The Effects of Vaginal Prolapse Surgery Using Synthetic Mesh on Vaginal Wall Sensibility,Vaginal Vasocongestion,and Sexual Function: A Prospective Single‐Center Study

IntroductionVaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction.AimWe aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP.MethodsA prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi‐probe.Main Outcome MeasuresThe combi‐probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse‐generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale‐Revised, and Subjective sexual arousal and affect questionnaire).ResultsSixteen women were included, 14 completed the 6‐month follow‐up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected.ConclusionsIn women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential. Weber MA, Lakeman MME, Laan E, and Roovers JPWR. The effects of vaginal prolapse surgery using synthetic mesh on vaginal wall sensibility, vaginal vasocongestion, and sexual function: A prospective single‐center study. J Sex Med 2014;11:1848–1855.     

Long-term results of prolapse recurrence and functional outcome after vaginal hysterectomy

ObjectiveTo evaluate the incidence of prolapse and prolapse-related symptoms following vaginal hysterectomy.MethodsData were reviewed from women who underwent vaginal hysterectomy between 1988, and 1995, at St George's Hospital, London, UK, and attended long-term follow-up. Outcome measures included a questionnaire for prolapse, urinary, bowel, and sexual symptoms; and a vaginal examination.ResultsAmong 94 women attending long-term evaluation, the mean follow-up time was 100.7 months (range 67.0–156.0 months). Before vaginal hysterectomy, urgency was noted among 23 (24.5%), urge incontinence among 11 (11.7%), and stress incontinence among 8 (8.5%) women. At follow-up, these symptoms were observed among 23 (24.5%), 13 (13.8%), and 6 (6.4%) women, respectively. De novo urge incontinence and de novo stress incontinence were observed among 3 (3.2%) and 2 (2.1%) women, respectively. Vaginal examination data were compared for 70 women, of whom 18 (25.7%) had grade 1, 40 (57.1%) had grade 2, and 6 (8.6%) had grade 3 uterine prolapsed before surgery. Postoperatively, vaginal vault prolapse occurred in 7 (10.0%) women and correlated with degree of posterior prolapse (P = 0.007), but not with severity of uterine descent (P = 0.205) or previous prolapse surgery (P = 0.573).ConclusionThe incidence of post-hysterectomy vault prolapse correlated with the degree of preoperative rectocele.     

Impact of incontinence surgery on sexual function: a systematic review and meta-analysis

IntroductionUrinary incontinence has an adverse impact on sexual function. The reports on sexual function following the treatment of urinary incontinence are confusing.AimTo investigate the impact of surgery for stress incontinence on coital incontinence and overall sexual function.MethodsCochrane Incontinence Group Specialized Register of Controlled Trials, The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched for trials of incontinence surgery assessing sexual function and coital incontinence before and after surgery. Observational studies and randomized controlled trials investigating the impact of surgical correction of stress urinary incontinence on sexual function were included. Surgical interventions included tension‐free vaginal tape (TVT), Tension Free Vaginal Tape‐Obturator (TVT‐O), transobturator tape (TOT), Burch, and autologous fascial sling (AFS). Studies that included patients undergoing concurrent prolapse surgery were excluded from the analysis. Data extraction and analysis was performed independently by two authors. Coital incontinence was analyzed separately and odds ratios (ORs) with 95% confidence intervals (CI) calculated. The data were analyzed in Review Manager 5 software.Main Outcome MeasureChanges in sexual function and coital incontinence following surgery for urinary incontinence.ResultsTwenty‐one articles were identified, which assessed sexual function and/or coital incontinence following continence surgery in the absence of prolapse. Results suggest evidence for a significant reduction in coital incontinence post surgery (OR 0.11; 95% CI 0.07, 0.17).ConclusionsCoital incontinence is significantly reduced following continence surgery. There were several methodological problems with the quality of the primary research particularly related to heterogeneity of studies, use of different outcome measures, and the absence of well‐designed randomized controlled trials. Jha S, Ammenbal M, and Metwally M. Impact of incontinence surgery on sexual function: A systematic review and meta‐analysis. J Sex Med 2012;9:34–43.     

Menopause Leading to Increased Vaginal Wall Thickness in Women with Genital Prolapse: Impact on Sexual Response

IntroductionHypoestrogenism causes structural changes in the vaginal wall that can lead to sexual dysfunction. A reduction in vaginal wall thickness has been reported to occur after menopause, although without precise morphometry.AimTo measure vaginal wall thickness in women with genital prolapse in normal and hypoestrogenic conditions and to correlate sexual dysfunction with vaginal wall thickness and estradiol levels.MethodsSurgical vaginal specimens from 18 normoestrogenic and 13 postmenopausal women submitted to surgery for genital prolapse grades I and II were examined. Patients were evaluated for FSH, estradiol, prolactin, glycemia, and serum TSH levels. For histological analysis, samples were stained with Masson's trichrome and hematoxylin‐eosin. Sexual function was assessed by the Golombok‐Rust Inventory of Sexual Satisfaction (GRISS).Main Outcome MeasuresGRISS questionnaire, histological analysis, morphometric methods, Masson's trichrome.ResultsThe vaginal wall was thicker in the postmenopausal than premenopausal group (2.72 ± 0.72 mm and 2.16 ± 0.43, P = 0.01, and 2.63 ± 0.71 mm and 2.07 ± 0.49 mm, P = 0.01, for the anterior and posterior walls, respectively). These thicknesses seem to be due to the muscular layer, which was also thicker in the postmenopausal group (1.54 ± 0.44 and 1.09 ± 0.3 mm, P = 0.02, and 1.45 ± 0.47 and 1.07 ± 0.44 mm, P = 0.03, for the anterior and posterior wall, respectively). The vaginal epithelium was thinner in the middle segment than in the proximal one in the posterior wall (0.17 ± 0.07 mm, 0.15 ± 0.05 mm, 0.24 ± 0.09 mm, P = 0.02). There was no correlation between coital pain, vaginal wall thickness, and estradiol levels in either group.ConclusionThe vaginal wall is thicker after menopause in women with genital prolapse. In this study, vaginal thickness and estrogen levels were not related to sexual dysfunction. da Silva Lara LA, Ribeiro‐Silva A, Rosa‐e‐Silva JC, Chaud F, Silva‐de‐Sá MF, Meireles e Silva AR, and Rosa‐e‐Silva ACJS. Menopause leading to increased vaginal wall thickness in women with genital prolapse: impact on sexual response.     

Morbidity of a Single Incision Transvaginal Mesh to Correct Apical Prolapse

Study ObjectiveTo determine complications and related reintervention rates associated with use of the Uphold Vaginal Support System (Boston Scientific, Boston, MA) for symptomatic vaginal apical prolapse.DesignA multicenter retrospective study.SettingTwo teaching hospitals.PatientsFifty-nine women with symptomatic vaginal apical prolapse.InterventionVaginal apical prolapse surgery using the Uphold Mesh Kit system with or without other concomitant procedures.Measurements and Main ResultsA chart review was performed, including the following parameters: perioperative and postoperative complications, repeat surgery, and recurrence rate. A total of 59 patients met the criteria for inclusion in the study. Bladder perforation occurred perioperatively in 1 patient. Postoperative voiding difficulties were observed in 16 patients (27.1%), including 9 women (15.2%) who left the hospital with an indwelling catheter in place. There were 5 cases (8.5%) of transient groin pain, all of which resolved spontaneously. One patient developed a vaginal hematoma. Nine women (15%) required reoperation, including 4 (6.7%) because of recurrent prolapse and 1 (2%) for pelvic pain considered related to the mesh. Three patients (5%) required release of a midurethral sling (MUS) that had been placed concomitantly with the Uphold system. Two patients (3%) required a MUS for de novo stress incontinence.ConclusionUse of the Uphold Vaginal Support System for symptomatic vaginal apical prolapse was associated with a significant risk of obstructed micturition. In our study population, 15% required repeat surgery, mainly for recurrent pelvic organ prolapse and de novo stress urinary incontinence. No surgical-related complication resulted in long-term morbidity.     

Retentissement de la chirurgie du prolapsus génital sur la sexualité des patientes

ObjectiveTo evaluate quality of life and sexual life of female patients after abdominal or vaginal approach for prolapse surgery.Patients and methodsTwo hundred and nineteen patients with stage 2 or 3 prolapse underwent surgery over a period of 7 years. In this retrospective work, patients have been invited by mail to answer questions on the phone. The questionnaire is a French translation of PISQ12. Time between surgery and study is about 4 years.ResultsWe got 176 answers: 52.3% of women underwent abdominal surgery (group 1) and 47.7% vaginal reconstructive surgery (group 2). In terms of quality of life, only 8.5% of patients are not satisfied in group 1, compared to 9.5% in group 2. In terms of sexuality, 64% have sexual intercourses. We find a significant total score difference to the detriment of vaginal way after surgery (p = 0.005). We note indeed a significant decrease in sexual desire, orgasm frequency and excitement and a significant worsening in dyspareunia after vaginal reconstructive surgery. The other significant factors on sexuality are age and urinary incontinence. After a multivaried study, only age remains the significant factor.Discussion and conclusionThis work confirms that both ways of surgery are an effective prolapse treatment, with identical functional results. Influence on sexuality seems to depend more on age than on the type of reconstructive surgery.     

The effect of prolapse repair on sexual function in women

IntroductionSexual dysfunction is common in women with pelvic organ prolapse (POP). Treatment of symptomatic prolapse often requires surgery. The outcome of prolapse symptoms following surgery is well studied and reported, but evidence on outcomes of sexual function following pelvic reconstructive surgeries is limited.AimThe objective of this study was to assess the impact of different forms of surgery for POP on sexual function using prospectively collected data.MethodsIn this ethically approved project, data were collected prospectively for women undergoing prolapse repair between 2008 and 2010 and were stratified into four groups: “posterior repair,”“anterior repair,”“anterior repair with vaginal hysterectomy,” and “combined anterior and posterior repair.” The electronic personal assessment questionnaire‐pelvic floor (ePAQ‐PF) was used to assess symptoms. The sexual dimension of ePAQ‐PF computes domain scores for sexual dysfunction secondary to vaginal symptoms and dyspareunia on a scale of 0–100 (0 = best possible and 100 = worst possible health status). ePAQ‐PF was completed in 123 sexually active women both pre‐ and 3–6 month postoperatively. Results were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Pre‐ and postoperative scores for each domain were compared in all groups (Student's t‐test). Individual symptoms in these domains were compared using Wilcoxon signed‐rank test.Main Outcome MeasuresChange in sexual symptoms and dyspareunia following prolapse surgery in each group.ResultsWomen undergoing anterior repair or anterior repair and vaginal hysterectomy reported significant improvement in sexual symptoms and dyspareunia. Women undergoing a posterior repair in isolation had improved sexual function following surgery though improvement in dyspareunia was not significant. Women undergoing combined anterior and posterior repair had the least improvement in sexual function.ConclusionsSexual function improves in women following pelvic reconstructive surgery, but the improvement is more substantial following anterior repair either alone or in combination with a vaginal hysterectomy when compared with posterior repair. Dua A, Jha S, Farkas A, and Radley S. The effect of prolapse repair on sexual function in women. J Sex Med 2012;9:1459–1465.     

Sexual Function Improvement Following Surgery for Stress Incontinence: The Relevance of Coital Incontinence

IntroductionLittle is known about the impact of surgery for stress urinary incontinence (SUI) on female sexual function, and results are conflicting.AimsWe aimed to clarify the impact of surgery for SUI on female sexual function.MethodsWe analyzed data collected from two studies evaluating sexual function in women after placement of the tension‐free vaginal tape, tension‐free vaginal tape obturator, or transobturator suburethral tape. A nonvalidated sexual questionnaire developed by Lemack, translated into Dutch, was mailed to all patients 3–12 months after the procedure.Main Outcome MeasuresPre‐ and postoperative results of a nonvalidated sexual questionnaire.ResultsA total of 136 sexually active women completed the questionnaires. Compared with preoperative responses, we observed no significant changes postsurgical regarding frequency of sexual intercourse or satisfaction of sexual intercourse, although a significant postoperative decrease in urinary coital incontinence (P ≤ 0.001) was found. Postoperatively, 29 women (21.3%) reported improved sexual intercourse, and eight women (5.9%) complained of a worsening. There was a significant higher rate of preoperative coital incontinence (86.2% women with coital incontinence) in the group of women who reported improved intercourse (P = 0.01).ConclusionWomen with coital incontinence show a significant higher improvement in sexual function after surgery for SUI compared to women without coital incontinence. Our results suggest that improvement in coital incontinence results in improvement of sexual function. Therefore, coital incontinence is a prognostic factor for improvement of sexual function following incontinence surgery. Bekker M, Beck J, Putter H, Venema P, Lycklama à Nijeholt A, Pelger R, and Elzevier H. Sexual function improvement following surgery for stress incontinence: The relevance of coital incontinence.     

Sexual Activity and Vaginal Topography in Women with Symptomatic Pelvic Floor Disorders

IntroductionPelvic floor disorders affect vaginal anatomy and may affect sexual function.AimsThe aims of this study were to explore the relationship between vaginal anatomy and sexual activity in women with symptomatic pelvic floor disorders and to assess whether vaginal measurements (topography) correlate with sexual function.MethodsThis is a retrospective cohort study comparing sexually active and nonsexually active women planning urogynecologic surgery. Our primary outcome was the difference in vaginal topography based on Pelvic Organ Prolapse Quantification (POP‐Q) exam between cohorts. Correlations between POP‐Q measurements and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ‐12) scores were assessed in sexually active women.Main Outcome MeasureThe POP‐Q is a quantitative and standardized examination for prolapse. The PISQ‐12 is a condition‐specific sexual function questionnaire validated in sexually active women with pelvic floor disorders.ResultsOf 535 women, 208 (39%) were sexually active and 327 (61%) were not. Median genital hiatus (GH) and perineal body (PB) measurements and a PB : GH ratio were not significantly different between the two cohorts. Total vaginal length (TVL) was longer in sexually active women (median 9 vs. 8 cm, P < 0.001). In a linear regression analysis controlling for potential confounders, sexually active women still had a longer TVL by 0.4 cm (95% confidence interval 0.07, 0.6 cm) compared with those who were not sexually active. Of the 327 nonsexually active women, 28% indicated they avoided sexual activity because of pelvic floor symptoms. There was poor correlation between TVL, GH, PB, and PB : GH ratio with PISQ‐12 scores (r = 0.10, −0.05, −0.09, −0.03, respectively).ConclusionsIn women with pelvic floor disorders, sexual activity is associated with a longer vaginal length. One‐quarter of women indicated they avoided sexual activity because of pelvic floor symptoms. Vaginal topography does not correlate with sexual function based on PISQ‐12 scores. Edenfield AL, Levin PJ, Dieter AA, Amundsen CL, and Siddiqui NY. Sexual activity and vaginal topography in women with symptomatic pelvic floor disorders. J Sex Med 2015;12::416–423.     

Prospective Follow‐Up of Female Sexual Function after Vaginal Surgery for Pelvic Organ Prolapse Using Transobturator Mesh Implants

IntroductionAlthough the use of transobturator mesh implants for pelvic organ prolapse repair has been shown to be safe and effective, concern exists that the presence of prosthetic material in the vagina may adversely affect sexual function.AimTo evaluate the impact of transobturator mesh implantation on sexual function using validated questionnaire.Main Outcome MeasuresFemale Sexual Function Index (FSFI), a validated 19‐item questionnaire that assesses six domains of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain), was used. The questionnaire was administered preoperatively, and at 3, 6, 12, and 24 months postoperatively. Clinical data were also recorded at each time point.MethodsProspective nonrandomized study including 96 women with pelvic organ prolapse (cystocele, rectocele, vault prolapse). Transvaginal anterior or posterior wall repair using transobturator mesh implants with or without concomitant transobturator sling procedure.ResultsMean age was 51.4 ± 5.2 years. Mean operating time was 47.6 ± 23.4 minutes, and the mean hospitalization period was 3.8 ± 1.6 days. After initial decrease during the first 3 months, patients experienced a steady improvement in their sexual function. At 24 months postoperatively, the total mean FSFI score reached significantly higher values compared to the baseline (P = 0.023). Furthermore, pain‐free intercourse improved during the follow‐up reaching mean score of 4.27 ± 0.79 (P < 0.05) after 2 years. Pelvic floor examination at 2 years follow‐up showed excellent surgical results with only 3.1% of the patients presenting with stage II vaginal wall prolapse.ConclusionsSurgical repair of symptomatic pelvic organ prolapse using mesh implants results in improvement of major parameters of sexual function. A worsening in pain with intercourse during the initial months postoperatively lessens after 3 months as healing is completed. Hoda MR, Wagner S, Greco F, Heynemann H, and Fornara P. Prospective follow‐up of female sexual function after vaginal surgery for pelvic organ prolapse using transobturator mesh implants.     

Vaginal estrogens for the treatment of dyspareunia

IntroductionVaginal atrophy, which is associated with vaginal itching, burning, dryness, irritation, and pain, is estimated to affect up to 40% of postmenopausal women. Estrogens play a key role in maintaining vaginal health; women with low serum estradiol are more likely to experience vaginal dryness, dyspareunia, and reduced sexual activity compared with women who have higher estradiol levels.AimsThe purpose of this review is to assess the prevalence and impact of dyspareunia, a symptom of vaginal atrophy, on the health of postmenopausal women and to evaluate treatment options using vaginal estrogens (U.S. Food and Drug Administration [FDA] approved).MethodsRelevant published literature was identified by searching Index Medicus using the PubMed online database. The search terms dyspareunia, vaginal estrogen, vaginal hormone therapy, vaginal atrophy, and atrophic vaginitis were the focus of the literature review.ResultsCurrent treatment guidelines for vaginal atrophy recommend the use of minimally absorbed local vaginal estrogens, along with non‐hormonal lubricants or moisturizers, coupled with maintenance of sexual activity. Vaginal estrogen therapy has been shown to provide improvement in the signs and symptoms of vaginal or vulvar atrophy. Vaginal tablets, rings, and creams are indicated for the treatment of vaginal atrophy, and the FDA has recently approved a low‐dose regimen of conjugated estrogens cream to treat moderate‐to‐severe postmenopausal dyspareunia. The use of low‐dose vaginal estrogens has been shown to be effective in treating symptoms of vaginal atrophy without causing significant proliferation of the endometrial lining, and no significant differences have been seen among vaginal preparations in terms of endometrial safety.ConclusionWomen should be informed of the potential benefits and risks of the treatment options available, and with the help of their healthcare provider, choose an intervention that is most suitable to their individual needs and circumstances. Krychman ML. Vaginal estrogens for the treatment of dyspareunia. J Sex Med 2011;8:666–674.     

Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence

OBJECTIVE: We sought to describe sexual function in women before and after surgery for either prolapse or urinary incontinence, or both. STUDY DESIGN: Women completed questionnaires, and vaginal dimensions were measured before and at least 6 months after surgery for prolapse or incontinence. Comparisons were made with signed-rank tests or the McNemar test. RESULTS: Eighty-one (49%) of 165 women were sexually active before and after surgery; their mean age was 54. 0 +/- 9.9 years. Mean frequency of intercourse did not change. Dyspareunia was reported by 6 (8%) women preoperatively and 15 (19%) women after surgery; dyspareunia persisted postoperatively in 1 woman, developed in 14, and resolved in 5 (P =.04). Dyspareunia occurred in 14 (26%) of 53 women after posterior colporrhaphy (P =. 01) and in 8 (38%) of 21 women who had Burch colposusupension and posterior colporrhaphy performed together (P =.02). Vaginal dimensions decreased slightly after surgery; however, this did not correlate with any change in sexual function. Preoperatively, 66 (82%) women were satisfied with their sexual relationships, compared with 71 (89%) who were satisfied postoperatively. CONCLUSION: Sexual function and satisfaction improved or did not change in most women after surgery for either prolapse or urinary incontinence, or both. However, the combination of Burch colposusupension and posterior colporrhaphy was especially likely to result in dyspareunia.     

The Effect of Pelvic Organ Prolapse on Sexual Function in a General Cohort of Women

IntroductionThis is a report about the effects of pelvic organ prolapse on sexual function in women.AimTo determine the effect of pelvic organ prolapse on sexual function in women.MethodsThe study group consisted of 1,267 sexually active women. Baseline characteristics, medical and obstetric history of the patients were recorded. All women underwent vaginal examination to determine the degree of prolapse by pelvic organ prolapse quantification (POPQ) system. Of 1,267 women, 342 (27.0%) had prolapse stage ≥2.Main Outcome Measure(s)The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire short form (PISQ-12) scores of the women were recorded.Result(s)Women with genital prolapse had lower PISQ-12 scores than women without it. The difference resulted mainly from urinary incontinence during sexual activity, fear of incontinence and avoidance of intercourse due to prolapse. Multivariate analyses showed that genital prolapse was one of the confounding factors for sexual function.Conclusion(s)Pelvic floor dysfunction is a multi-faceted problem because it has both anatomical and functional aspects. Although pelvic organ prolapse had an effect on some aspects of sexuality, it has no effect on certain aspects of sexual function such as orgasm and sexual satisfaction. Tok EC, Yasa O, Ertunc D, Savas A, Durukan H, and Kanik A. The effect of pelvic organ prolapse on sexual function in a general cohort of women.     

Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: A prospective randomized study with long-term outcome evaluation

OBJECTIVES: Our purpose was to determine whether a vaginal or abdominal approach is more effective in correcting uterovaginal prolapse. STUDY DESIGN: Eighty-eight women with cervical prolapse to or beyond the hymen or with vaginal vault inversion >50% of its length and anterior vaginal wall descent to or beyond the hymen were randomized to a vaginal versus abdominal surgical approach. Forty-eight women underwent a vaginal approach with bilateral sacrospinous vault suspension and paravaginal repair, and 40 women underwent an abdominal approach with colposacral suspension and paravaginal repair. Ancillary procedures were performed as indicated. Detailed pelvic examination was performed postoperatively by the nonsurgeon coauthor yearly up to 5 years. The women were examined while standing during maximum strain. Surgery was classified as optimally effective if the woman remained asymptomatic, the vaginal apex was supported above the levator plate, and no protrusion of any vaginal tissue beyond the hymen occurred. Surgical effectiveness was considered unsatisfactory if the woman was symptomatic, the apex descended >50% of its length, or the vaginal wall protruded beyond the hymen. RESULTS: Eighty women (vaginal 42, abdominal 38) were available for evaluation at 1 to 5.5 years (mean 2.5 years). The groups were similar in age, weight, parity, and estrogen status, and 56% had undergone prior pelvic surgery. There was no significant difference between the groups in morbidity, complications, hemoglobin change, dyspareunia, pain, or hospital stay. The vaginal group had longer catheter use, more urinary tract infections, more incontinence, decreased operative time, and lower hospital charge. Surgical effectiveness was optimal in 29% of the vaginal group and 58% of the abdominal group and was unsatisfactory leading to reoperation in 33% of the vaginal group and 16% of the abdominal group. The reoperations included procedures for recurrent incontinence in 12% of the vaginal and 2% of the abdominal groups. The relative risk of optimal effectiveness by the abdominal route is 2.03 (95% confidence interval 1.22 to 9.83), and the relative risk of unsatisfactory outcome using the vaginal route is 2.11 (95% confidence interval 0.90 to 4.94). CONCLUSIONS: Reconstructive pelvic surgery for correction of significant pelvic support defects was more effective with an abdominal approach. (Am J Obstet Gynecol 1996;175:1418-22.)     

Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence

ObjectiveThe purpose of this study was to evaluate the efficacy and feasibility of concomitant trocar-guided transvaginal mesh (TVM) surgery with a midurethral sling (MUS) for treating women with advanced pelvic organ prolapse (POP) and stress urinary incontinence (SUI) or occult SUI (OSUI).Materials and methodsEighty-nine women with advanced POP and SUI or OSUI were retrospectively enrolled. The Total Prolift and Tension-free Vaginal Tape-Obturator Systems were used for trocar-guided TVM surgery and MUS. Patients received regular follow-up at 1 week, and 1 month, 3 months, 6 months, and 12 months postoperatively, and then annually thereafter. The endpoints were the success rate for POP, and perioperative and postoperative complications. Functional outcomes were the presence of voiding difficulty, persistent or de novo overactive bladder symptoms, postoperative SUI, and paresthesia.ResultsThe median follow-up period was 35 months (range, 12–50 months). Within the follow-up period, 84 patients (94.4%) were objectively cured, five patients (5.6%) had vaginal apical mesh exposure, 29 individuals (32.6%) had persistent or de novo overactive bladder symptoms, six individuals (22.5%) had de novo SUI (two were found by urodynamics), and nine individuals (10.1%) had voiding difficulties (two were found by urodynamics). In addition, the vaginal hysterectomy group had greater blood loss, longer operation times, and a higher mesh erosion rate compared to the uterine suspension group.ConclusionConcomitant trocar-guided TVM surgery and MUS with the use of total Prolift and Tension-free Vaginal Tape-Obturator offer good efficacy in treating women with advanced POP and SUI or OSUI. The vaginal hysterectomy group had more perioperative complications.     

Self-Reported Vaginal Laxity—Prevalence,Impact, and Associated Symptoms in Women Attending a Urogynecology Clinic

Introduction

Vaginal laxity is increasingly recognized as an important condition, although little is known regarding its prevalence and associated symptoms.

Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh

OBJECTIVE: To evaluate the effects of prolene mesh on urinary, bowel and sexual function in prolapse surgery. DESIGN: Prospective observational study on consecutive women. SETTING: Two referral uorgynaecological units in Italy. POPULATION: Women requiring prolapse repair for anterior or posterior vaginal prolapse. METHODS: All women were assessed for urinary, bowel, prolapse symptoms and dyspareunia pre- and post-operatively. Urodynamics was performed in selected cases. Surgery consisted of an anterior or posterior repair plus a prolene mesh. Follow up was after 1, 6 and 12 months. The ANOVA test was used for statistical analysis. MAIN OUTCOME MEASURES: Vaginal anatomical restoration, urinary, bowel and sexual function. RESULTS: We recruited 63 women (mean age 63 years) with a mean follow up of 17 months. Anatomically, the success rate was 94%. Thirty-two women had an anterior repair. Among this group, the sexual activity rate did not alter but dyspareunia increased by 20%. Urge and stress incontinence did not change post-operatively but urgency improved in 10% and 13% had vaginal erosion of the mesh. Thirty-one women had a posterior repair. Among this group, sexual activity decreased by 12% and dyspareunia increased in 63%. Constipation improved in 15% and anal incontinence in 4%, and 6.5% of women had vaginal erosion of the mesh and one required mesh removal for pelvic abscess. CONCLUSIONS: Although this study shows good anatomical results with the use of prolene mesh for prolapse repair, there was a high rate of morbidity. We believe that the use of prolene mesh should be abandoned.     

Self‐Assessment of Genital Anatomy and Sexual Function within a Belgian,Dutch‐Speaking Female Population: A Validation Study

IntroductionData on self‐perceived genital anatomy and sensitivity should be part of the long‐term follow‐up of genitoplasty procedures. However, no normative data, based on a large sample, exist to date.AimsValidation of the Self‐Assessment of Genital Anatomy and Sexual Function, Female version (SAGAS‐F) questionnaire within a Belgian, Dutch‐speaking female population.MethodsSeven hundred forty‐nine women with no history of genital surgery (aged 18–69 years, median 25 years) completed an Internet‐based survey of whom 21 women underwent a gynecological examination as to correlate self‐reported genital sensitivity assessed in an experimental setting.Main Outcome MeasuresThe SAGAS‐F enables women to rate the sexual pleasure, discomfort, intensity of orgasm, and effort required for achieving orgasm in specified areas around the clitoris and within the vagina, as well as genital appearance. The latter was similarly evaluated by an experienced gynecologist, and women were asked to functionally rate the anatomical areas pointed out with a vaginal swab.ResultsSexual pleasure and orgasm were strongest, and effort to attain orgasm and discomfort was lowest when stimulating the clitoris and sides of the clitoris (P < 0.05). Vaginal sensitivity increased with increasing vaginal depth, but overall orgasmic sensitivity was lower as compared with the clitoris. Functional scores on the SAGAS‐F and during gynecological examination corresponded highly on most anatomical areas (P < 0.05). Gynecologist's ratings corresponded highly with the women's ratings for vaginal size (90%) but not for clitoral size (48%).ConclusionsReplication of the original pilot study results support the validity of the questionnaire. The SAGAS‐F discriminates reasonably well between various genital areas in terms of erotic sensitivity. The clitoris itself appeared to be the most sensitive, consistent with maximum nerve density in this area. Surgery to the clitoris could disrupt neurological pathways and compromise erotic sensation and pleasure. Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, and Hoebeke P. Self‐assessment of genital anatomy and sexual function in women (SAGAS‐F): Validation within a Belgian, Dutch‐speaking population. J Sex Med 2013;10:3006–3018.     

Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial

BackgroundVaginal looseness and decreased sensation during intercourse is prevalent in up to 30%–55% of premenopausal women. The efficacy and safety of CO2 laser have been demonstrated for these indications; however, the effect is temporary, up to 6–12 months. No studies regarding the efficacy and safety of adjuvant laser treatments have been conducted to date.AimTo evaluate the efficacy and safety of a single maintenance CO₂ laser treatment in women with vaginal looseness and a concurrent decline in sexual sensation during intercourse.MethodsThis prospective double-blinded randomized controlled trial included premenopausal women who experienced significant temporary improvement in symptoms following previous treatment with CO2 laser due to the abovementioned indications. Participants were randomized to either a single CO2 laser treatment or a single sham treatment.OutcomesTreatment efficacy evaluated with the female sexual function index (FSFI) and the vaginal health index (VHI).ResultsOverall, 119 women were included in the study. Mean VHI and FSFI scores were significantly higher in the study group compared to the control group at three months post-treatment (17.34±1.39 vs 12.86±2.23, P = .023 and 30.93±1.79 vs 25.78±1.87, P = .044, respectively). In the study group, both VHI and FSFI returned to baseline at six months post-treatment. The median rate of sexual intercourse per month was increased in the study group at three months post-treatment (8 vs 4, P = .011), and returned to baseline at six months post-treatment.Clinical implicationsMaintenance laser treatment provides a temporary non-surgical alternative for women with vaginal looseness and associated sexual dysfunction, though treatment effect seems to be limited to less than 6 months, requiring additional maintenance sessions.Strengths and limitationsThe strengths of the current study include a randomized-sham controlled design. Furthermore, VHI was used as an objective evaluation tool, in addition to the FSFI, and assessment of the rate of sexual intercourse. The homogeneity and the relatively small sample size of the cohort is a limitation, and calls for caution in interpretation of the results, and the use of CO2 laser treatment in different age groups and populations.ConclusionA single maintenance laser treatment in women who previously underwent successful treatment with laser is an effective, well-tolerated, and safe procedure for treating symptoms of vaginal looseness and sexual dysfunction, though effects are temporary.Lauterbach R, Aharoni S, Farago N, et al. Maintenance Laser Treatment for Vaginal Looseness and Sexual Dysfunction: A Double-blinded Randomized Controlled Trial. J Sex Med 2022;19:1404–1411.