Female Sexual Function and the Pelvic Floor

Sarit O. Aschkenazi;   Roger P. Goldberg

Disclosures

Expert Rev of Obstet Gynecol. 2009;4(2):165-178. 

In This Article

Abstract and Introduction

Abstract

Female sexual disorders are prevalent in developed countries, affecting approximately 25-60% of women. Sexual function is an important aspect of quality of life, sparingly investigated in women compared with other quality-of-life areas. A growing interest in female sexuality, mediators and cellular mechanisms affecting the female sexual response is evolving. Increased research has provided appreciation of the complexity of the female sexual cycle and its impact on biologic, psychological and interpersonal factors. Female sexual function is age dependent and closely related to menopause, but dysfunction is also highly prevalent in premenopausal women and can be very distressing for younger women. Pelvic floor functioning is tightly linked to a healthy female sexual cycle and female sexual disorders have often been associated with concomitant pelvic floor disorders. The goals of this paper are to review the definitions, diagnosis and relationship between pelvic floor function and female sexual disorders, and assess the impact of pelvic floor reconstructive surgery on female sexual function.

Introduction

Pelvic floor disorders (PFDs) are very common and are thought to affect at least a third of all women. In the aging female population this proportion is much higher, affecting half of all women aged 55 years and older. These conditions are not life threatening but cause a considerable burden on quality of life. Most importantly, PFDs are treatable with significant improvement to complete resolution of symptoms in the majority of women. The main cause for the development of PFDs occurs when there is weakening of the pelvic floor musculature and connective tissue, which results in varying degrees of loss of support of the pelvic organs in their anatomical position within a woman's body.

In recent years, female sexual function has become a sought-after research area, as we gain insight into the importance of sexual function in determining quality of life. It has become apparent that female sexual disorders (FSDs) are extremely prevalent and affect adult women throughout their lifespan. As the average life expectancy of women is increasing, and has risen to well above 80 years in Western countries, quality-of-life issues, and female sexual function in particular, are gaining importance and are currently being investigated intensely. As we commence the second millennium, it is expected that women will live approximately a third of their lives after menopause. In the older postmenopausal population living today, it has become an acceptable and expected part of life to engage in sexual activity and maintain sexual desire. Studies have shown that the great majority of women and men, provided they are in good enough health and have an adequate partner, remain sexually interested and active until the end of life[1].

This review will address the definition of recognized FSDs, addressing the latest models to characterize the healthy female sexual cycle. PFDs are intricately related to sexual function. After defining the major categories of what encompasses PFDs, we will review recent data regarding the association between various PFD and sexual functioning in women. Finally, we will address how various treatment modalities for PFDs may have implications on female sexual function and what the recommendations are to improve and maintain female sexual function when concomitant PFDs are present.

The pelvic floor consists of muscles, ligaments and connective tissue supporting the pelvic organs - including the uterus, bladder and rectum - like a hammock. The pelvic floor has a triple function that entails pelvic organ support to prevent these organs from prolapsing out, as well as maintaining their normal function by the virtue of keeping these organs in their anatomical position. The pelvic floor also allows for pregnancy and parturition. The urethra, vagina and rectum are kept closed by the constant resting tone of the levator ani muscle fibers that loop around these openings. Voiding is facilitated by a well-coordinated relaxation of the pelvic floor musculature in synchronization with a bladder contraction.

The pelvic diaphragm has a crucial role in sexual response. The innermost layer includes the levator ani muscles (puborectalis, pubococcygeus and illiococcygeus). The ischiocavernous, bulbocavernous and superficial transverse perineal muscles are part of the anterior and superficial portion of the pelvic floor, and may often be altered or damaged by vaginal childbirth. Pelvic organs that become engorged during sexual arousal are the clitoris, labia minora and vestibular bulbs on either side of the female urethra[2]. Vascular changes occurring with arousal are mediated by autonomic nerves. The autonomic sympathetic and parasympathetic fiber innervation to the vagina originates from the hypogastric and sacral plexus through the uterovaginal nerves. The somatic sensory innervation from the skin arises from the dorsal nerve of the clitoris to the pudendal nerve. Clitoral innervation receives sympathetic input from T1-L3 spinal nerve roots and parasympathetic innervation from nerve roots S2-S4. Any insult to the pelvic floor can potentially lead to dennervation of the female erectile tissues with sexual dysfunction following.

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