consultant: Astellas, Pfizer, Rottapharm, Schering-Plough, SEP, Speaker Honorarium: Astellas, Pfizer, Rottapharm, Trial Participation: Astellas, Pfizer, Research grant: Pfizer.

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