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Pelvic organ prolapse and sexual function

Abstract

Sexual dysfunction is one of the symptoms associated with pelvic organ prolapse (POP) that motivates women to seek medical help. Women with POP are likely to restrict sexual activity owing to a perceived of loss of attractiveness and fear of incontinence. Conservative (pelvic floor muscles training or pessary) or surgical management (transabdominally or transvaginally) can be offered to treat POP but questions remain regarding sexual outcome. Despite the usual improvement in sexual function after surgery, a risk of de novo dyspareunia exists irrespective of the procedure used with slightly increased risk after transvaginal repair. Preoperative patient counselling, ideally with a cross-disciplinary approach is an important part of management of POP.

Key points

  • The effect of pelvic organ prolapse (POP) on sexual function does not correlate with its anatomical stage.

  • Sexual function usually improves after surgery, irrespective of the technique used; this improvement is primarily caused by improved body image in response to correction of the POP.

  • Sexual well-being before surgery is a major predictor of postoperative sexual well-being. Preoperative counselling is an important step before surgery.

  • Sacrocolpopexy remains the gold-standard treatment for POP repair, particularly in women <70 years old, with the lowest proportion of de novo dyspareunia. However, although long disparaged, vaginal surgery can be offered to sexually active patients provided the principles of good practice are followed.

  • The incidence of de novo dyspareunia and the global Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score is not different between vaginal repair with or without mesh.

  • With the vaginal approach, occurrence of dyspareunia is much reduced with the new generation of lightweight, flexible, non-absorbable meshes but is still higher than that reported after sacrocolpopexy.

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Fig. 1: Sacrocolpopexy.
Fig. 2: Anterior repair with native tissue.
Fig. 3: Posterior repair.
Fig. 4: Sacrospinous fixation (Richter procedure).
Fig. 5: Uterosacral ligament suspension.
Fig. 6: Transvaginal mesh.

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Acknowledgements

Review criteria

Medline and PubMed databases were searched without date or language restriction for original articles focusing on sexual function in women with pelvic organ prolapse (POP) using the search terms “sexual function”, “sexual outcome”, “dyspareunia”, “female sexual dysfunction”, “female sexual disorders”, “de novo dyspareunia”, “sacrocolpopexy”, “transvaginal repair”, “transvaginal mesh repair”, “mesh repair”, “native tissue repair”, “pelvic organ prolapse”, “genital prolapse”, “pelvic organ prolapse surgery”, “vaginal surgery”, “laparoscopic sacrocolpopexy” and “robotic sacrocolpopexy”. Reference lists of identified articles were also searched. Relevant data and results were then commented on and discussed and the authors have provided their interpretation of the literature. Priority was given to randomized controlled trials (RCTs), large studies using validated questionnaires and systematic reviews. Retrospective studies and/or studies with small sample sizes have also been included if they provided additional and interesting data in the field of sexual function in women with POP before or after surgery. Owing to the paucity of data on the effect of POP surgery on sexual function, several studies (including RCTs) with incomplete sexual data and some papers with small sample sizes have been included.

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All authors researched data for the article, made a substantial contribution to discussion of the content, and reviewed and edited the manuscript before submission. B.F. wrote the manuscript.

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Correspondence to Brigitte Fatton.

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B.F. is a consultant for Astellas, Allergan and Boston Scientific. R.d.T. is a consultant for Boston Scientific and Coloplast. V.L. is a consultant for Cook. S.H. declares no competing interests.

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Nature Reviews Urology thanks L. Cardozo, X. Deffieux, C. Maher, R. Dmochowski and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Fatton, B., de Tayrac, R., Letouzey, V. et al. Pelvic organ prolapse and sexual function. Nat Rev Urol 17, 373–390 (2020). https://doi.org/10.1038/s41585-020-0334-8

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