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

Vaginal Mesh Kits For POP Repair

A major difficulty encountered when attempting to repair POP surgically is the high recurrence rate of approximately 30%. This has led many to seek augmentation techniques using synthetic permanent mesh or temporary biologic grafts to improve the longevity of the repair. The main rationale of using mesh or graft for reinforcement of the reconstructive procedure is to provide better support to the already attenuated or absent connective pelvic floor tissues that have failed. One step further is the use of vaginal mesh kits, which are rapidly gaining popularity among caregivers engaged in prolapse repair. The vaginal mesh kits have the added advantage of rapid application of the preformed mesh and addressing multiple vaginal compartment defects. Concomitant anti-incontinence procedures can be carried out at the same surgical encounter in the form of a midurethral sling. However, the price for longevity is not trivial. A whole gamut of postoperative complication is associated with the use of vaginal mesh, some of which were never seen before the introduction of prosthetics to the vagina. In view of the increasing use and concomitant increase in complication rates related to vaginal mesh, the US FDA issued a statement and warning pertaining to the use of vaginal mesh[103]. Complications encountered with vaginal mesh use include vaginal mesh extrusion, pain, especially during vaginal intercourse, for both partners in the presence of exposed vaginal mesh, infection, voiding dysfunction and recurrent prolapse and incontinence. The FDA statement summarized that there were insufficient data regarding dyspareunia, sexual function, voiding or defecatory dysfunction. When use of mesh is necessary, the type 1 monofilament, macroporous polypropylene should be used because it has been suggested to have the lowest incidence of infection and erosion among the nonabsorbable prostheses. When such complications develop, removal of the mesh is often unavoidable, which can be a daunting procedure, especially when intense scarring occurs to the surrounding connective tissue and pelvic organs, such as the urethra, bladder and rectal walls. Usage of the kits requires a learning curve, as well as an unavoidable blind passage of trocars, in order to place the mesh at its destined location. In the process, perforation injury to the bowel, bladder and blood vessels are continuously reported. In its statement, the FDA proposed several recommendations, physicians should:

  • Obtain specialized training for each mesh-placement technique and be aware of its risks;

  • Be vigilant for potential adverse events from the mesh, especially erosion and infection;

  • Watch for complications associated with the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations;

  • Inform patients that implantation of surgical mesh is permanent and that some complications associated with the implanted mesh may require additional surgery that may or may not correct the complication;

  • Inform patients about the potential for serious complications and their effect on quality of life, including pain during sexual intercourse, scarring and narrowing of the vaginal wall (in POP repair);

  • Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if available.

In the second half of 2008, the Society of Gynecologic Surgeons Systematic Review Group published a comprehensive review of literature regarding graft use in transvaginal POP repair[61]. The aim of the study was to estimate the efficacy of graft (synthetic and biological) use in transvaginal prolapse repair, as well as describe the severity, type and prevalence of adverse events associated with its use. The authors found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women and ten case reports of adverse events. Examining the anterior compartment, one randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use documented favorable subjective and objective outcomes with graft use. As for the use of graft for the posterior and apical vaginal compartments, there was insufficient information available to determine its efficacy. Similarly, there was a paucity of knowledge regarding efficiency of use of biologic absorbable graft in all vaginal compartments. The rates and spectrum of adverse events associated with graft use included bleeding (0-3%), visceral injury (1-4%), urinary infection (0-19%), graft erosion (0-30%) and fistula (1%). The authors concluded that the available data are limited to draw guidelines for vaginal mesh insertion for POP repair, and that adequately powered and well-designed randomized trials are needed to assess anatomic and subjective outcomes.

What is becoming evident, with regards to use of mesh augmentation in vaginal reconstructive surgery, is that, the newly developed vaginal mesh kits offer rapid alternative solutions to multiple vaginal compartment prolapses, the unanswered questions remain numerous. Pertinent dilemmas involving transvaginal mesh use, to name a few, include but are not limited to: should mesh be used for primary repair or only be reserved for cases that have failed once already? Should patients be treated differently when presenting with risk factors for recurrence? When should biologic-absorbable versus synthetic permanent mesh be used? In which compartments should mesh be used? How much mesh is regarded as safe? A crucial question summarizing some of these debates is when do the benefits of mesh use outweigh the risk profile for complications to render mesh usage acceptable and cost effective? As stated by the FDA and the Society of Gynecologic Surgeons Systematic Review Group, all these pertinent questions will serve as incentives for future research.

Vaginal Vault Suspension

A short version Cochrane review meta-analysis was conducted summarizing the outcomes of various reconstructive surgical approaches to the different vaginal compartments and anticontinence procedures. Anatomical, subjective and quality-of-life outcomes were reviewed, including the impact on sexual function postoperatively[62]. The meta-analysis included 22 randomized, control trials evaluating 2368 women. Better anatomical results and quicker return to sexual function was obtained with vaginal vault suspension through an abdominal approach by an abdominal sacrocolpopexy (ASC) compared with a vaginal approach through a sacrospinous vaginal vault suspension. The relative a risk of vault prolapse recurrence with an ASC was risk ratio (RR) of 0.23 (95% confidence interval [CI]: 0.07-0.77) and that for dyspareunia was significantly lower (RR: 0.39; 95% CI: 0.18-0.86). However, there was no significant difference in the reoperation rate for a recurrent prolapse between the abdominal versus vaginal approach. In fact, the vaginal vault suspension was a cheaper and quicker procedure, with less blood loss, quicker discharge home and significantly faster return to activities of daily life for the patient.

Anterior Compartment

The meta-analysis reviewed surgical techniques for anterior compartment repair, investigating studies comparing a standard midline cystocele plication for anterior repair versus a standard repair with additional mesh reinforcement. There were fewer recurrent cystocele cases with use of porcine dermis augmentation (RR: 2.72; 95% CI: 1.20-6.14)[63]. Use of this mesh did not cause increased dyspareunia and/or voiding dysfunction. Another study on 72 women for a mean follow-up of 8 months compared the use of synthetic polypropylene mesh versus porcine dermis and did not find significant differences in anatomical and subjective results, as well as postoperative sexual function[64].

Posterior Compartment

Pelvic floor defects localized to the posterior vaginal compartment are very common among PFD patients. Most are a result of detachment of the connective tissue that supports the posterior wall of the vagina and its attachment to the pelvic walls. Traditional repair entails plication of the native tissue in order to reinforce site-specific defects or performing a midline plication to correct a more centralized defect. There has been conflicting published evidence regarding the association of posterior colporrhaphy with the development of post-operative dyspareunia. One study prospectively evaluated pre- to postoperative changes in sexual function in women who had undergone posterior vaginal repair compared with women who did not[65], using the condition-specific, validated sexual function questionnaire, PISQ[31]. Sexual function improved in both groups, whether they had a posterior colporrhaphy or not, which was determined by better total PISQ scores postoperatively. The authors concluded that sexual function after reconstructive pelvic surgery was not significantly adversely affected by the addition of a posterior colporrhaphy and that the major positive effects of repairing the incontinence and prolapse were dominant, minimizing a potential detrimental effect of posterior colporrhaphy on sexual function.

Another study by Paraiso et al. was undertaken to compare outcomes of three different rectocele-repair techniques[66]. This is one of the few randomized, controlled trials available addressing this question. Women (n = 106) with advanced rectocele (≥stage 2) were randomly assigned to either posterior colporrhaphy (n = 37), site-specific rectocele repair (n = 37),or site-specific rectocele repair augmented with a porcine small intestinal submucosa graft (n = 32). Subjects underwent a physical examination and completed three validated pelvic floor instruments at baseline and 6 months, 1 year and 2 years after surgery. Anatomic failure was defined as pelvic organ prolapse quantification system (POPQ) point Bp-2 or more at 1 year. In total, 93% of women returned for follow-up, which ranged over 17.5 ± 7 months. All three groups demonstrated significant improvement 1 year after surgery in prolapse and colorectal scales of the Pelvic Floor Distress Inventory short form 20 (PFDI-20) and the Pelvic Floor Impact Questionnaire short form 7 (PFIQ-7) (p < 0.001 for each) with no differences among groups. Functional failure was approximately 15% for all groups. Pain with intercourse was the same in all groups, without a significant change 1 year after surgery. Importantly, sexual function assessed by the PISQ-12 improved in all groups after surgery (p < 0.001). The authors' conclusion was that all three repairs (midline, site-specific and graft addition) significantly improved symptoms, quality of life and sexual function, and that addition of a porcine graft did not further improve the results.

The meta-analysis mentioned earlier included a review of studies on posterior compartment repairs[62]. The vaginal approach was associated with less recurrent rectocele/enterocele than the transanal approach (RR: 0.24; 95% CI: 0.09-0.64). There were not sufficient data to draw reliable conclusions on differences in sexual function, bowel function, morbidity and mesh/graft augmentations. A separate study found that dyspareunia occurs in 21-27% after posterior repair approached vaginally with concomitant levator ani plication[69]. This study identified that, in cases of postoperative dyspareunia, the introital caliber was reduced to a mean of 1.4 cm. In comparison, Porter et al. found, in a study of 125 patients, that posterior repair without perineorrhaphy and levatator ani plication did not adversely affect sexual function and actually improved dyspareunia postoperatively[68]. The authors recommended when performing a posterior repair to restore or maintain an average vaginal length of 8-11 cm and an adequate caliber to admit two or three fingers at the vaginal introitus during surgery.

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