The concern that vaginal birth will result in loose vagina and negatively affect their postnatal sexual life is one of the main reasons that many women choose cesarean section. Here we aimed to implement a new device to measure and compare the intra-vaginal pressures between women who gave vaginal birth and those who had cesarean section, and to evaluate the relationship between sexual function and type of delivery by Female Sexual Function Index (FSFI). A total of 165 women including 88 in the vaginal-delivery group and 77 in the cesarean-delivery group were recruited in the study. Significant differences in intra-vaginal pressures were found between the two groups, and intra-vaginal pressures of vaginal-delivery group were lower than those of cesarean-delivery group. Significant difference was also found in coitus time. However, no significant difference was found regarding sexual satisfaction and sexual function indicated by the FSFI. We concluded that vaginal delivery indeed may result in loose vagina compared with cesarean delivery. However, it did not negatively affect the postnatal sexual function. Therefore, women should be assured that their sexual functions won’t be affected by the types of delivery.
Sexual relationship is very important for couples, as it affects many aspects of life especially the self-confidence of the husbands and wives. Abnormal sexual relationship including abnormal coitus may reduce quality of life, lower self-esteem, cause unstable mood and negatively affect the partner relationship.
There are many factors that may cause abnormal coitus. Erectile dysfunction is one of the most common causes for men. It is relatively easy to assess as the penile rigidity, which can be judged by the patients themselves. In clinic, erection hardness is a physiological response that can be measured objectively with the use of penile tumescence monitoring (RigiScan; Dacomed, Minneapolis, MN, USA) and can be graded subjectively on the Erection Hardness Grading Scale.1 On the other hand, the resistance of a penis in the vagina during intercourse has been less defined and no standard measurement was developed. Developing a device and standardizing the measurement will have important clinical implications. Some men had complained difficulty penetrating their partner’s vagina even though their erectile hardness scale was over 3, which generally allows full sexual intercourse.2 Clearly some factors other than rigidity contribute to the problem, and one of the potential factors is the resistance produced by vagina. To improve diagnosis and ultimately provide better treatment options, we implemented a device that could accurately measure the resistance that a penis would encounter during vaginal intercourse.
One of the potential usages of such new device was to quantitatively investigate the so-called ‘loose vagina’ many women complained about after vaginal birth. In fact, the concern that vaginal birth would result in loose vagina and negatively affect their postnatal sexual life was one of the main reasons that many women chose cesarean section. As childbirth is one of the main events of most women’s marital life, it is therefore important to systematically investigate the relationship between the type of delivery and the intra-vaginal pressures during postnatal sexual intercourse. More importantly, whether and how the delivery means can affect women’s sexual function should be investigated because few studies have addressed this important issue. Information obtained from such study may have great impact on the decision making of a great number of women for their choice of delivery.
Materials and methods
This was a case–control study. We conducted this study in the Department of Infertility and Sexual Medicine, The Third Affiliated Hospital, Sun Yat-sen University, from January 2011 to May 2011. Patients received a questionnaire during their initial visit to our hospital for infertile issues. The duration of coitus time was estimated and provided by the patients. All participants met the following inclusion criteria: (1) the age of 22–35 years old; (2) having regular sexual intercourses and stable sexual partners; (3) delivered in 37–42 pregnancy weeks, primipara, single pregnancy; (4) underwent vaginal delivery with episiotomy, or cesarean section; (5) at least 1 year elapsed from the delivery.
Written informed consent was obtained from all patients before their participation. The study was approved by the Reproductive Ethics Committee of The Third Affiliated Hospital, Sun Yat-sen University and has therefore been performed in accordance with ethical standards.
Intra-vaginal pressure monitor
To measure the intra-vaginal resistance during intercourse, we designed and implemented a novel vaginal pressure monitor by combining the regular mercury sphygmomanometer, a syringe and an artificial penis. The artificial penis (diameter: 2.5 cm; length: 12 cm) was connected to the piston end of a 50-ml syringe, and the tip of the syringe were linked to the catheter of the mercury sphygmomanometer (with the blood pressure balloon and the cuff removed). When the artificial penis was inserted into the vagina, we could record the pressure with 50 ml air in the syringe (the piston pulled to 50 ml calibration) (Figure 1).
Sexual function determination
Patients were interviewed using a questionnaire designed to document their socio-demographic characteristics and to evaluate their sexual function. The Female Sexual Function Index (FSFI) consists of 19 questions covering six domains—desire (two questions), arousal (four questions), lubrication (four questions), orgasm, satisfaction and pain (three questions each).3 Individual domain scores were obtained by adding the scores of the individual questions that comprised the domain and multiplying the sum by the domain factor provided in the FSFI for each domain. The full-scale score was obtained by adding the six domain scores.4
Measurement of intra-vaginal pressures
Before gynecological examination, intra-vaginal pressure monitoring was performed. The pressures were registered when patients were at rest without being sexually aroused. A trained and experienced technician helped those recruited women one by one to complete the procedures. The artificial penis was lubricated and put into the vagina by the technician. The pressure right after the artificial glans penis being totally inserted into the vagina was recorded as pressure 1 (P1), the pressure when the artificial penis being inserted 6 cm inward the vagina was recorded as pressure 2 (P2), and the pressure right before the artificial glans penis being taken out of the vagina was recorded as pressure 3 (P3).
Statistical analysis was conducted with SPSS 11.0 and Microsoft Excel 2003. Chi-square test for association and t-test for the mean were used in the analysis. P<0.05 was considered statistically significant.
A total of 165 women were included in this study. No significant differences were found between the vaginal-delivery group (N=88) and the cesarean-delivery group (N=77) regarding their socio-demographic characteristics (Table 1). None of the patients has reported receiving the instrument-aid postpartum pelvic floor muscle training before this study.
Quantitative measurement of intra-vaginal pressure
In both groups, significant differences were found among pressure 1, pressure 2 and pressure 3; and pressure 1 was much higher than pressure 2 or pressure 3. Using this novel system, we have found that there was a significant difference for intra-vaginal pressures between the two groups, and the vaginal-delivery group demonstrated lower pressures than those of cesarean-delivery group (Table 2).
Postnatal sexual function and type of delivery
For foreplay time, sexual satisfaction or FSFI domain scores, no significant differences were found between the two groups. Significant differences were found between the two groups for coitus time, and fewer patients in cesarean-delivery group reported less than 1 min of coitus time.
Here we designed a device to measure the intra-vaginal pressure during masturbation, and the pressures were assumed to represent the vaginal looseness. There has been a report on micro-tip transducer pressure catheters used to measure intra-vaginal as well as intra-rectal pressures in cases of undergoing routine clinical cystometry for a variety of clinical indications.5 The pressure monitor we designed was different from the reported catheter in that it was capable of monitoring the dynamic intra-vaginal pressure during sexual intercourse. During normal sexual activity, the vagina was closed before sexual intercourse and was lubricated during foreplay. Our results by using the pressure monitor have shown that the intra-vaginal pressure at the beginning of the artificial penis penetration into the vagina was much higher, with P1>P2>P3, which was in accordance with the anticipation based on the anatomical characteristics of the vagina. These results have validated the sensitivity of the pressure monitor for evaluating intra-vaginal pressure.
With this vaginal pressure monitor, we have also found a significant difference between the vaginal-delivery group and the cesarean-section group in intra-vaginal pressures, which were significantly lower in the vaginal-delivery group than those in the cesarean-delivery group.
Maternal/family request was the number one reason for cesarean delivery in both rural China6 and major cities of China. Cesarean section was often considered by the patients and their families as a quicker and safer alternative for the mother and the fetus. However, some women chose cesarean section solely based on the concern of the possibility of resulting in loosened vagina after labor, which might affect their sexual satisfaction. Studies have shown that women who were concerned about the effect of vaginal delivery on their own sexual health in the future, and feared of sexual dysfunction in the future had accounted for 58–59% of all who chose cesarean section as the delivery method.7 This fear of sexual dysfunction will affect the women’ confidence to complete the sexual activity and reduce their sexual satisfaction, which is a predisposing factor of inter-related biological, psychological and contextual variables that can combine to produce distressing symptoms for both of the couples.
Here we provided an objective method to confirm the general concern that vagina birth indeed contributed to a looser vagina than cesarean delivery did. In China, episiotomy was applied to most vaginal-delivery women, for the purpose of reducing the tear of the perineum, and it was thought to be helpful for the postpartum recovery of the perineum. Though one study has shown that women with vaginal delivery and emergency cesarean section, who usually experienced the process of vaginal expansion, had statistically significant lower FSFI, compared with planned cesarean-section women,8 there was also a study that showed no correlation between sexual function and pelvic muscle strength.9 Lower pelvic floor muscle strength may lead to the looseness of the vagina, and lower intra-vaginal pressures.
By analyzing our comprehensive survey of the 165 participants, we have found no significant differences between the two groups regarding the FSFI domain scores, foreplay time and sexual satisfaction, though there was significant difference for the coitus time. These results illustrated the fact that women’s sexual function was not affected by the labor types, being consistent with the study that there was no significant association between sexual function and delivery, age and the type of delivery.10 According to the literature, 70% of the UK women and 89% of Taiwanese women were generally satisfied with their sex life during the postnatal period,11 and in this study, for both type of delivery, the sexual satisfaction rate was 79.5% and 71.4%, respectively. In this study, the mean domain scores of both groups are less than the cutoff scores to determine the presence of difficulties on the six domains according to the literature.12 This may be due to the characteristics of patients, for all of them came to the hospital for infertile issues. Relationship satisfaction explained levels of sexual satisfaction during pregnancy, and was a predictor of sexual desire in the postpartum.13 Here we found that fewer cesarean-delivery women claimed coitus time of <1 min, and one possible reason was the sexual self-confidence and good relationship satisfaction of the couples.
Our data suggest that vaginal delivery indeed resulted in loose vagina compared with cesarean delivery. However, it did not negatively affect the postnatal sexual function. Therefore, women should be assured that their sexual functions won’t be affected by the types of delivery.
Aslan Y, Tuncel A, Aydin O, Balci M, Karabulut E, Atan A . The association between Erection Hardness Grading Scale and International Index of Erectile Function in men with erectile dysfunction treated with sildenafil citrate. Urol Int 2011; 86: 434–438.
Gruenwald I, Appel B, Vardi Y . Low-intensity extracorporeal shock wave therapy-a novel effective treatment for erectile dysfunction in severe ED patients who respond poorly to PDE5 inhibitor therapy. J Sex Med 2012; 9: 259–264.
Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191–208.
Wiegel M, Meston C, Rosen R . The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. J Sex Marital Ther 2005; 31: 1–20.
Wall LL, Hewitt JK, Helms MJ . Are vaginal and rectal pressures equivalent approximations of one another for the purpose of performing subtracted cystometry? Obstet Gynecol 1995; 85: 488–493.
Qin C, Zhou M, Callaghan WM, Posner SF, Zhang J, Berg CJ et al. Clinical indications and determinants of the rise of cesarean section in three hospitals in rural China. Matern Child Health J 2012; 16: 1484–1490.
van Brummen HJ, Bruinse HW, van de Pol G, Heintz AP, van der Vaart CH . Which factors determine the sexual function 1 year after childbirth? BJOG 2006; 113: 914–918.
Safarinejad MR, Kolahi AA, Hosseini L . The effect of the mode of delivery on the quality of life, sexual function, and sexual satisfaction in primiparous women and their husbands. J Sex Med 2009; 6: 1645–1667.
Baytur YB, Deveci A, Uyar Y, Ozcakir HT, Kizilkaya S, Caglar H . Mode of delivery and pelvic floor muscle strength and sexual function after childbirth. Int J Gynaecol Obstet 2005; 88: 276–280.
Boroumandfar K, Rahmati MG, Farajzadegan Z, Hoseini H . Reviewing sexual function after delivery and its association with some of the reproductive factors. Iran J Nurs Midwifery Res 2010; 15: 220–223.
Huang YC, Mathers NJ . A comparison of sexual satisfaction and post-natal depression in the UK and Taiwan. Int Nurs Rev 2006; 53: 197–204.
Singh JC, Tharyan P, Kekre NS, Singh G, Gopalakrishnan G . Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med 2009; 55: 113–120.
DeJudicibus MA, McCabe MP . Psychological factors and the sexuality of pregnant and postpartum women. J Sex Res 2002; 39: 94–103.
The authors declare no conflict of interest.
About this article
Cite this article
Cai, L., Zhang, B., Lin, H. et al. Does vaginal delivery affect postnatal coitus?. Int J Impot Res 26, 24–27 (2014). https://doi.org/10.1038/ijir.2013.25
- sexual behavior
Association between sexual dysfunction and avulsion of the levator ani muscle after instrumental vaginal delivery
Acta Obstetricia et Gynecologica Scandinavica (2020)
International Journal of Gynecology & Obstetrics (2019)
Archives of Gynecology and Obstetrics (2017)
Open Journal of Obstetrics and Gynecology (2017)