Int Urogynecol J (2013) 24:1853–1857 DOI 10.1007/s00192-013-2176-x
POP SURGERY REVIEW
Pelvic organ prolapse and sexual function Viviane Dietz & Christopher Maher
# ICUD-EAU 2013
Abstract Introduction and hypothesis The aim was to review the impact of pelvic organ prolapse surgery on sexual function. Methods Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the Englishlanguage scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi process expert opinion. Grade D “no
recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without formal analytical process, such as by Delphi. Results With regard to the anterior compartment, the use of mesh is associated with neither a worsening in sexual function nor an increase in de novo dyspareunia compared with traditional anterior colporrhaphy (grade B). There is insufficient information to provide evidence-based recommendations on sexual function after vaginal mesh in the posterior compartment or after new lightweight or absorbable meshes (grade D). Conclusion There is a paucity of data on the impact of prolapse surgery on sexual function. Sexual function and dyspareunia rates are similar after anterior polypropylene mesh and anterior colporrhaphy (grade B). We recommend using validated questionnaires measuring sexual function in women before and after prolapse surgery and reporting sexual activity and dyspareunia rates pre- and post-intervention in all patients.
On behalf of Committee 15 “Surgical Management of Pelvic Organ Prolapse” from the 5th International Consultation on Incontinence held in Paris, February 2012
Keywords Dyspareunia . Transvaginal mesh . Sexual function
This work has been previously published as: Maher C, Baessler K, Barber M, Cheon C, Deitz V, DeTayrac R, Gutman R, Karram M, Sentilhes L (2013) Surgical management of pelvic organ prolapse. In: Abrams, Cardozo, Khoury, Wein (eds) 5th International Consultation on Incontinence. Health Publication Ltd, Paris, Chapter 15 and modified for publication in International Urogynaecology Journal. V. Dietz Catharina Medical Center, Michelangelolaan, Eindhoven, The Netherlands C. Maher (*) University of Queensland, Royal Brisbane and Wesley Urogynaecology, 30 Chaseley Street, Auchenflower, 4067 Brisbane, Queensland, Australia e-mail: [email protected]
Sexual health is an essential component of a woman’s wellbeing. Female sexual dysfunction is defined as a sexual desire, sexual arousal, orgasm and/or sexual pain disorder that causes personal distress [1]. Up to 64 % of sexually active women attending a urogynecology clinic suffer from female sexual dysfunction [2]. The data on sexual function after prolapse surgery are conflicting, although in most cases sexual function will improve or remain the same. Apart from anatomical outcome, clinicians increasingly understand the importance of functional data after POP surgery. To measure sexual function, validated questionnaires on sexual function are necessary. Some validated quality of
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Int Urogynecol J (2013) 24:1853–1857
Table 1 Meta-analysis sexual function data from randomised controlled trials (RCT) comparing transvaginal mesh with native tissue repairs Reference
De novo dyspareunia
Postoperative dyspareunia
Postoperative PISQ score
Vaginal mesh
Mesh
Native tissue
Mesh
Native tissue
8/110
2/101
33.1±6.7 35.1 (1.4)
32.2±7.2 35.0 (1.4)
12/30
13/33
Change −6.9
Change −7.8
33±3 34±6 31/34 35±5.7 34.0±6.7 0.09 (−0.17, 0.36) No difference
32±4 33±3 32/35 31.5±7.2 34.7±5.7
Native tissue
Altman et al. [15] Vollebregt et al. [11] Carey et al. [12] Sivaslioglu et al. [14] Nguyen and Burchette [13] Iglesia et al. [21] Milani et al. [17]
3/20 5/18 2/43 2/22 1/11 3/37
2/21 5/12 0/42 4/26 3/14 3/29
2/23
2/23
9/53
12/51
Total
16/151 (10.6 %)
17/144 (11.8 %)
31/216 (14.4 %)
26/207 (12.5 %)
life and symptom questionnaires are inclusive of sexual function [3] or there are dedicated questionnaires specific to sexual function that provide a discreet and reproducible method of evaluating sexual health. The Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) [4] and the Female Sexual Function Index (FSFI) [5] are two questionnaires frequently used.
Sexual function after prolapse surgery without mesh Overall, sexual function improves after prolapse surgery without mesh [6–8]. In two randomised controlled trials (RCT), sexual function was measured after sacrospinous hysteropexy and vaginal hysterectomy. No differences were found between the two groups [9, 10]. No validated questionnaires were used.
Table 2 Meta-analysis of sexual function from prospective evaluations of transvaginal meshes Reference
n
De novo dyspareunia (%)
Follow-up (months)
Mesh
PISQ-12 pre
PISQ-12 post
Withagen et al. [22] Maher [23] Long [42] Milani et al. [35] Sergent [43] Sayer et al. [32] Jacquetin et al. [37] Moore et al. [31]
294 55 60 (Perigee™) 48 (Prolift™) 127 101 110 90 87
20/71 (28) 3/21 (14) 10/60 (16) 12/48 (25) 1/43 (2) 4/52 (8) 2/32 (6) 5/35 (14) 6/65 (9)
12 24 6 6 12 57 24 3 24
PP PP PP PP PP light Coated PP PP PP PP
33.4±7.7
39.0±4.4
32.2±6.2
Fayyad et al. [26] Feiner et al. [38] Wetta et al. [30] Milani et al. [39] Altman et al. [28] Su et al. [29] Lowman et al. [40] Hinoul et al. [41] Sentilhes et al. [33] de Tayrac et al. [36] Total
36 117 50 46 69 33 57 48 83 143 –
7/16 (43) 4/51 (8)
24 12 12 1 12 6 12 12 1 10 –
PP PP PP PP PP PP PP PP PP Coated PP –
2/11 (18)
6/36 (17) 3/20 (15) 6/37 (16) 10/78 (12.8) 102/680 (15.0)
33.4±7.7
36.8±5.5 No 36.8±5.5
NA NA 20.2±4.9
NA NA 16.2±6.0
15.5±8.0 29.5±9.0 NA NA 33.4±7.8
11.7±6.7 19.3±14.7 NA NA 35.5±7.3 No –
–
Int Urogynecol J (2013) 24:1853–1857
Sexual function after prolapse surgery with mesh Increasing data on sexual function after mesh repair are becoming available. Excellent randomised controlled trials on the efficacy of mesh prolapse surgery have been published and while most have not utilised validated questionnaires regarding sexual function most do include data on dyspareunia. Data from level 1 studies comparing transvaginal mesh and native tissue repairs are summarised in Table 1. When comparing sexual function in the anterior compartment with or without mesh, no differences in de novo dyspareunia, post-operative dyspareunia or PISQ scores were found [11–17]. Most women improved or remained the same. In one study by Vollebregt et al. [11], baseline dyspareunia disappeared more often after anterior colporrhaphy than after mesh implantation (80 % vs 20 %, p=0.018). Natale et al. showed that the use of porcine dermis graft (Pelvicol), compared with polypropylene mesh (Gynemesh) in the anterior compartment, was associated with an improvement in the PISQ scores [18]. Possibly, porcine dermis allows more flexibility to the anterior wall, resulting in less pain; however, this requires further evaluation. In the posterior compartment, fewer RCTs have been performed comparing native tissue repairs with mesh repairs. Paraiso et al. compared three techniques (posterior colporrhaphy, site-specific repair and use of porcine small intestine sub mucosa) [19]. No differences in sexual outcome were found between the groups and PISQ scores improved after surgery in all three groups. Trials that analysed anterior and posterior mesh together also reported no differences in sexual outcome between native tissue and mesh repairs [17, 20, 21]. Overall, after mesh surgery in the anterior and/or posterior compartments, de novo dyspareunia ranged from 5 % to 28 % of women [11–14, 22]. Data on the apical compartment using mesh showed less dyspareunia after abdominal sacral colpopexy compared with vaginal sacrospinous colpopexy [23–25]. Meta-analyses from all RCT comparing transvaginal mesh and native tissue repairs shown in Table 2 demonstrated no difference in the rate of de novo dyspareunia (mesh 10.6 % versus 11.8 % native tissue), post-operative dyspareunia (14.4 % versus 12.5 %) and PISQ scores (WMD 0.09 95 % CI −0.17 to 0.36). Although data from RCTs are valuable, sexual function was a secondary outcome measurement and most studies are underpowered to detect differences in sexual function. Therefore, reports from level 3 cohort studies on the use of mesh were evaluated. The rate of de novo dyspareunia after anterior and/or posterior mesh in these cohort studies was comparable to those of the RCTs mentioned previously and ranged from 21 % to 43 % (Table 2) [17, 26]. Milani et al. stated that mesh should be abandoned because of high dyspareunia scores (20 % more dyspareunia after anterior mesh and 63 % more dyspareunia after posterior Mesh) [27].
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However, when measuring sexual function with questionnaires, the impact of transvaginal meshes was variable, with some demonstrating poorer sexual outcomes [28–30] (lower PISQ scores) and some improved outcomes or no change following surgery [17, 31–33]. Altman et al. showed lower scores on sexual function 1 year after mesh surgery (anterior repair and posterior repair); however, this was related to behavioural–emotional function and partner=related items, not to physical function [28]. Pain and dyspareunia before surgery with mesh was a risk factor for pain and dyspareunia after mesh surgery [22]. There is some evidence that light meshes, partly absorbable meshes or nonanchored meshes have fewer negative side effects on sexual function; however, comparative studies or RCTs on this aspect have not been performed [34–36].
Recommendations Grade B With regard to the anterior compartment, the use of mesh is associated with neither a worsening in sexual function nor with an increase in de novo dyspareunia compared with traditional anterior colporrhaphy. Grade D There is insufficient information to provide evidence-based recommendations on sexual function after vaginal mesh in the posterior compartment. There is insufficient information to provide evidencebased recommendations on sexual function after new light or partially absorbable vaginal meshes. It is essential to use validated questionnaires measuring sexual function in women before and after prolapse surgery. We also recommend reporting sexual activity and dyspareunia rates pre- and post-intervention in all patients. Acknowledgements This publication results from the work of the Committee on Pelvic Organ Prolapse Surgery, part of the 5th International Consultation on Incontinence, held in Paris in February 2012, under the auspices of the International Consultation on Urological Diseases, and enabled by the support of the European Association of Urology. The authors wish to acknowledge the fine work of previous consultations led by Professor Linda Brubaker. Conflicts of interest None.
References 1. Basson R, Berman J, Burnett A et al (2000) Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 163(3):888–893
1856 2. Pauls RN, Segal JL, Silva WA, Kleeman SD, Karram MM (2006) Sexual function in patients presenting to a urogynecology practice. Int Urogynecol J Pelvic Floor Dysfunct 17(6):576–580 3. Baessler K, O’Neill SM, Maher CF et al (2010) A validated selfadministered female pelvic floor questionnaire. Int Urogynecol J 21(2):163–172 4. Rogers RG, Kammerer-Doak D, Villarreal A, Coates K, Qualls C (2001) A new instrument to measure sexual function in women with urinary incontinence or pelvic organ prolapse. Am J Obstet Gynecol 184(4):552–558 5. Rosen R, Brown C, Heiman J et al (2000) The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 26(2):191–208 6. Ghielmetti T, Kuhn P, Dreher EF, Kuhn A (2006) Gynaecological operations: do they improve sexual life? Eur J Obstet Gynecol Reprod Biol 129(2):104–110 7. Rogers RG, Kammerer-Doak D, Darrow A et al (2006) Does sexual function change after surgery for stress urinary incontinence and/or pelvic organ prolapse? A multicenter prospective study. Am J Obstet Gynecol 195(5):e1–e4 8. Komesu YM, Rogers RG, Kammerer-Doak DN, Barber MD, Olsen AL (2007) Posterior repair and sexual function. Am J Obstet Gynecol 197(1):101e1–101e6 9. Jeng CJ, Yang YC, Tzeng CR, Shen J, Wang LR (2005) Sexual functioning after vaginal hysterectomy or transvaginal sacrospinous uterine suspension for uterine prolapse: a comparison. J Reprod Med 50(9):669–674 10. Dietz V, van der Vaart CH, van der Graaf Y, Heintz P, Schraffordt Koops SE (2010) One-year follow-up after sacrospinous hysteropexy and vaginal hysterectomy for uterine descent: a randomized study. Int Urogynecol J 21(2):209–216 11. Vollebregt A, Fischer K, Gietelink D, van der Vaart CH (2011) Primary surgical repair of anterior vaginal prolapse: a randomised trial comparing anatomical and functional outcome between anterior colporrhaphy and trocar-guided transobturator anterior mesh. BJOG 118(12):1518–1527 12. Carey M, Higgs P, Goh J et al (2009) Vaginal repair with mesh versus colporrhaphy for prolapse: a randomised controlled trial. BJOG 116(10):1380–1386 13. Nguyen JN, Burchette RJ (2008) Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol 111(4):891–898 14. Sivaslioglu AA, Unlubilgin E, Dolen I (2008) A randomized comparison of polypropylene mesh surgery with site-specific surgery in the treatment of cystocoele. Int Urogynecol J Pelvic Floor Dysfunct 19(4):467–471 15. Altman D, Vayrynen T, Engh ME, Axelsen S, Falconer C (2011) Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med 364(19):1826–1836 16. Nieminen K, Hiltunen R, Takala T et al (2010) Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up. Am J Obstet Gynecol 203(3):235e1–235e8 17. Milani AL, Withagen MI, Hok S, Nedelcu-van der Wijk I, Vierhout ME (2011) Sexual function following trocar-guided mesh or vaginal native tissue repair in recurrent prolapse: a randomized controlled trial. J Sex Med 8(10):2944–2953 18. Natale F, La Penna C, Padoa A, Agostini M, De Simone E, Cervigni M (2009) A prospective, randomized, controlled study comparing Gynemesh, a synthetic mesh, and Pelvicol, a biologic graft, in the surgical treatment of recurrent cystocele. Int Urogynecol J Pelvic Floor Dysfunct 20(1):75–81 19. Paraiso MF, Barber MD, Muir TW, Walters MD (2006) Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol 195(6):1762–1771
Int Urogynecol J (2013) 24:1853–1857 20. Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME (2011) Trocar-guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial. Obstet Gynecol 117(2 Pt 1):242–250 21. Iglesia CB, Sokol AI, Sokol ER et al (2010) Vaginal mesh for prolapse: a randomized controlled trial. Obstet Gynecol 116(2 Pt 1):293–303 22. Withagen MI, Vierhout ME, Hendriks JC, Kluivers KB, Milani AL (2011) Risk factors for exposure, pain, and dyspareunia after tensionfree vaginal mesh procedure. Obstet Gynecol 118(3):629–636 23. Maher CF, Feiner B, DeCuyper E, Nichlos C, Hickey K, O'Rourke P (2011) Laparoscopic sacral colpopexy versus total vaginal mesh for vaginal vault prolapse: a randomized trial. Am J Obstet Gynecol 204(4):360e1–7 24. Benson JT, Lucente V, McClellan E (1996) Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol 175(6):1418–1421 25. Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener CM (2010) Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 4:CD004014 26. Fayyad AM, North C, Reid FM, Smith AR (2011) Prospective study of anterior transobturator mesh kit (Prolift) for the management of recurrent anterior vaginal wall prolapse. Int Urogynecol J Pelvic Floor Dysfunct 22(2):157–163 27. Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M (2005) Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh. BJOG 112(1):107–111 28. Altman D, Elmer C, Kiilholma P, Kinne I, Tegerstedt G, Falconer C (2009) Sexual dysfunction after trocar-guided transvaginal mesh repair of pelvic organ prolapse. Obstet Gynecol 113(1):127–133 29. Su TH, Lau HH, Huang WC et al (2009) Short term impact on female sexual function of pelvic floor reconstruction with the Prolift procedure. J Sex Med 6(11):3201–3207 30. Wetta LA, Gerten KA, Wheeler TL 2nd, Holley RL, Varner RE, Richter HE (2009) Synthetic graft use in vaginal prolapse surgery: objective and subjective outcomes. Int Urogynecol J Pelvic Floor Dysfunct 20(11):1307–1312 31. Moore RD, Beyer RD, Jacoby K, Freedman SJ, McCammon KA, Gambla MT (2000) Prospective multicenter trial assessing type I, polypropylene mesh placed via transobturator route for the treatment of anterior vaginal prolapse with 2-year follow-up. Int Urogynecol J 21(5):545–52 32. Sayer T, Lim J, Gauld JM, et al. (2012) Medium-term clinical outcomes following surgical repair for vaginal prolapse with tension-free mesh and vaginal support device. Int Urogynecol J 23(4):487–493 33. Sentilhes L, Berthier A, Sergent F et al (2008) Infracoccygeal sacropexy reinforced with posterior mesh interposition for apical and posterior compartment prolapse. Eur J Obstet Gynecol Reprod Biol 137(1):108–113 34. Zyczynski HM, Carey MP, Smith AR et al (2010) One-year clinical outcomes after prolapse surgery with nonanchored mesh and vaginal support device. Am J Obstet Gynecol 203(6):587e1–587e8 35. Milani AL, Hinoul P, Gauld JM, Sikirica V, van Drie D, Cosson M (2011) Trocar-guided mesh repair of vaginal prolapse using partially absorbable mesh: 1 year outcomes. Am J Obstet Gynecol 204(1):74e1–74e8 36. de Tayrac R, Devoldere G, Renaudie J, Villard P, Guilbaud O, Eglin G (2007) Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study. Int Urogynecol J Pelvic Floor Dysfunct 18(3):251–256 37. Jacquetin B, Fatton B, Rosenthal C et al. (2010) Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 3-year prospective follow-up study. Int Urogynecol J 21(12):1455–1462 38. Feiner B, Gietelink L, Maher C (2010) Anterior vaginal mesh sacrospinous hysteropexy and posterior fascial plication for anterior
Int Urogynecol J (2013) 24:1853–1857 compartment dominated uterovaginal prolapse. Int Urogynecol J 21(2):203–208 39. Milani AL, Withagen MI, Vierhout ME (2009) Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse. Int Urogynecol J Pelvic Floor Dysfunct 20(10):1203– 1211 40. Lowman JK, Jones LA, Woodman PJ, Hale DS (2008)Does the Prolift system cause dyspareunia?Am J Obstet Gynecol 199(6):707e1–707e6 41. Hinoul P, Ombelet WU, Burger MP, Roovers JP (2008) A prospective study to evaluate the anatomic and functional outcome of a
1857 transobturator mesh kit (prolift anterior) for symptomatic cystocele repair.J Minim Invasive Gynecol 15(5):615–620 42. Long CY, Hsu CS, Wu MP, Lo TS, Liu CM, Tsai EM (2011) Comparison of the changes in sexual function of premenopausal and postmenopausal women following transvaginal mesh surgery. J Sex Med 8(7):2009–2016 43. Sergent F, Resch B, Al-Khattabi M, Richourg A, Schaal J, Marpeau L (2011) Transvaginal mesh repair of pelvic organ prolapse by the transobturator -infracoccygeal hammock technique: long-term anatomical and functional outcomes. Neurorol Urodyn 30(3):384–389
POP SURGERY REVIEW
Pelvic organ prolapse and sexual function Viviane Dietz & Christopher Maher
# ICUD-EAU 2013
Abstract Introduction and hypothesis The aim was to review the impact of pelvic organ prolapse surgery on sexual function. Methods Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the Englishlanguage scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi process expert opinion. Grade D “no
recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without formal analytical process, such as by Delphi. Results With regard to the anterior compartment, the use of mesh is associated with neither a worsening in sexual function nor an increase in de novo dyspareunia compared with traditional anterior colporrhaphy (grade B). There is insufficient information to provide evidence-based recommendations on sexual function after vaginal mesh in the posterior compartment or after new lightweight or absorbable meshes (grade D). Conclusion There is a paucity of data on the impact of prolapse surgery on sexual function. Sexual function and dyspareunia rates are similar after anterior polypropylene mesh and anterior colporrhaphy (grade B). We recommend using validated questionnaires measuring sexual function in women before and after prolapse surgery and reporting sexual activity and dyspareunia rates pre- and post-intervention in all patients.
On behalf of Committee 15 “Surgical Management of Pelvic Organ Prolapse” from the 5th International Consultation on Incontinence held in Paris, February 2012
Keywords Dyspareunia . Transvaginal mesh . Sexual function
This work has been previously published as: Maher C, Baessler K, Barber M, Cheon C, Deitz V, DeTayrac R, Gutman R, Karram M, Sentilhes L (2013) Surgical management of pelvic organ prolapse. In: Abrams, Cardozo, Khoury, Wein (eds) 5th International Consultation on Incontinence. Health Publication Ltd, Paris, Chapter 15 and modified for publication in International Urogynaecology Journal. V. Dietz Catharina Medical Center, Michelangelolaan, Eindhoven, The Netherlands C. Maher (*) University of Queensland, Royal Brisbane and Wesley Urogynaecology, 30 Chaseley Street, Auchenflower, 4067 Brisbane, Queensland, Australia e-mail: [email protected]
Sexual health is an essential component of a woman’s wellbeing. Female sexual dysfunction is defined as a sexual desire, sexual arousal, orgasm and/or sexual pain disorder that causes personal distress [1]. Up to 64 % of sexually active women attending a urogynecology clinic suffer from female sexual dysfunction [2]. The data on sexual function after prolapse surgery are conflicting, although in most cases sexual function will improve or remain the same. Apart from anatomical outcome, clinicians increasingly understand the importance of functional data after POP surgery. To measure sexual function, validated questionnaires on sexual function are necessary. Some validated quality of
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Int Urogynecol J (2013) 24:1853–1857
Table 1 Meta-analysis sexual function data from randomised controlled trials (RCT) comparing transvaginal mesh with native tissue repairs Reference
De novo dyspareunia
Postoperative dyspareunia
Postoperative PISQ score
Vaginal mesh
Mesh
Native tissue
Mesh
Native tissue
8/110
2/101
33.1±6.7 35.1 (1.4)
32.2±7.2 35.0 (1.4)
12/30
13/33
Change −6.9
Change −7.8
33±3 34±6 31/34 35±5.7 34.0±6.7 0.09 (−0.17, 0.36) No difference
32±4 33±3 32/35 31.5±7.2 34.7±5.7
Native tissue
Altman et al. [15] Vollebregt et al. [11] Carey et al. [12] Sivaslioglu et al. [14] Nguyen and Burchette [13] Iglesia et al. [21] Milani et al. [17]
3/20 5/18 2/43 2/22 1/11 3/37
2/21 5/12 0/42 4/26 3/14 3/29
2/23
2/23
9/53
12/51
Total
16/151 (10.6 %)
17/144 (11.8 %)
31/216 (14.4 %)
26/207 (12.5 %)
life and symptom questionnaires are inclusive of sexual function [3] or there are dedicated questionnaires specific to sexual function that provide a discreet and reproducible method of evaluating sexual health. The Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) [4] and the Female Sexual Function Index (FSFI) [5] are two questionnaires frequently used.
Sexual function after prolapse surgery without mesh Overall, sexual function improves after prolapse surgery without mesh [6–8]. In two randomised controlled trials (RCT), sexual function was measured after sacrospinous hysteropexy and vaginal hysterectomy. No differences were found between the two groups [9, 10]. No validated questionnaires were used.
Table 2 Meta-analysis of sexual function from prospective evaluations of transvaginal meshes Reference
n
De novo dyspareunia (%)
Follow-up (months)
Mesh
PISQ-12 pre
PISQ-12 post
Withagen et al. [22] Maher [23] Long [42] Milani et al. [35] Sergent [43] Sayer et al. [32] Jacquetin et al. [37] Moore et al. [31]
294 55 60 (Perigee™) 48 (Prolift™) 127 101 110 90 87
20/71 (28) 3/21 (14) 10/60 (16) 12/48 (25) 1/43 (2) 4/52 (8) 2/32 (6) 5/35 (14) 6/65 (9)
12 24 6 6 12 57 24 3 24
PP PP PP PP PP light Coated PP PP PP PP
33.4±7.7
39.0±4.4
32.2±6.2
Fayyad et al. [26] Feiner et al. [38] Wetta et al. [30] Milani et al. [39] Altman et al. [28] Su et al. [29] Lowman et al. [40] Hinoul et al. [41] Sentilhes et al. [33] de Tayrac et al. [36] Total
36 117 50 46 69 33 57 48 83 143 –
7/16 (43) 4/51 (8)
24 12 12 1 12 6 12 12 1 10 –
PP PP PP PP PP PP PP PP PP Coated PP –
2/11 (18)
6/36 (17) 3/20 (15) 6/37 (16) 10/78 (12.8) 102/680 (15.0)
33.4±7.7
36.8±5.5 No 36.8±5.5
NA NA 20.2±4.9
NA NA 16.2±6.0
15.5±8.0 29.5±9.0 NA NA 33.4±7.8
11.7±6.7 19.3±14.7 NA NA 35.5±7.3 No –
–
Int Urogynecol J (2013) 24:1853–1857
Sexual function after prolapse surgery with mesh Increasing data on sexual function after mesh repair are becoming available. Excellent randomised controlled trials on the efficacy of mesh prolapse surgery have been published and while most have not utilised validated questionnaires regarding sexual function most do include data on dyspareunia. Data from level 1 studies comparing transvaginal mesh and native tissue repairs are summarised in Table 1. When comparing sexual function in the anterior compartment with or without mesh, no differences in de novo dyspareunia, post-operative dyspareunia or PISQ scores were found [11–17]. Most women improved or remained the same. In one study by Vollebregt et al. [11], baseline dyspareunia disappeared more often after anterior colporrhaphy than after mesh implantation (80 % vs 20 %, p=0.018). Natale et al. showed that the use of porcine dermis graft (Pelvicol), compared with polypropylene mesh (Gynemesh) in the anterior compartment, was associated with an improvement in the PISQ scores [18]. Possibly, porcine dermis allows more flexibility to the anterior wall, resulting in less pain; however, this requires further evaluation. In the posterior compartment, fewer RCTs have been performed comparing native tissue repairs with mesh repairs. Paraiso et al. compared three techniques (posterior colporrhaphy, site-specific repair and use of porcine small intestine sub mucosa) [19]. No differences in sexual outcome were found between the groups and PISQ scores improved after surgery in all three groups. Trials that analysed anterior and posterior mesh together also reported no differences in sexual outcome between native tissue and mesh repairs [17, 20, 21]. Overall, after mesh surgery in the anterior and/or posterior compartments, de novo dyspareunia ranged from 5 % to 28 % of women [11–14, 22]. Data on the apical compartment using mesh showed less dyspareunia after abdominal sacral colpopexy compared with vaginal sacrospinous colpopexy [23–25]. Meta-analyses from all RCT comparing transvaginal mesh and native tissue repairs shown in Table 2 demonstrated no difference in the rate of de novo dyspareunia (mesh 10.6 % versus 11.8 % native tissue), post-operative dyspareunia (14.4 % versus 12.5 %) and PISQ scores (WMD 0.09 95 % CI −0.17 to 0.36). Although data from RCTs are valuable, sexual function was a secondary outcome measurement and most studies are underpowered to detect differences in sexual function. Therefore, reports from level 3 cohort studies on the use of mesh were evaluated. The rate of de novo dyspareunia after anterior and/or posterior mesh in these cohort studies was comparable to those of the RCTs mentioned previously and ranged from 21 % to 43 % (Table 2) [17, 26]. Milani et al. stated that mesh should be abandoned because of high dyspareunia scores (20 % more dyspareunia after anterior mesh and 63 % more dyspareunia after posterior Mesh) [27].
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However, when measuring sexual function with questionnaires, the impact of transvaginal meshes was variable, with some demonstrating poorer sexual outcomes [28–30] (lower PISQ scores) and some improved outcomes or no change following surgery [17, 31–33]. Altman et al. showed lower scores on sexual function 1 year after mesh surgery (anterior repair and posterior repair); however, this was related to behavioural–emotional function and partner=related items, not to physical function [28]. Pain and dyspareunia before surgery with mesh was a risk factor for pain and dyspareunia after mesh surgery [22]. There is some evidence that light meshes, partly absorbable meshes or nonanchored meshes have fewer negative side effects on sexual function; however, comparative studies or RCTs on this aspect have not been performed [34–36].
Recommendations Grade B With regard to the anterior compartment, the use of mesh is associated with neither a worsening in sexual function nor with an increase in de novo dyspareunia compared with traditional anterior colporrhaphy. Grade D There is insufficient information to provide evidence-based recommendations on sexual function after vaginal mesh in the posterior compartment. There is insufficient information to provide evidencebased recommendations on sexual function after new light or partially absorbable vaginal meshes. It is essential to use validated questionnaires measuring sexual function in women before and after prolapse surgery. We also recommend reporting sexual activity and dyspareunia rates pre- and post-intervention in all patients. Acknowledgements This publication results from the work of the Committee on Pelvic Organ Prolapse Surgery, part of the 5th International Consultation on Incontinence, held in Paris in February 2012, under the auspices of the International Consultation on Urological Diseases, and enabled by the support of the European Association of Urology. The authors wish to acknowledge the fine work of previous consultations led by Professor Linda Brubaker. Conflicts of interest None.
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