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

Five-year View

Its is now acknowledged that female sexuality includes a multitude of facets, uniting anatomical, psychological and social as well as physiological elements, which involve hormonal levels, neuronal modulation, and vascular and smooth muscle function of the pelvic floor. The interaction between all of these factors is under continuous study, and it is perceivable that, within the next 5 years, new knowledge will improve our understanding of the impact of these factors on normal and dysfunctional sexual responses and how to improve the treatment of sexual disorders. As the definitions of FSDs become established and familiar, they will serve as a solid basis for future studies improving the quality of research targeted to elucidate well-defined dysfunctional entities, facilitating diagnosis and leading to more specific and efficient treatment modalities. By achieving a better classification that is noncontroversial and agreed upon, it will be possible to conduct studies that are based on comparable cohorts. This will improve the accumulation of knowledge and the ability to draw meaningful conclusions that are evidence based. It will also help in creating treatment algorithms that are simple to use in clinical environments with approaches targeted to specific sexual disorders.

Our growing understanding of normal pelvic floor function as well as PFDs will also provide significant tools in addressing the development of sexual dysfunction related to PFDs, and how these adverse effects can be treated or, better yet, avoided completely. The role of synthetic mesh or absorbable graft in vaginal reconstructive surgery will also be better defined, with guidelines established of when to use mesh/graft, in which vaginal compartments and for which defects, and how to optimize cost-effectiveness, increasing the longevity of the repair while at the same time minimizing the complications associated with its use.

The advancements in establishing definitions of normal and abnormal female sexuality, classification and use of validated questionnaires, as well as the increased understanding of the complex physiology and organic disorders that can affect female sexuality, is leading to the development of new treatment modalities. These include new pharmaceutical approaches to address the various symptoms of FSD. Hormone-replacement therapy is the major cornerstone, estrogen replacement being considered first in treating dysfunction in sexuality in women. However, at the same time there is an increased realization that decreased androgen levels play a major role in the establishment of sexual dysfunction that is not responsive to estrogen replacement. Well-designed, randomized, controlled studies have shown the potential benefit that lies with testosterone supplementation, however, this is yet to be FDA approved as more knowledge accrues regarding the risks and benefits that are entailed in this form of therapy.

Other pharmacological agents that may become applicable for the treatment of FSD in the near future include sildenafile citrate and other phosphodiesterase type 5 inhibitors that are currently in development. It will be interesting to define which subpopulations would have the potential to benefit most from this treatment modality. Most likely, women with sexual disorders such as acquired genital sexual arousal disorders would benefit more than women with neurogenic dysfunction.

Similar to sexual dysfunction in males, females may also benefit from decreased adrenergic influence on genital tissues obtained from α1- and α2-adrenergic receptors, such as phentolamine. A few pilot studies have been conducted, with promising results, in women that were also receiving estrogen supplementation, suggesting that this could evolve as a therapeutic option for women with subjective sexual arousal disorders.

Other areas of research originating from research on human males have suggested a potential role for dopamine-receptor agonists, such as apomorphine. In males, erectile activity is increased by dopamine-receptor stimulation of hypothalamic neurons, triggering the central and spinal release of oxytocin from the posterior pituitary. Women who received apomorphine demonstrated significant changes in clitoral blood flow, subjective arousal and lubrication. This is promising and will hopefully lead to future studies in larger cohorts and subpopulations with specific sexual disorders.

Finally, melanocortins have also been been studied recently as supporters of a normal sexual response in men and women, including sexual arousal and genital vascularity. The mechanism of action proposed is through the dopaminergic receptors in the hypothalamus, in centers controlling reproductive behavior in males and females. Based on rat studies, a synthetically modified peptide analog (PT-141) has been tested as to its impact on sexual arousal and desire in premenopausal women with desire and arousal disorders. In Phase IIb trials, women reported increased sexual desire following nasal administration of bremelanotide compared with the placebo group, and were more sexually satisfied after intercourse within 24 h of administration of the drug. Clearly, this is a promising field in the treatment of sexual arousal and desire disorders.

The prevalence in the pre- and postmenopausal population is considerable and is expected to grow even further as our knowledge increases and diagnosis becomes more accurate. Increased awareness among women is expected, as misconceptions are cleared and embarrassment regarding sexuality and sexual disorder diminishes. The same applies to embarrassment regarding pelvic floor function and PFDs. Increased awareness of the high prevalence of these disorders, as well as patient appreciation that a whole gamut of treatment modalities is available to cure their condition and greatly improve their quality of life, will ultimately lead to better diagnosis and improved functionality and quality of life for the individual patient and for society as a whole.

With respect to pelvic floor surgery, it is recognized that well-controlled studies are necessary to evaluate the impact that pelvic floor surgery has on postoperative sexual function and the importance of determining baseline sexual function preoperatively using validated questionnaires. The available literature indicates that overall sexual satisfaction appears to be independent of surgical management of POP and urinary incontinence, and most women are satisfied with the results. The majority of women with urinary incontinence can expect a positive effect in sexual function due to the successful outcome of curing the incontinence. An open, informative and clear discussion has to be made with all patients destined to undergo pelvic reconstructive surgery regarding sexual function postoperatively, especially when use of transvaginal mesh is contemplated. Informed consent should be obtained in writing and discussion of the risk of sexual dysfunction should always be conducted prior to embarking on the path of reconstructive pelvic floor repair, especially when augmentation with mesh is undertaken.

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