Abstract
Background
There is a need to determine how preoperative sexual activity, uterine preservation, and hysterectomy affect sexual function after pelvic organ prolapse surgery.
Aim
(1) To determine changes in sexual function in women, stratified by preoperative sexual activity status, after native-tissue pelvic organ prolapse surgery. (2) To examine the impact of hysterectomy and uterine preservation on sexual function. (3) To determine predictors for postoperative dyspareunia.
Methods
This was a planned secondary analysis of a prospective cohort study. Sexual function was evaluated preoperatively and 6 and 12 months postoperatively. Sexual function was compared between those who had a hysterectomy and those who had uterine-preserving prolapse surgery. A logistic regression analysis was performed to assess predictors for dyspareunia.
Outcomes
Pelvic Organ Prolapse–Urinary Incontinence Sexual Function Questionnaire.
Results
At 12 months, 59 patients underwent surgery and were followed up (hysterectomy [n = 28, 47.5%] vs no hysterectomy [n = 31, 52.5%]; sexually active [n = 26, 44.1%] vs non–sexually active [n = 33, 55.9%]). Of those who did not undergo a hysterectomy, 17 (54.8%) had a uterine-preserving procedure. At 12 months, sexually active patients had significant improvement in sexual function (mean ± SD, 0.37 ± 0.43; P = .005), while non–sexually active patients reported significant improvement in satisfaction of sex life (P = .04) and not feeling sexually inferior (P = .003) or angry (P = .03) because of prolapse. No variables were associated with dyspareunia on bivariate analysis.
Clinical Implications
It did not appear that either uterine preservation or hysterectomy had any impact on sexual function. There was a 10% increase in people who were sexually active after surgery.
Strengths and Limitations
The major strength of our study is the use of a condition-specific validated questionnaire intended for sexually active and non–sexually active women. We interpreted our results utilizing a validated minimal clinically important difference score to provide interpretation of our results with statistical and clinical significance. The limitation of our study is that it was a secondary analysis that was not powered for these specific outcomes.
Conclusion
At 12 months, for patients who were sexually active preoperatively, there was a clinically meaningful improvement in sexual function after native-tissue pelvic organ prolapse surgery. Non–sexually active women reported improvement in satisfaction of sex life. There was no difference in the sexual function of patients undergoing uterine preservation or posthysterectomy colpopexy when compared with those with concurrent hysterectomy, though this sample size was small.
Keywords: pelvic organ prolapse, sexual function, dyspareunia, prolapse surgery, hysteropexy
Introduction
Improvement in sexual function has been consistently demonstrated after pelvic organ prolapse surgery of all modalities.1-3 In a systematic review including 18 articles of 1803 women, Antosh et al showed that sexual function as measured by the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire–12 (PISQ-12) and the International Consultation on Incontinence Questionnaire–Vaginal Symptoms Module improved after native-tissue pelvic organ prolapse surgery.4 Dua et al utilized the Female Sexual Function Index to measure sexual function before and after native-tissue prolapse surgery.5 Across the entire cohort, there was statistically significant improvement in sexual function, including overall improvement, reduced avoidance of intercourse and partner, and anxiety secondary to prolapse. The improvement in sexual function correlated with improvement of overall quality-of-life score, and this was observed after all prolapse procedures whether concomitant treatment for urinary incontinence was performed or not.6
Despite the encouraging data, there remains heterogeneity in the types of validated instruments used to measure sexual function. The questionnaires used in previously published studies were not always condition specific to patients with pelvic organ prolapse and not applicable for sexually active and non–sexually active patients; furthermore, the improvements were not always interpreted with a minimal clinically important difference (MCID). The MCID is important, as it sets the minimal difference that would translate to an improvement perceived by patients, regardless of the observed statistical changes. Additionally, previous studies have compared differences in sexual function between prolapse surgery with and without concurrent vaginal mesh placement or anti-incontinence procedures,7 but few have directly compared the effect of hysterectomy vs uterine preservation at the time of native-tissue prolapse surgery.
Therefore, the objective of this study was to determine changes in sexual function in sexually active and non–sexually active patients after native-tissue pelvic organ prolapse surgery. The secondary objectives were to examine the impact of hysterectomy and uterine-preserving prolapse surgery on sexual function and to determine predictors for postoperative dyspareunia.
Methods
This was a planned secondary analysis of a prospective cohort study evaluating the impact of intraoperative resting genital hiatus size on prolapse recurrence after native-tissue vaginal prolapse surgery.8 The prospective cohort study was conducted at 2 hospitals within a tertiary hospital system from 2019 to 2021. Patients ≥18 years old undergoing vaginal pelvic organ prolapse surgery with apical suspension were eligible to participate. Patients with connective tissue disorder, prior prolapse repair with mesh, and/or pregnancy were excluded. Baseline patient demographics and characteristics were collected. A complete or modified Pelvic Organ Prolapse Quantification (POP-Q) examination was conducted pre-, intra-, and postoperatively. For functional outcomes, patients completed components of the Pelvic Floor Dysfunction Index–20,9 specifically the Pelvic Organ Prolapse Distress Inventory and the Colorectal Distress Inventory. Sexual function was measured with the Pelvic Organ Prolapse–Urinary Incontinence Sexual Function Questionnaire–Questionnaire (PISQ-IR), measuring sexual function for women with pelvic organ prolapse, urinary incontinence, and/or fecal incontinence, as developed by the International Urogynecological Association.10 The PISQ-IR was validated as a condition-specific questionnaire that assesses female sexual function in those with urinary incontinence and/or pelvic organ prolapse in sexually active and non–sexually active women. The scoring was completed per the questionnaire guidelines.11 Because the PISQ-IR total score can be calculated only for sexually active patients, we reported responses for select questions for non–sexually active patients. Functional outcomes were collected at baseline and 6 weeks, 6 months, and 12 months postoperatively.
All surgical procedures were performed by 1 of 5 attendings in female pelvic medicine and reconstructive surgery with a fellow and/or resident. Apical suspension techniques included intraperitoneal/uterosacral or extraperitoneal/sacrospinous ligament colpopexy. Intraperitoneal/uterosacral ligament colpopexy was completed with the use of 3 delayed-absorbable sutures (0-polydioxanone) on each side, and extraperitoneal/sacrospinous ligament colpopexy was completed with the use of 2 or 3 delayed-absorbable sutures (0-polydioxanone) unilaterally. Patients with a uterus underwent either hysterectomy or uterine-preserving hysteropexy. Patients without a uterus underwent colpopexy only, most commonly sacrospinous ligament colpopexy with a suture-capturing device.
The primary outcome was change in sexual function over time, as measured by PISQ-IR score, in patients who were sexually active over the 12-month period. To determine meaningful improvement in sexual function, the MCID was set at 0.31 based on the literature.12 For non–sexually active patients, we compared PISQ-IR questions 4a, 4b, 5a, 5b, 5c, and 6 before and after surgery.
For patients who were not sexually active, dyspareunia was defined as strongly or somewhat agreeing to PISQ-IR question 2e: that pain was the reason for avoiding sexual activity. For patients who were sexually active, it was defined as answering sometimes, usually, or always to PISQ-IR question 11: “How often do you feel pain during sexual intercourse?” De novo dyspareunia was defined as an absence of dyspareunia when the questionnaires were completed preoperatively, with development of new dyspareunia symptoms per the aforementioned criteria.
To examine the impact of hysterectomy and uterine preservation on sexual function, the following groups were compared: (1) hysterectomy vs no hysterectomy (posthysterectomy colpopexy and hysteropexy) and (2) hysterectomy vs hysteropexy.
Approximately normally distributed continuous measures were summarized with means and standard deviations and compared between groups with 2-sample t-tests. Continuous measures that showed departure from normality or ordinal measures were summarized via median and IQR and compared with Wilcoxon rank sum tests. Categorical factors were summarized with frequencies and percentages and compared with Pearson chi-square tests or Fisher exact tests. Paired 1-sample t-tests were performed for the PISQ-IR, and McNemar tests were performed for dyspareunia and de novo dyspareunia by pairing patients with themselves between baseline and 6 months, baseline and 12 months, as well as 6 months and 12 months (only for de novo dyspareunia). All analyses were performed with SAS (version 9.4; SAS Institute), and P < .05 was considered statistically significant.
Results
Of the 68 patients enrolled into the prospective cohort study, 59 (86.8%) completed follow-up at 12 months (hysterectomy, n = 28, 47.5%; no hysterectomy, n = 31, 52.5%). Of those who did not undergo a hysterectomy, 17 (54.8%) had a uterine-preserving procedure. On univariate analysis, there were no differences in patient characteristics among those with a hysterectomy, those without a hysterectomy, and those with a hysteropexy procedure (Table 1).
Table 1.
Univariate analysis of patients with pelvic organ prolapse surgery with or without hysterectomy.a
| Variable | Hysterectomy (n = 28) | No hysterectomy (n = 31) | P value b | Hysteropexy (n = 17) | P value c |
|---|---|---|---|---|---|
| Age on day of surgery, y | 61.6 ± 11.4 | 64.9 ± 11.6 | .28d | 62.4 ± 13.5 | .83d |
| Body mass index, kg/m2 | 29.4 ± 4.8 | 29.1 ± 6.1 | .81d | 29.0 ± 6.7 | .80d |
| Race | .80e | .77e | |||
| White | 25 (89.3) | 29 (93.5) | 15 (88.2) | ||
| Black/African American | 2 (7.1) | 2 (6.5) | 2 (11.8) | ||
| Mixed race | 1 (3.6) | 0 (0.00) | 0 (0.00) | ||
| Vaginal parity | 2.0 [2.0-3.0] | 2.0 [1.00-3.0] | .99f | 2.0 [1.00-3.0] | .70f |
| Sexually active at baselineg | 14 (50.0) | 11 (37.9) | .36h | 7 (43.8) | .69h |
| Postmenopausal | 20 (71.4) | 27 (87.1) | .40e | 13 (76.5) | .99e |
| Oral hormone replacement therapyg | 0 (0.00) | 2 (6.7) | .49e | 0 (0.00) | .99e |
| Vaginal estrogen therapyg | 6 (21.4) | 8 (26.7) | .64h | 2 (12.5) | .69e |
| Diabetes | 4 (14.3) | 2 (6.5) | .41e | 1 (5.9) | .64h |
| Tobacco useg | 3 (11.1) | 1 (3.2) | .33e | 1 (5.9) | .99e |
| Prior prolapse surgery | 0 (0.00) | 1 (3.2) | .99e | 0 (0.00) | .99e |
aData are presented as mean ± SD, median [IQR], No. (% [column]).
bNo hysterectomy vs hysterectomy.
cHysteropexy vs hysterectomy.
d t test.
eFisher exact test.
fWilcoxon rank sum test.
gMissing values: sexually active, n = 2; oral hormone replacement therapy, n = 1; vaginal estrogen therapy, n = 1; tobacco use, n = 1.
hPearson chi-square test.
At baseline, 26 (44.1%) patients were sexually active. Those who were not sexually active strongly agreed that the lack of sexual activity was attributed to the combination of the following reasons: presence of prolapse (n = 11, 33.3%), no partner or partner with sexual dysfunction (n = 9, 28.1%), no interest (n = 8, 25%), and pain (n = 5, 15.6%). At 12 months postoperatively, 29 (53.7%) patients were sexually active. Eight patients (14%) who were not sexually active preoperatively became sexually active at 12 months, while 3 (5.3%) who were sexually active became nonactive. Amongst those who were not sexually active, patients strongly agreed that reasons for lack of sexual activity included no partner or partner with sexual dysfunction (n = 10, 40%), no interest (n = 8, 32.0%), and presence of prolapse (n = 1, 4.0%).
For patients who were sexually active preoperatively, there was a statistically significant improvement in sexual function at 12 months (mean ± SD, 0.37 ± 0.43; P = .005), exceeding the MCID (Table 2).
Table 2.
Changes in sexual function over time after pelvic organ prolapse surgery.a
| PISQ-IR | Baseline | 6 mo | No. of pairs b | P value c | 12 mo | No. of pairs b | P value c |
|---|---|---|---|---|---|---|---|
| Total score: sexually active patients (n = 25) | |||||||
| Sexually active | 3.3 [3.1-3.9] | 3.8 [3.6-4.0]d | 19 | .008e | 3.9 [3.5-4.1]f | 15 | .005e |
| Individual questions for non–sexually active patients (n = 33) | |||||||
| 4a: Satisfaction with sex life | |||||||
| 1 (satisfied) | 5 (15.2) | 8 (26.7) | 30 | .90g | 8 (32.0) | 25 | .042g |
| 2 | 5 (15.2) | 2 (6.7) | 3 (12.0) | ||||
| 3 | 7 (21.2) | 9 (30.0) | 10 (40.0) | ||||
| 4 | 5 (15.2) | 3 (10.0) | 1 (4.0) | ||||
| 5 (dissatisfied) | 11 (33.3) | 3 (10.0) | 3 (12.0) | ||||
| 4b: Satisfaction with the adequacy of sex life | |||||||
| 1 (satisfied) | 7 (21.2) | 7 (23.3) | 30 | .97g | 7 (29.2) | 25 | .056g |
| 2 | 3 (9.1) | 4 (13.3) | 2 (8.3) | ||||
| 3 | 5 (15.2) | 6 (20.0) | 10 (41.7) | ||||
| 4 | 6 (18.2) | 3 (10.0) | 1 (4.2) | ||||
| 5 (dissatisfied) | 12 (36.4) | 10 (33.3) | 4 (16.7) | ||||
| 5a: Frustration with sex life | |||||||
| Strongly agree | 7 (21.2) | 1 (3.3) | 30 | .59g | 3 (12.0) | 25 | .22g |
| Somewhat agree | 6 (18.2) | 7 (23.3) | 6 (24.0) | ||||
| Somewhat disagree | 8 (24.2) | 10 (33.3) | 4 (16.0) | ||||
| Strongly disagree | 12 (36.4) | 12 (40.0) | 12 (48.0) | ||||
| 5b: Feeling sexually inferior due to incontinence and/or prolapse | |||||||
| Strongly agree | 5 (15.2) | 1 (3.3) | 30 | .002g | 0 (0) | 25 | .003g |
| Somewhat agree | 7 (21.2) | 0 (0) | 2 (8.0) | ||||
| Somewhat disagree | 5 (15.2) | 1 (3.3) | 3 (12.0) | ||||
| Strongly disagree | 16 (48.5) | 28 (93.3) | 20 (80.0) | ||||
| 5c: Feeling angry because of the impact that incontinence and/or prolapse has on sex life | |||||||
| Strongly agree | 1 (3.1) | 0 (0) | 30 | .04g | 0 (0) | 25 | .03g |
| Somewhat agree | 6 (18.8) | 0 (0) | 0 (0) | ||||
| Somewhat disagree | 4 (12.5) | 2 (6.7) | 2 (8.0) | ||||
| Strongly disagree | 21 (65.6) | 28 (93.3) | 23 (92.0) | ||||
| 6: “How bothersome is it to you that you are not sexually active?” | |||||||
| Not at all | 6 (18.2) | 8 (26.7) | 30 | .17g | 13 (52.0) | 25 | <.001g |
| A little | 8 (24.2) | 12 (40.0) | 6 (24.0) | ||||
| Some | 13 (39.4) | 8 (26.7) | 5 (20.0) | ||||
| A lot | 6 (18.2) | 2 (6.7) | 1 (4.0) | ||||
| Dyspareunia | |||||||
| All patients (n = 57) | 20 (35.1) | 16 (29.6) | 52 | .78h | 13 (24.1) | 53 | .13h |
| Sexually active (n = 25) | 12 (48.0) | 13 (52.0) | 20 | .74h | 12 (41.4) | 22 | .48h |
| Not active (n = 32) | 8 (25.0) | 3 (10.3) | 25 | .32h | 1 (4.0) | 21 | .16h |
| De novo dyspareunia | 6 (16.2) | 3 (8.1) | 37 | .08h,i | |||
Abbreviation: PISQ-IR, Pelvic Organ Prolapse–Urinary Incontinence Sexual Function Questionnaire–IUGA Revised.
aThe PISQ-IR measures sexual function for women with pelvic organ prolapse, urinary incontinence, and/or fecal incontinence. Data are presented as median [IQR], mean ± SD, or No. (%).
bNumber of pairs for the statistical tests.
cPatients were paired with themselves to tests between baseline and 6 months or baseline and 12 months.
dSix-month change in score: 0.32 ± 0.47.
ePaired 1-sample t test.
fTwelve-month change in score: 0.37 ± 0.43.
gWilcoxon signed rank test.
hMcNemar test.
iComparison of incidence of de novo dyspareunia from 6 to 12 months.
For patients who were not sexually active preoperatively, there was a significantly smaller proportion who reported feeling sexually inferior (P = .002) and angry (P = .04) because of their incontinence and/or prolapse at 6 months as compared with baseline. At 12 months, there were significant improvements in satisfaction of sex life (P = .04) and not feeling sexually inferior (P = .003) or angry (P = .03) because of the incontinence and/or prolapse. At 12 months, over half the patients were not bothered with the lack of sexual activity (n = 13, 52%), as opposed to 18.2% at baseline (n = 6, P < .001).
Based on our definition of dyspareunia, 35.1% (n = 20) of patients reported dyspareunia at baseline as compared with 29.6% (n = 16, P = .78) at 6 months and 24.1% (n = 13, P = .13) at 12 months. There were no differences in the incidence of dyspareunia over time when stratified by sexual activity. Regarding de novo dyspareunia, the rate was 16.2% (n = 6) at 6 months and decreased to 8.1% (n = 3, P = .08) at 12 months.
On univariate analysis, no variables were significantly associated with dyspareunia (Table 3). In particular, there was no difference in pre-, intra-, or postoperative genital hiatus size in those with and without dyspareunia. Varying techniques for apical suspension and posterior colporrhaphy, from suture choice to excision of vaginal epithelium, did not differ as well. Because the outcome of interest, dyspareunia, occurred in only 13 patients, a multivariable logistic regression was not performed, particularly in the absence of other variables associated with dyspareunia on univariate analysis.
Table 3.
Univariate analysis for those with or without dyspareunia at 12 months.a
| Variable | Total (N = 54) | No dyspareunia (n = 41) | Dyspareunia (n = 13) | P value |
|---|---|---|---|---|
| Age, y | 62.9 ± 11.6 | 63.2 ± 12.1 | 61.9 ± 10.4 | .73b |
| Body mass index, kg/m2 | 29.3 ± 5.5 | 29.6 ± 5.9 | 28.5 ± 3.9 | .52b |
| Patient self-identified race | .99c | |||
| White | 49 (90.7) | 37 (90.2) | 12 (92.3) | |
| Black or African American | 4 (7.4) | 3 (7.3) | 1 (7.7) | |
| Mixed race | 1 (1.9) | 1 (2.4) | 0 (0.00) | |
| Vaginal parity | 2.0 [1.00-3.0] | 3.0 [1.00-3.0] | 2.0 [1.00-2.0] | .32d |
| Postmenopausal | 42 (77.8) | 33 (80.5) | 9 (69.2) | .26c |
| Oral hormone replacement therapye | 2 (3.8) | 1 (2.5) | 1 (7.7) | .43c |
| Vaginal estrogen therapye | 12 (22.6) | 7 (17.5) | 5 (38.5) | .14c |
| Diabetes | 6 (11.1) | 4 (9.8) | 2 (15.4) | .62c |
| Pelvic organ prolapse anatomic measurements, cm | ||||
| Preoperative GHe | 4.0 [3.5-5.0] | 4.0 [3.5-5.0] | 4.0 [3.5-5.0] | .48d |
| Intraoperative resting GH | 3.0 [2.5-3.5] | 3.0 [2.5-3.5] | 3.0 [2.5-3.0] | .67d |
| Postoperative GH | 3.0 [2.0-3.0] | 3.0 [2.5-3.5] | 2.5 [2.0-3.0] | .16d |
| Operative variables | ||||
| Method of apical suspension | .50c | |||
| Uterosacral ligament suspension | 35 (64.8) | 27 (65.9) | 8 (61.5) | |
| Sacrospinous ligament suspension | 18 (33.3) | 14 (34.1) | 4 (30.8) | |
| Ileococcygeus muscle suspension | 1 (1.9) | 0 (0) | 1 (7.7) | |
| Concurrent posterior colporrhaphy | 43 (79.6) | 31 (75.6) | 12 (92.3) | .26c |
| Sutures used for posterior colporrhaphy | .69f | |||
| Polydioxanone (mostly) | 20 (46.5) | 15 (48.4) | 5 (41.7) | |
| Polyglactin only | 23 (53.5) | 16 (51.6) | 7 (58.3) | |
| Shape of vaginal epithelium excised as part of perineorrhaphy | .99c | |||
| Diamond | 28 (63.6) | 20 (62.5) | 8 (66.7) | |
| Vertical incision | 15 (34.1) | 11 (34.4) | 4 (33.3) | |
| Otherg | 1 (2.3) | 1 (3.1) | 0 (0.00) |
Abbreviation: GH, genital hiatus.
aData are presented as mean ± SD, median [IQR], No. (% [column]).
b t test.
cFisher exact test.
dWilcoxon rank sum test.
eMissing values: oral hormone replacement therapy, n = 1; vaginal estrogen therapy, n = 1; preoperative GH, n = 1; postoperative GH, n = 7; sutures used for posterior colporrhaphy, n = 11; shape of vaginal epithelium excised as part of perineorrhaphy, n = 10.
fPearson chi-square test.
gInverted triangle.
At 12 months, there was no difference in PISQ-IR score in sexually active patients who underwent a hysteropexy vs hysterectomy (P = .76) and no difference between no hysterectomy and hysterectomy (P = .51; Table 4). As compared with baseline, patients who had a hysterectomy had a median 0.48 increase in PISQ-IR score (IQR, −0.05 to 0.71), meeting the MCID, as similarly seen in patients who had a hysteropexy at a median increase of 0.45 (IQR, −0.02 to 0.78), again meeting the MCID. There were no statistical differences in change of PISQ-IR score over 12 months in those who had a hysterectomy vs no hysterectomy or a hysterectomy vs hysteropexy. There were no differences in de novo dyspareunia in hysterectomy vs no hysterectomy (P = .99) or hysterectomy vs hysteropexy (P = .99).
Table 4.
Sexual function at 12 months of patients with pelvic organ prolapse surgery with or without hysterectomy.a
| Variable | No. | Hysterectomy (n = 28) | No. | No hysterectomy (n = 31) | P value b | No. | Hysteropexy (n = 17) | P value c |
|---|---|---|---|---|---|---|---|---|
| Sexually active patients | ||||||||
| PISQ-IR at baseline | 12 | 3.3 [3.1, 3.9] | 13 | 3.6 [3.1, 3.9] | .91d | 8 | 3.7 [3.3, 3.9] | .54d |
| PISQ-IR at 12 mo | 9 | 3.9 [3.5, 4.1] | 14 | 3.8 [3.3, 4.1] | .51e | 7 | 4.1 [3.7, 4.1] | .76e |
| Change in PISQ-IR from baseline to 12 mo | 6 | 0.48 [−0.05, 0.71] | 9 | 0.29 [0.19, 0.65] | .73e | 4 | 0.45 [−0.02, 0.78] | .92e |
| Dyspareunia at 12 mo | 13 | 6 (46.2) | 16 | 6 (37.5) | .64d | 9 | 2 (22.2) | .38f |
| De novo dyspareunia at 12 mo for all patients | 20 | 2 (10.0) | 17 | 1 (5.9) | .99f | 9 | 1 (11.1) | .99f |
Abbreviation: PISQ-IR, Pelvic Organ Prolapse–Urinary Incontinence Sexual Function Questionnaire.
aThe PISQ-IR measures sexual function for women with pelvic organ prolapse, urinary incontinence, and/or fecal incontinence. Data are presented as median [IQR] or No. (%).
bNo hysterectomy vs hysterectomy.
cHysteropexy vs hysterectomy.
dPearson chi-square test.
eWilcoxon rank sum test.
fFisher exact test.
Discussion
In this prospective cohort study, there was a statistically significant and clinically meaningful improvement in sexual function at 12 months after native-tissue pelvic organ prolapse surgery with apical suspension in those who were sexually active preoperatively. For patients who were not sexually active preoperatively, there was a statistically significant improvement in satisfaction of sex life and feeling less angry or sexually inferior due to incontinence and/or prolapse. There was no significant difference in the sexual function of patients undergoing hysteropexy or posthysterectomy colpopexy vs patients undergoing apical prolapse surgery with hysterectomy.
In our study, we report the change of sexual function in terms of statistical significance but, more important, in the context of the MCID. The MCID translates statistical change into a clinically meaningful and noticeable change for the patients.12 For patients who were sexually active preoperatively, there was statistically and clinically improved sexual function after prolapse repair, as similarly demonstrated with the PISQ-12.13 However, the PISQ-12 was designed to be used in sexually active women only; thus, non–sexually active patients were not included in that analysis. Since we used the PISQ-IR, which is a condition-specific validated instrument that measures sexual function for sexually active and non–sexually active women, we can conclude that when sexual activity was accounted for, significant improvement in sexual function was also seen in non–sexually active women by evaluating individual questions. Our study demonstrated that non–sexually active women reported significant improvement in sexual satisfaction, feeling less angry and not feeling sexually inferior due to incontinence and/or prolapse.
We found that a higher proportion of patients became sexually active after prolapse surgery. In a pooled secondary analysis by Lukacz et al, sexual activity increased from 57.3% to 62.8% (odds ratio, 1.2; 95% CI, 1.1-1.4).13 Our cohort demonstrated that at baseline, prolapse was the primary reason why patients avoided sexual activity. In contrast, at 1 year, the most common primary reason was the lack of partner or a partner with sexual dysfunction. As a result, prolapse surgery directly addressed the prolapse and its impact on sexual function and thus contributed to clinically significant improvement in sexual function after surgery. In contrast, for those who were not sexually active postoperatively, the most common reason included no partner or a partner with sexual dysfunction. Because prolapse surgery cannot address partner-related issues, it is not surprising that we did not observe a clinically significant improvement in sexual function in this group. Nonetheless, we found that there was no deterioration in sexual function in all patients regardless of sexual activity, which is an important point for surgical counseling.
Sexual dysfunction, particularly dyspareunia, has been reported as one of the more concerning complications after posterior colporrhaphy,14-16 though these studies were limited by the grouping of postoperative dyspareunia to include baseline and de novo dyspareunia. In the previously mentioned secondary analysis by Lukacz et al, baseline dyspareunia was the only factor that was predictive of dyspareunia at 12 months after surgery (adjusted odds ratio, 7.8; 95% CI, 4.2-14.4).13 While concurrent posterior colporrhaphies or a small intraoperative resting genital hiatus has been considered to be a risk factor for dyspareunia, in this analysis, we did not find a significant difference in the incidence of dyspareunia. In other studies, sexual function improved after prolapse repair with posterior colporrhaphy, although this finding was not statistically significant6,17; more important, however, there was no deterioration in sexual function with concurrent posterior colporrhaphy. Based on our study and the existing literature, it does not appear that overall sexual function worsens after concurrent posterior colporrhaphy.
Regarding de novo dyspareunia, the rate in our cohort was 8.1% at 12 months. This is similar to other studies showing a de novo dyspareunia rate of 3.8% after prolapse repair with or without mesh augmentation or 9% after native-tissue prolapse repair only.4,13 We found that the incidence of dyspareunia decreased by 50% over 6 months, which can be helpful for counseling that de novo dyspareunia may improve over time.
Our study also aimed to examine the role of hysterectomy and uterine preservation on sexual function. In terms of improvement of sexual function over 12 months, sexually active patients who had concurrent hysterectomy and hysteropexy had improvement in sexual function meeting the MCID. However, for the PISQ-IR score across all 3 groups at 12 months, there was no statistical difference among groups. As a result, it does not appear that concurrent hysterectomy affects the PISQ-IR score at 12 months. In the SAVE U trial by Detollenaere et al (sacrospinous fixation vs vaginal hysterectomy in treatment of uterine prolapse ≥2), there was no statistically significant difference in overall sexual function between hysteropexy and hysterectomy at the time of prolapse repair at 24 months.18 This has been similarly demonstrated in other studies reporting unchanged or overall improvement in sexual function after prolapse surgery, with or without hysterectomy.17,19
The limitation of our study is that this was a secondary analysis that was not powered for these specific outcomes. However, our results are in line with the findings found in the existing literature.
The major strength of our study is the use of a condition-specific validated questionnaire intended for sexually active and non–sexually active women. Since most prior studies utilize the Female Sexual Function Index and PISQ-12, which are not intended for non–sexually active women, we can accurately reflect sexual function for all participants utilizing the summary score for sexually active patients and the individual questions for non–sexually active patients. Because this was a planned secondary analysis of a prospective cohort study, we were able to ensure reliable follow-up over time with a high patient retention rate. Last, we interpreted our results utilizing a validated MCID score to provide interpretation of our results with statistical and clinical significance.
Conclusions
In summary, at 12 months, there was a statistically significant and clinically meaningful improvement in sexual function after all types of native-tissue pelvic organ prolapse surgery in patients who were sexually active preoperatively. Patients who were not sexually active preoperatively reported increased sexual satisfaction at 12 months. A higher proportion of patients became sexually active after surgery, and de novo dyspareunia appeared to improve over time. There was no significant difference in the sexual function of patients undergoing hysteropexy or posthysterectomy colpopexy when compared with patients undergoing apical prolapse surgery with hysterectomy.
Acknowledgments
This study was an oral presentation at the 48th Annual Meeting of the Society of Gynecologic Surgeons, San Antonio, TX, March 27-30, 2022.
Contributor Information
Olivia H Chang, Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
Meng Yao, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States.
Cecile A Ferrando, Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
Marie Fidela R Paraiso, Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
Katie Propst, Center for Urogynecology and Pelvic Reconstructive Surgery, Women’s Health Institute, Cleveland Clinic, Cleveland, OH 44195, United States.
Funding
This study was funded by a grant from the Cleveland Clinic Research Program Committees.
Conflicts of interest: None declared.
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