Female Sexual Dysfunction Following Vaginal Surgery: A Review

Hari S. G. R. Tunuguntla and Angelo E. Gousse*,†

From the Division of Female Urology, Voiding Dysfunction, Neuro-Urology and Urodynamics, Department of Urology, University of
Miami, School of Medicine, Miami, Florida

Purpose: Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including
decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve
orgasm. In this review we addressee the etiologies and incidence, evaluation and treatment of female sexual dysfunction
following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior
colporrhaphy, perineoplasty and vaginal vault prolapse.
Materials and Methods: Literature on the mechanisms by which vaginal surgery affects female sexual function are
discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and
introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular
damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunc-
tion following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal
fistula repair were also discussed.
Results: Current literature does not support an association between vaginal length following vaginal surgery and sexual
function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery
for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual
function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience
improved overall sexual function due to complete relief from coital incontinence
Conclusions: Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall
sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect
specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible
etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

Key Words: vagina, sexuality, bladder, urethra, reproductive and urinary physiology

he female sexual response cycle is a 3 phase model, lower urinary tract dysfunction and sexual difficulties.

T consisting of desire, arousal and orgasm.1 The percep-

tion of sexual satisfaction depends on the interactions
among emotional well-being, intimacy with the partner,
quality of life and physical health. The 1998 American Fed-
eration for Urological Disease classification of FSD includes
hypoactive sexual desire disorders, sexual arousal disorders,
orgasmic disorders and sexual pain disorders.2
The subjective experience of arousal in women may corre-
late poorly with signals reflective of genital congestion and
activation of areas of the brain involved in organizing reflexive
genital vasocongestion. These aspects have been incorporated
into new models of sexual response (nonlinear model of Bas-
son). The definition of female sexual dysfunction has recently
been revised to be consonant with these concepts.
The close anatomical proximity of the bladder and ure-
thra to the vaginal canal allows an association between
Submitted for publication January 23, 2005.
* Correspondence: Division of Female Urology, Pelvic Floor Dys-
function, Neuro-urology, Voiding Dysfunction and Reconstructive
Urology, Department of Urology, University of Miami School of Med-
icine, 1400 Northwest 10th Ave., Suite 507-A, Miami, Florida 33136
(telephone: 305-243-2973; FAX: 305-243-3164; e-mail: Agousse@
aol.com).
† Financial interest and/or other relationship with Pfizer, Ameri-
can Medical Systems, Allergan and Yamanouchi.
Causes and effects may be bidirectional, in that sexual ac-
tivity can cause or aggravate urinary problems and urinary
problems can result in FSD.
The clinical manifestations of FSD are decreased vaginal
lubrication, pain and discomfort during intercourse, de-
creased arousal, difficulty in achieving orgasm and hypoac-
tive sexual dysfunction disorder. It has been suggested that
the term subjective arousal should be used to differentiate
the subjective and objective aspects of arousal.
In a retrospective postal survey of 66 women who under-
went pelvic floor surgery Poad et al found new onset dyspareu-
nia in 10 who were never affected before surgery.3 However,
dyspareunia resolved completely in 12 of 23 patients who had
the symptom prior to surgery. Decreased libido was noted in
29% of cases, decreased lubrication was noted in 38% and
decreased genital sensation was noted in 18%. In this review
we addressed the incidence, etiology and pathophysiology of
sexual dysfunction following vaginal surgery.
ANATOMY AND NERVE SUPPLY
OF THE FEMALE GENITAL TRACT
The female external genitalia are collectively known as the
vulva. They consist of the labia majora and labia minora,
interlabial space and female erectile organs, including the

0022-5347/06/1752-0439/0 439 Vol. 175, 439-446, February 2006

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/S0022-5347(05)00168-0
440 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
clitoris and vestibular bulbs. The clitoris is made up of the
outermost glans, the midline corpus or body and the inner-
most crura.
The pelvic organs that become engorged during sexual
arousal are the clitoris, labia minora and vestibular bulbs.4
The bulbs are oblong structures of erectile tissue located on
either side of the female urethra. The vascular changes that
occur in these organs with arousal are mediated by auto-
nomic nerves. Clitoral and bulbar engorgement, homologous
to penile erection in the male, is a genital manifestation of
female sexual arousal mediated by autonomic nerve fibers.5
A presumed etiology of genital arousal disorders is auto-
nomic denervation of the female erectile tissue. Such auto-
nomic denervations can potentially occur during pelvic
surgery.
Autonomic innervation to the vagina originates from the
hypogastric and sacral plexus, giving rise to the uterovagi-
nal nerves containing sympathetic and parasympathetic fi-
bers, while somatic sensory innervation is provided by the
pudendal nerve (fig. 1). The clitoral innervation derives from
sympathetic (T1 to L3) and parasympathetic (S2 to S4) fi-
bers. Somatic sensory innervation arising from the skin
travels through the dorsal nerve of the clitoris and continues
in the pudendal nerve. The pelvic floor is made up of several
tissues spanning the opening in the bony pelvis. It supports
the abdominal and pelvic organs, maintains continence of
urine and stool, and allows intercourse and parturition.
Among the pelvic floor musculature the pelvic diaphragm is
formed by the levator ani muscle, urogenital diaphragm and
perineal membrane (fig. 2). The perineal membrane, consist-
ing of the ischiocavernous, bulbocavernous and superficial
transverse perineal muscles, has a crucial role in sexual
response. All of these structures may be altered during
transvaginal surgery.
INTRAPELVIC NERVE SUPPLY
AS APPLIED TO PELVIC FLOOR SURGERY
Yucel et al emphasized that during pelvic surgery every
effort should be made to avoid injury to the intrapelvic
somatic nerve originating from the pudendal nerve that
courses on the lateral border of the mid urethra to reach the
FIG. 1. Lateral view of major nerves of pelvis. n., nexus. Adapted
from Cundiff and Fenner.50
FIG. 2. Oblique view of perineal anatomy. Superf., superficial.
Adapted from Cundiff and Fenner.50
endopelvic fascia.6 The autonomic nerve plexus occupies the
anterolateral sides of the rectum at the 2 and 10 o’clock
positions. It gives off branches to the lateral vaginal walls to
form the vaginal nervous plexus at the 2 and 10 o’clock
positions on the anterolateral vaginal walls. These auto-
nomic nerves are immunoreactive to nNOS and vesicular
acetylcholine transporter, which is specific for cholinergic
nerves, whereas the pudendal nerve, which is a somatosen-
sory and motor mixed nerve, is devoid of nNOS immunore-
activity. The anterior and lateral vaginal walls are most
densely innervated by nNOS immunoreactive nerves. Pelvic
autonomic nerves innervating the vagina, urethra and blad-
der are critical for preserving sexual function and urinary
continence in females (figs. 1 and 2).6 Caution should be
exercised during posterior dissection of the proximal and
mid urethra during vaginal surgery to preserve the cavern-
ous and continence nerves.6
Physiology of female sexual response. Sexual arousal
results in increased vaginal lubrication, vaginal wall en-
gorgement and luminal diameter as well as increased clito-
ris length and diameter. Nitric oxide, phosphodiesterase-V
and vasoactive intestinal peptide have been considered to
have a role in mediating female sexual response at the
neurogenic level.6 Estrogens (estradiol) and testosterone
have a role in the regulation of the female sexual response.
VAGINAL ANATOMY AND SEXUAL FUNCTION
Weber et al noted no correlation between vaginal anatomy
and sexual function, particularly symptoms of dyspareunia
and vaginal dryness.7 Menopausal status, current estrogen
use, introital caliber and vaginal length were not different in
women with dyspareunia and/or vaginal dryness compared
to those in women with neither symptom. Premenopausal
women with dyspareunia and/or vaginal dryness had signif-
icantly higher global sexual function scores, reflecting worse
sexual function, compared with those in premenopausal
women without these symptoms. However, there was no
significant difference in postmenopausal women. Most
women who complained of vaginal dryness or tightness in
this study had a large introital diameter. Lack of estrogen
replacement in postmenopausal women was not associated
with dyspareunia. However, a potential limitation of this
study is the sample selection. In addition, a longitudinal
 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
TABLE 1. Effect of surgery for SUI on sexual function
Colposuspension,
Needle or AC9 Colpourethropexy10
Mean age 52
% Sexually active:
Preop Not given
Postop 68
% Sexual dysfunction:
Preop Not given 42 (dyspareunia)
Postop 22 (deteriorated) 20 (deteriorated)
Followup (mos) Mean 12
Adapted from Lemack and Zimmern10
study is required to determine how many women may have
stopped sexual activity because of symptoms.
POST-PELVIC FLOOR
SURGERY SEXUAL FUNCTION
The maintenance of sexual function requires preservation of
a vaginal length and caliber adequate for sexual intercourse.
The surgical procedure and psychosocial issues may contrib-
ute to altered sexual function following vaginal surgery.
Improvements in sexual function following vaginal surgery
were believed to be due to the cessation of incontinence
during intercourse, whereas worsening sexual function was
believed to be caused by dyspareunia following perineorrha-
phy.
Incidence and prevalence. Haase and Skibsted reported
that 91% of 55 women who underwent anteroposterior re-
pair or anteroposterior repair with colposuspension experi-
enced improvement or no change in sexual life following
surgery for incontinence.8 Black et al noted that 78% of 355
women, of whom most had undergone colposuspension or
AC, considered that their sex life had improved or was same
as their preoperative condition.9
Lemack and Zimmern reported that 20% of women noticed
pain during intercourse following anterior vaginal wall sus-
pension for SUI, which was slightly lower than the preoper-
ative incidence of 29% (table 1).10 Of the patients 18%
reported that intercourse was worse following surgery. The
investigators found that premenopausal and postmeno-
pausal women on hormone replacement therapy were more
likely to be sexually active following surgery than those not
on hormone replacement (46% vs 17%).
ETIOLOGY OF FSD
FOLLOWING VAGINAL SURGERY
Sexual dysfunction may be affected positively or negatively
by surgical treatment for SUI. The causes of sexual dysfunc-
tion following vaginal surgery may be classified as organic,
emotional and psychological. Organic causes are anatomical,
physiological, vascular, neural and hormonal factors. Clito-
ral and vaginal vascular insufficiency syndrome may result
in decreased genital blood flow and in turn decreased pelvic
441
AC, AC ⫹ Burch or Retropubic Urethropexy
Burch8 or Pubococcygeal Repair11
41 49 50
100 100 91
95 100 86
33 (dyspareunia) 33 (dyspareunia), 39
(orgasm dysfunction),
55 (decreased
lubrication), 27
(decreased desire)
9 (dyspareunia) 28 (dyspareunia), 48
(orgasm dysfunction),
48 (decreased
lubrication), 20
(decreased desire)
12–24 Mean 6 Mean 12
blood flow can cause vaginal smooth muscle fibrosis, result-
ing in vaginal dryness and dyspareunia.11 In addition, any
surgical disruption of the iliohypogastric and/or pudendal
arterial bed may result in compromised blood flow and sex-
ual complaints. Compared to the emotional etiology the psy-
chological causes of sexual dysfunction include the entire
gamut of life stressors, past sexuality, mental health prob-
lems (eg anxiety, depression and other psychopathology re-
sulting in sexual dysfunction) and contextual factors, among
others.
Colpoperineorrhaphy can result in dyspareunia due to
narrowing of the vagina.8 However, vaginal narrowing may
not be entirely responsible for altered sexual functioning
and sexual dissatisfaction after vaginal surgery. Vaginal
innervation is concentrated on the anterior and distal as-
pects of the vaginal wall.12 It may be affected by operations
for SUI and paravaginal repair of cystocele that are typically
directed toward this region. Others believe that altered sex-
ual functioning (dysfunction during the orgasm phase)
might be attributable to other causes, such as unreasonable
expectations following surgery in women with SUI, of whom
many had preexisting sexual dysfunction.13
Vaginal narrowing/shortening following posterior repair
has been reported to result in sexual dysfunction in 17% of
the women surveyed.12 Lemack and Zimmern reported that
women on hormone replacement therapy are more than
twice as likely to be sexually active as those who are not.10
If not medically contraindicated, they recommended hor-
mone replacement therapy to optimize the likelihood of re-
maining sexually active or resuming sexual activity
following vaginal surgery for SUI. Strauss et al reported
that sexual dysfunction following vaginal hysterectomy is
more likely to be related to preoperative psychological traits
than to the surgery.14
ASSESSMENT OF SEXUAL FUNCTION
The limitations of current methods of sexual function eval-
uation are their retrospective nature, that is mostly nonvali-
dated questionnaires and assessment by telephone contact,
and inadequate followup (maximum up to 6 months). Only
few methods, eg PISQ and IIQ-7 as used by Rogers et al,15
are prospective and validated. PISQ assesses the effect of
442 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
TABLE 2. Vaginal dimensions before and after POP surgery in
15 women with and 65 without dyspareunia
Median (range) (cm)
Postop introital caliber:
With dyspareunia 9.5 (8.0–12.0)
Without dyspareunia 10.0 (8.0–12.0)
Introital caliber change:*
With dyspareunia ⫺1.0 (⫺3.0–0.5)
Without dyspareunia ⫺1.0 (⫺7.0–4.0)
Postop vaginal length:
With dyspareunia 9.75 (9.0–11.0)
Without dyspareunia 10.0 (7.0–12.0)
Vaginal length change:*
With dyspareunia ⫺1.0 (⫺5.0–4.0)
Without dyspareunia ⫺1.0 (⫺3.0–3.5)
Adapted from Weber et al.45
* From preoperative to postoperative measurement.
prolapse and incontinence on sexual function, whereas IIQ-7
assesses the impact of incontinence on social function. We-
ber et al assessed sexual function before, and 6 months and
1 year following surgery for POP and urinary incontinence
using a multiple choice questionnaire.7 Yeni et al evaluated
sexual function in terms of desire, arousal, orgasm, pain and
satisfaction using the Index of Female Sexual Function and
continence status during coitus.16
Porter et al used telephone contact or a mailed, validated,
standardized questionnaire that assessed quality of life,
bowel symptoms and sexual activity by asking patients to
compare symptoms before and 6 months after surgery.17
Barber et al used validated quality of life questionnaires, the
Urogenital Distress Inventory and IIQ-Revised, a condition
specific sexual function questionnaire after surgery for uri-
nary incontinence and POP.18 Via an independent nurse
Petrou et al contacted their patients by telephone and used
a 5-point scale.19 Liang et al used a telephone interview to
assess orgasm, dyspareunia and sexual satisfaction.20
PREOPERATIVE EVALUATION
OF SEXUAL FUNCTION
This should include an assessment of patient sexuality, at-
titude toward sexual relations and impact of pelvic pathol-
ogy on sexual relations, and patient assessment of orgasm
quality and libido. Preexisting sexual problems in the ab-
sence of pelvic pathology can predict a suboptimal out-
come.21
Psychiatric evaluation includes a history of depression
and any current psychiatric disorders, such as low grade or
major depression, generalized anxiety disorder and post-
traumatic stress disorder. A validated questionnaire, that is
self-reported event logs or questionnaires, is useful. If the
patient is perimenopausal, the preoperative assessment
should include menopausal symptoms.
PELVIC ORGAN PROLAPSE
AND STRESS URINARY INCONTINENCE
Sexual function might be improved, unchanged or worsened
by surgical treatment for SUI, such as various sling proce-
dures and laparoscopic/open colposuspension. Improvement
may be related to emotional amelioration due to the cessa-
tion of incontinence. On the other hand, deterioration may
occur due to organic causes such as fibrosis, stenosis, neu-
ronal or vascular damage to the anterior vaginal wall and
clitoral region, which may result in sexual pain disorder,
and consequent arousal and orgasmic disorders. Although
some groups have reported worsening sexual function with
dyspareunia or apareunia caused by vaginal narrowing after
posterior colporrhaphy8,12 or SSLF,22 they did not correlate
patient symptoms with objective measures of postoperative
vaginal dimensions.
Weber et al reported that sexual function and satisfaction
improved or did not change in most women after surgery for
prolapse and/or urinary incontinence (tables 2 and 3).7 How-
ever, they could not correlate symptoms with objective
changes in vaginal length/caliber in those with sexual dys-
function after surgery. Combined Burch colposuspension
and posterior colporrhaphy were particularly likely to result
in dyspareunia, that is usually or always pain during sexual
intercourse. Dyspareunia following Burch colposuspension
may be due to the posterior vaginal ridge that has been
frequently noted. Of the women 8% had preoperative dyspa-
reunia compared to 19% after surgery. Dyspareunia oc-
curred in 26% of patients after posterior colporrhaphy and in
38% following Burch colposuspension with concomitant pos-
terior colporrhaphy. Although vaginal dimensions decreased
after surgery; that did not correlate with any change in
sexual function. Of the women 82% had satisfactory preop-
erative sexual relationships compared with 89% postopera-
tively. Vaginal dryness, that is dryness that interfered with
sexual activity usually or always, was not significantly as-
sociated with postoperative vaginal dimensions, changes in
preoperative to postoperative dimensions or patient percep-
tion of vaginal length or introital caliber.
Based on a mailed questionnaire Lemack and Zimmern
reported that the percent of women who were sexually active
did not appear to be affected by a vaginal suspension proce-
dure for incontinence.10 Symptomatic vaginal narrowing
was rare even in women undergoing simultaneous posterior
repair.
Haase and Skibsted noted improvement in sexual life in
24% of patients, no change in 67% and deterioration of
sexual function in 9% in a prospective study of 55 sexually
active women involving an interview and gynecological ex-
amination 6 months following surgery for stress inconti-
nence and/or POP.8 They concluded that the prognosis for
sexual life following vaginal surgery is good, provided that
patients are well informed. Dyspareunia was more common
in women who underwent colpoperineoplasty in combination
with anterior colporrhaphy.
TABLE 3. Patient perception and objective measurement of vaginal
dimensions in 81 women after prolapse or incontinence surgery
(78)
Median Postop Median Change
Pt Perception No. Pts (range) (cm) (range)* (cm)
Vaginal callber:
Too loose 4 10.25 (9.0–11.5) ⫺0.25 (⫺1.0–1.5)
Not problem 66 9.75 (8.0–12.0) ⫺1.0 (⫺7.0–1.0)
Too tight 8 9.5 (8.0–11.5) ⫺1.50 (⫺3.0–4.0)
Vaginal length:
Too short 8 9.0 (7.0–12.0) ⫺1.25 (⫺4.0–1.0)
Not problem 68 10.0 (7.0–12.0) ⫺1.0 (⫺5.0–4.0)
Too long 2 9.5 (8.0–11.0) ⫺2.5 (⫺5.0–0.0)
Adapted from Weber et al.45
* From preoperative to postoperative measurement.
 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY 443

TABLE 4. Sexual symptoms and conditions before and after defect specific rectocele repair
No/Total No. (%)
Preop Postop Improvement/Cure p Value

Sexually active 39/72 (54) 40/72 (55) Not applicable 1.0000

Sexual importance 39/39 (100) 39/39 (100) 4/39 (10) 1.0000
Sexual satisfaction 37/39 (95) 37/39 (95) 13/37 (35) 0.5235
Dyspareunia 26/39 (67) 18/39 (46) 19/26 (73) 0.0357
Vaginal dryness 27/39 (69) 29/39 (74) 9/27 (33) 0.5034
Sexual desire 33/39 (85) 34/39 (87) 8/33 (24) 0.6072
Orgasm 35/39 (85) 33/39 (85) 12/35 (34) 0.3593
Coital frequency 33/39 (85) 33/39 (85) 6/35 (18) 1.0000
Adapted from Porter et al.17

POSTERIOR COLPORRHAPHY of 8 to 11 cm at vaginal reconstructive surgery. We com-

AND RECTOCELE REPAIR
Dyspareunia occurs in 21% to 27% of women following pos-
terior colporrhaphy if the latter involves levator ani plica-
tion.23 Introital caliber was reduced a mean of 1.4 cm
following this procedure.8,12,23 However, this was not asso-
ciated with the development of symptoms in most women
and there was no significant difference in the reduction of
caliber in women who did and did not have symptoms.7
Dyspareunia caused by introital narrowing can be
avoided with meticulous posterior colporrhaphy and perin-
eoplasty. Caution should be exercised while performing pos-
terior colporrhaphy with the Burch procedure with care
taken to avoid the exacerbation of posterior vaginal ridging
by excessive plication or excision of vaginal epithelium.
In a study of 343 women who were older than 45 years
Barber et al found that those with grade III or IV prolapse
were more likely to implicate pelvic floor symptoms as the
reason for preoperative sexual inactivity compared to
women with SUI.18 Of the women 1 of 3 reporting moderate
to severe adverse influence on their ability to achieve sexual
relations with similar sexual satisfaction rates in the 2
groups.
In the absence of specific data to the contrary it seems
reasonable to restore or maintain an average vaginal length
monly refer to finger breadths with the objective of restoring
or maintaining adequate caliber to admit 2 or 3 fingers at
vaginal reconstructive surgery.22
Porter et al reported that posterior colporrhaphy alone or
with other vaginal surgery does not adversely affect sexual
function and in fact it may aid in the resumption of sexual
activity, significantly improving quality of life and social
aspects of daily living (tables 4 and 5).17 Dyspareunia sig-
nificantly improved or was cured following surgery in 73% of
125 patients, while it worsened in 19% of patients and arose
de novo in 3. There was no change in vaginal dryness,
orgasm ability, sexual desire, sexual frequency or sexual
satisfaction. Porter et al believed that defect specific repair
without levator ani plication appears to improve sexual
function.
In 1961 Francis and Jeffcoate reported a 50% rate of
dyspareunia after vaginal operations as a result of introital
narrowing.22 Yucel et al observed a dyspareunia rate of 9%
with 24% of patients reporting improvement in sexual life
after the operation.6 This group concluded that this low rate
of dyspareunia was caused by the early return to sexual
intercourse only 3 weeks after the operation.
Miklos et al reported 2 cases of postoperative dyspareu-
nia following the levatorplasty technique for rectocele.24 Ar-

TABLE 5. Cure rates, and effects on bowel and sexual function in other studies
% Difficulty % Pelvic
Emptying Pressure % Vaginal % Fecal % Anatomical
References % Constipation Bowels Pain Lump % Splinting Incontinence % Dyspareunia Cure

Cundiff et al:*,46
Preop 46 39 13 29
Postop 13 16 15 25 8 19
Kahn and Stanton:23
Preop 22 27 64 18
Postop 33 38 22 36 33 27 76
Francis and Jeffcoate:22 30
Murthy et al:47
Preop 40 9 25 29
Postop 12 8 12 8
Mellgren et al:48
Preop 100 13 8 6
Postop 88 8 8 19
Janssen and van Dijke:49
Preop 37 30
Postop 54 33 82
Arnold et al:25
Preop 75 23 20
Postop transanal 54 4 38 21 80
Postop transvaginal 54 32 36 23 80
Adapted from Porter et al.17
* Site specific repair.
444 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
nold et al found no functional difference between
transvaginal and transanal rectocele repair in terms of the
incidence of vaginal tightness/sexual dysfunction, which was
22% in each group.25
SUBURETHRAL SYNTHETIC VAGINAL TAPES
The major vessels in the retropubic space and anterior ab-
dominal wall lay 0.9 to 6.7 cm lateral to tension-free vaginal
tape needles. Mesh exposure can create dyspareunia and
vaginal bleeding. At times the sexual partner complains of
penile pain or scratches after vaginal penetration. If the
tension-free vaginal tape needle is too laterally aimed or
rotated, major vascular injury can occur. Maaita et al re-
ported no significant change in sexual function/activity after
a TVT procedure in 67 women 6 to 36 months following
surgery.26 On the other hand, Yeni et al noted a statistically
insignificant decrease in the mean domain scores of the
Index of Female Sexual Function, namely desire, arousal,
orgasm, pain and overall satisfaction, 6 months following a
TVT procedure.16 However, compared to controls all pa-
tients had a significant decrease in all scores except desire
and arousal following the TVT operation. Overall the sur-
gery negatively affected sexual function. The investigators
believed that the TVT decreases genital sensation and vag-
inal lubrication or wetness, which may result in painful
intercourse and inevitably inhibit orgasm.
POST-VAGINAL SURGERY FEMALE
SEXUAL DYSFUNCTION: PROSPECTIVE DATA
In a multicenter, prospective study of sexual function follow-
ing surgery for stress incontinence and/or POP Rogers et al
reported mixed results with improved sexual function in
21% of women and worsened function in 22% using 2 vali-
dated, condition specific questionnaires (PISQ and IIQ-7)
preoperatively, and 3 and 6 months after surgery in 102
women with a mean age of 47 years.15 They brought forth
the caveat of postoperative anatomical measures as indica-
tors of sexual function. Of the women 4% had normal
arousal after surgery compared to 83% preoperatively. The
incidence of women reporting weekly sexual desire de-
creased from 63% to 11%, arousal with sexual activity de-
creased from 83% to 4% and the frequency of orgasm
universally decreased, although reportedly the intensity did
not change. Positive changes included an improved rate of
coital incontinence (from 60% to 25%) and no dyspareunia.
Decreased postoperative sexual function scores are signifi-
cant in view of the younger age of the study population and
the fact that patients did not report more pain with sexual
activity after surgery. The investigators hypothesized that
the change in the perception of genital health of the women
due to surgical alteration of the genitalia and the fear of
harming themselves by engaging in sexual activity after
surgery were the contributing factors, coupled with the part-
ner fear of harming the women following vaginal surgery.
Vaginal erosion of slingplasty and FSD. Vaginal ero-
sion of various synthetic slings, which occurs in 1% to 12% of
cases, can mechanically contribute to sexual dysfunction.
Often the male partner feels the tape first during penile-
vaginal penetration. In a recent article Kobashi and Govier
reported nonoperative management of vaginal erosion using
a SPARCTM sling and they recommended abstinence from
sexual intercourse until spontaneous epithelialization over
the mesh.27 On the other hand, Sweat et al suggested that
polypropylene tape erosion should be treated with complete
removal of the mesh.28
HYSTERECTOMY
Many women are concerned that hysterectomy may affect
their sexual well-being or sexual attractiveness.29 Hysterec-
tomy has been reported as having adverse as well as bene-
ficial effects on sexual well-being.21,30 –34
Because hysterectomy disrupts the local nerve supply
and anatomical relationships of the pelvic organs, it has
been thought that the function of these organs may be ad-
versely affected. The idea that sexual well-being may differ
according to the type of hysterectomy is based on the hy-
pothesis that the techniques damage the innervation and
supportive structures of the pelvic floor differently. During
hysterectomy the pelvic plexus may be damaged in 4 ways.
1) The main branches of the plexus passing beneath the
uterine arteries may be damaged during the division of the
cardinal ligaments.35 2) The major part of the vesical inner-
vation, which enters the bladder base before spreading
throughout the detrusor muscle, may be damaged during
blunt dissection of the bladder from the uterus and cervix.35
3) The extensive dissection of the paravaginal tissue may
disrupt the pelvic nerves passing from the lateral aspect of
the vagina.36 4) The removal of the cervix may result in the
loss of a large segment of intimately related plexus.36 Auto-
nomic and somatic neural disruption of the upper vagina
may interfere with lubrication and orgasm. However, Gutl
et al reported that sexual desire and activity increased pro-
gressively during a 2-year postoperative period, accompa-
nied by decreases in dyspareunia, vaginismus and
anorgasmia.37 Rhodes et al found increased sexual activity
with more women experiencing orgasm following surgery
than preoperatively.21 Kilkku et al observed that supracervi-
cal hysterectomy can have a limited impact on sexual function
compared with abdominal hysterectomy.32 Berman reported
that nerve sparing hysterectomy (sparing the autonomic pelvic
nerves) may prevent sexual and bladder function.38
Dragisic and Milad reported no change in sexual desire,
orgasm frequency or orgasm intensity in 75 patients follow-
ing hysterectomy.39 Cosson et al noted that many long-term
complications following hysterectomy, including the worsen-
ing of all urinary problems, digestive problems and sexual
intercourse, cannot be attributable to the intervention.40
They believed that vaginal hysterectomy should not be con-
sidered responsible for major complications appearing dur-
ing the first 4 years of followup. Strauss et al noted that the
sexual consequences of hysterectomy are more likely to be
predicted based on psychological traits that existed before
surgery.14
VAGINAL VAULT SUSPENSION
Vaginal repair of vault prolapse may result in a narrowed
and shortened vagina with decreased function. Abdominal
sacral colpopexy attaches the vaginal apex to the sacral
promontory and restores the physiological position of the
vagina. Geomini et al noted that only 10 of 27 patients (37%)
were symptom-free at followup of those with a combination
 FEMALE SEXUAL DYSFUNCTION FOLLOWING VAGINAL SURGERY
of preoperative symptoms of vaginal protrusion, sexual dys-
function, urinary incontinence and defecation problems com-
pared to success in 13 of 14 (93%) with only vaginal
protrusion as the presenting symptom.41
Holley et al reported that SSLF did not predispose to
dyspareunia unless vaginal narrowing due to repair of asso-
ciated defects was present.12 Paraiso et al noted that ap-
proximately 20% of 243 women who underwent SSLF had
sexual dysfunction before surgery.42 Long-term (74 months)
followup in patients following surgery revealed worsening
sexual function.43 The inconsistency in data reporting may
have resulted in variations in outcome data and prospective
studies with validated questionnaires are indicated.
MARTIUS FLAP HARVEST
Petrou et al reported that Martius flap harvest in women is
not associated with a significant perceived cosmetic disfig-
urement of the labium majus and it has little effect on sexual
relations despite associated numbness and decreased sensa-
tion at the harvest site in 62% of their patients.19 Only 1 of
8 women reported interference with coital relations due to
associated pain. They believed that concomitant transvagi-
nal urethrolysis rather than Martius flap harvest was the
culprit.
A Martius flap is also used for transvaginal (vesicovagi-
nal and rectovaginal) fistula repairs. Elkins et al reported a
25% incidence of dyspareunia over the Martius flap harvest
site following fistula repair.44 They noted a dual blood sup-
ply for the Martius graft, posterior labial branches of the
internal pudendal artery and vein posteroinferior, and
branches of the external pudendal vessels anterosuperior.
Webster et al reported decreased sensation at the labial
harvest site in 17% of cases when a Martius flap was used for
post-urethrolysis interposition.43
CONCLUSIONS
Current literature does not support an association between
vaginal length following vaginal surgery and sexual func-
tion. The proportion of women who are sexually active does
not appear to be affected by vaginal surgery. It is important
to draw a distinction between overall sexual function and
individual parameters, eg self/body image, sexual desire,
orgasm frequency and overall sexual satisfaction. Sling sur-
gery for urinary incontinence does not appear to adversely
affect overall sexual function, although individual parame-
ters of sexual function scores may vary, eg a significant
percent of women report pain during intercourse. In fact,
some patients report improved overall sexual function due to
complete relief from coital incontinence, thereby, improving
self-image and body image as well as confidence despite
dyspareunia.
Symptomatic vaginal narrowing is rare even in those
undergoing simultaneous posterior repair. Overall sexual
satisfaction appears to be independent of therapy for uri-
nary incontinence or prolapse. Condition specific sexual
function questionnaires specifically designed to elucidate
the complex associations among various types of vaginal
surgery and sexual functions are essential. Such outcome
measures have not been routinely used in vaginal surgery
outcome data reporting. Posterior colporrhaphy and perine-
orrhaphy have been noted to cause dyspareunia due to vag-
445
inal stenosis. Many clinicians argue that posterior
colpoperineorrhaphy may be unnecessary for low grade pos-
terior compartment POP. Some data indicate that defect
specific posterior colporrhaphy with the avoidance of levator
ani plication may improve sexual function.
A perception of genital health change due to surgical
alteration of the genitalia and fear of harming themselves by
engaging in sexual activity after surgery are the contribut-
ing factors, coupled with the partner fear of causing harm
following vaginal surgery. Counseling might have a crucial
role in returning these women to their preoperative level of
sexual function.
The relationship between dyspareunia, vaginal dryness
and sexual function in postmenopausal women and the in-
fluence of hormone replacement therapy need further re-
search. Future prospective long-term studies should focus on
postoperative vaginal changes associated with aging,
changes in sexual activity and estrogen use with respect to
symptoms and sexual dysfunction.
ACKNOWLEDGMENT
Lianne Krueger Sullivan provided the illustrations.
Abbreviations and Acronyms
AC ⫽ anterior colporrhaphy
FSD ⫽ female sexual dysfunction
IIQ-7 ⫽ Incontinence Impact Questionnaire-7
nNOS ⫽ neuronal nitric oxide synthase
PISQ ⫽ Pelvic Organ Prolapse Urinary
Incontinence Sexual Questionnaire
POP ⫽ pelvic organ prolapse
SSLF ⫽ sacrospinous ligament fixation
SUI ⫽ stress urinary incontinence
TVT ⫽ tension-free vaginal tape
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