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Female sexual function in urological practice H.W. Elzevier
Female sexual function in
urological practice
H.W. Elzevier
Female sexual function in
urological practice
HENK ELZEVIER
© 2008 Henk Elzevier, all rights reserved
Cover: Detail of female pelvis draw by Prof. P.J. Donker
Graphic design: René Marc Blom - Studio Erembée, Egmond-Binnen, Holland
Printed by: UFB/GraMedia
Female sexual function in
urological practice
Proefschrift
ter verkrijging van
de graad van Doctor aan de Universiteit Leiden
op gezag van de Rector Magnicus prof.mr.P.F. van der Heijden,
volgens het besluit van het College voor Promoties
te verdedigen op woensdag 12 november 2008
klokke 13.45 uur
door
Hendrik Willem Elzevier
geboren te Zwolle
in 1964
Promotiecommissie
Promotor: Prof. Dr. A.A.B. Lycklama à Nijeholt
Co-promotor: Dr. R.C.M. Pelger
Referent: Prof. Dr. W.C.M. Weijmar Schultz (UMCG, Groningen)
Overige leden: Prof. Dr. E.J.H. Meuleman (VUMC, Amsterdam)
Prof. Dr. A.A.W. Peters
Dr. E.T.M. Laan (AMC, Amsterdam)
The studies of this thesis were initiated by the
Pelvic Floor & Sexuality Research Group Leiden and
supported by unrestricted grants of Pzer and Stichting Amsterdam 98.
Contents
Chapter 1 General introduction 7
Chapter 2 Evaluation of sexual function in women attending
an outpatient urological clinic; a survey study of 326 patients
(submitted 2008) 17
Chapter 3 Multiple pelvic oor complaints are correlated
with sexual abuse history
(accepted by J Sex Med July 2008) 35
Chapter 4 How reliable is a self-administered questionnaire in
detecting sexual abuse: a retrospective study in patients
with pelvic-oor complaints and a review of literature
(J Sex Med 2007; 4: 956-963) 47
Chapter 5 Sexual function after tension-free vaginal tape (TVT)
for stress incontinence: results of a mailed questionnaire
(Int Urogynecol J 2004; 15: 313-318) 63
Chapter 6 Female Sexual Function after Surgery for Stress Urinary
Incontinence: Transobturator Suburethral Tape vs.
Tension-Free Vaginal Tape Obturator
(J Sex Med 2008; 5: 400-406) 79
Chapter 7 Female Sexual Function and Activity following cystectomy
and continent urinary tract deviation for benign indication
(J Sex Med 2007; 4: 406–416) 97
Chapter 8 Sexual function after partial cystectomy and urothelial
stripping in a 32-year-old woman with radiation cystitis
(Int Urogynecol J 2005; 16: 412-414) 121
Chapter 9 Summery and general discussion 127
Chapter 10 Nederlandse samenvatting 135
Curriculum Vitae 147
Publications 149
Voor Peet en Quinten
Voor mijn ouders
7
CHAPTER 1
General introduction
Chapter 1
8
UROLOGY AND FEMALE SEXUAL FUNCTION
Sexual dysfunction in women is a multifactorial and multidimensional condition
combining several biological, psychological, medical, interpersonal and social
components. The World Health Organization dened Sexual dysfunction as
“the various ways in which an individual is unable to participate in a sexual
relationship as he or she would wish”. The Report of the International Consensus
Development Conference on Female Sexual Dysfunction (FSD) classied sexual
dysfunction in women into sexual desire disorders, namely, hypoactive sexual
desire disorder (HSDD) and sexual aversion disorder, female sexual arousal
disorder (FSAD), sexual orgasmic disorder and sexual pain disorders (dyspareunia,
vaginismus and non-coital sexual pain disorder) (1). According to the National
Health and Social Life Survey, the most frequently cited study (2) approximately
43% of American women suer of sexual disorders. Unfortunately, this study does
not provide information on prevalence rates in women over the age of 59 and
does not include in the denition an element of personal distress caused by the
dysfunction.
Why should the urologist play a role in managing female sexual dysfunction?
The relation between urological disorders and female sexual function was poorly
studied and understood. The contributions of urologists like Raz (3), McGuire and
Kursh (4) supplied a more holistic few on female urology including female sexual
function. Women’s specic anatomy, and specially the role of the pelvic oor, was
reconsidered, with increasing attention to the physiologic role of sexual hormones
and bladder, genitals and sexual response.
Based on everyday clinical practice and according to the most recent publications
(5-7), there is a relevant correlation between urogynaecological conditions and
FSD. In this scenario, the role of the urologist in the management of FSD should
be to attempt to reveil, diagnose and treat sexual disorders in female patients
suering from urological problems or refer patients to a sexologist. Besides that,
urologist and other surgeons should try to avoid FSD as collatereal damage due to
surgical procedures.
UROLOGICAL ANATOMY EN FEMALE SEXUAL
FUNCTION
Although 30%–50% of women suer from sexual dysfunction, only recently
has more medical and clinical research been focused on the problems related
to urological and surgical and gynecological operations (8-10). The inferior
hypogastric plexus, also called ‘pelvic plexus’, is the pathway for eerent and
Female sexual function in urological practice
9
aerent sympathetic and parasympathetic autonomic nerves and some sensory
nerves supplying the rectum, uterus, vagina, vastibular bulbs,the clitoris, bladder
and urethra. The superior hypogastric plexus and the hypogastric nerves are
mainly sympathetic; the pelvic splanchnic nerves mainly parasympathetic.
Theoretically, disruption of the pelvic plexus could lead to altered vascular
function during sexual arousal and possibly disordered orgasm. The pelvic plexus
supplies the blood vessels of the internal genitals and is involved in the neural
control of vasocongestion and, consequently, the lubrication-swelling response.
The innervation of the vaginal wall originates mostly from the pelvic plexus. In
addition, signicant devascularization of the clitoris often occurs with removal of
the distal urethra, aecting subsequent sexual arousal and desire. Recently Yucel
et al reported that the cavernous nerve supplies the female urethral sphincter
complex and clitoris (11). The branches of the cavernous nerve were noted to join
the clitoral “dorsal” nerve at the hilum of the clitoral bodies. These branches stain
positive for neuronal nitric oxide synthase. The cavernous nerves originate from
the vaginal plexus component of the pelvic plexus. They travel at the 2 and 10
o’clock positions along the anterior vaginal wall, and then at the 5 and 7 o’clock
positions along the urethra. In this study the cavernous nerves in fetuses were
clearly demonstrated, highlighting the importance of further studies in adults to
dene the anatomy accurately to preserve their integrity during reconstructive
and ablative surgery. The sensation of the external genitalia is not related to the
pelvic plexus: pudendal nerve branches are the somatosensory pathways for the
vulva.
UROLOGICAL COMPLAINTS, DISEASES AND
FEMALE SEXUAL FUNCTION
FSD is commonly reported in relation to Lower Urinary Tract Symptoms (LUTS)
in general (12-14) and Urinary Incontinence (UI) (15). Also related to pelvic
oor disorders FSD is prevalent and a challanging problems. These disorders
include prolapse of the uterus, cervix, vagina, bladder and rectum as well as
incontinence. Women with pelvic oor disorders often have co-existing urological,
gynecological, faecal and sexual complaints (16).
UI in women is a highly prevalent condition in urological and gynecological
practice. In 2002, Shaw (15) reported the results of a review of all primary
epidemiological articles reporting the prevalence of “sexual incontinence” and
the impact of UI on sexual function in women. Notwithstanding the great
methodological heterogenecity of the dierent studies, the analysis showed a
prevalence of FSD ranging between 0.6 and 64% among studies. In a review by
Barber et al (17) there was a greater incidence of sexual dysfunction in women who
Chapter 1
10
were incontinent or had LUTS, compared to the general population.
In a review published by Salonia et al.(18), the diagnosis of overactive bladder
(OB) negatively the quality of life and sexual function of women.
In specic urological diseases like Interstitial Cystitis/Pelvic Pain Syndrome (IC)
sexual dysfunction is an important issue (19-21). IC is characterized by chronic
urinary urgency, frequency, and/or pelvic pain in the absence of any known
etiology. Several studies have focused attention on dyspareunia as one of IC
related symptoms in female patients (22-25). The importancy of sexual counseling
in relation to IC is clear.
The inuence of Spina Bida on female sexual function was nicely reviewed by de
Vylder et al (26). Because of the growing life expectancy of Spina Bida patients,
there is more interest in sexual functioning. How to deal with this topic in Spina
Bida treatment is nicely described by Verhoef et al (27). She gives a good advice
and format of the interview on sex education, relationship and sexuality for young
adults with Spina Bida.
IMPACT OF UROLOGICAL SURGERY ON FEMALE
SEXUAL FUNCTION
The impact of urological surgery on female sexual function may be the result of
neurovascular damage or disturbance of vaginal anatomy.
Female sexual dysfunction is prevalent after radical cystectomy, and especially in a
younger population, sexual dysfunction is an important concern. With improved
detection and oncological control of bladder cancer, earlier surgical therapy can
be tailored allowing preservation of neurovascular bundles and other adjacent
structures such as the vagina and cervix. Historically, radical cystectomy removed
or damaged the neurovascular bundles on the lateral walls of the anterior vagina,
causing signicant devascularization of the clitoris. Clitoral devascularization
also occurs with removal of the distal urethra. Urethral sparing and neurovascular
preservation potentially saves the nerves and vasculature of this region. The
rst publication on radical cystectomy in relation to female sexual function
was published in 1985 by Schover et al (28). More studies on sexual implications
followed (29-31). Only recently the rst manuscript on nerve sparing cystectomy
in relation to female sexual function was published (32).
The close anatomical proximity of the bladder and urethra to the vaginal
canal allows an association between lower urinary tract dysfunction and sexual
diculties. The alteration of vaginal anatomy after surgery is another issue
related to radical cystectomy but also in relation to vaginal surgery like prolaps
(33;34) and incontinence operations. The maintenance of sexual function requires
preservation of a vaginal length and caliber adequate for sexual intercourse and
Female sexual function in urological practice
11
preservation of the innervation of the clitoral nerves.
Another issue is the inuence of surgery on body image in general but also specic
to operations like urostoma (35). The impact of the urostoma on female sexual
function is seldom discussed by urologists and hopefully discussed by the stoma-
care nurse. This is an area of sexual function in urological practice that needs
attention.
SEXUAL ABUSE IN UROLOGICAL PRACTICE
The importance of discussing abuse with a patient before performing an invasive
gynaeco-urological examination is clear. Survivors of sexual abuse rated the
gynecological care experience more negatively than the controls, experienced
more intensely negative feelings, and reported being more uncomfortable
during almost every stage of the gynecological examination than the controls.
In urological practice, studies on the prevalence of sexual abuse are rare. In
gynecological and obstetric care abuse was prevalent in 10-20% (36-40) and 19,4-
27,5% in pelvic pain patients (41-43). In general physicians mention many barriers
to ask women about sexual abuse, including lack of time and resources of support,
fear of oending women, lack of training, fear of opening the “Box of Pandora”.
Actually, this is still a “black box” in urology, demanding research and education of
urologists.
PELVIC FLOOR & SEXUALITY RESEARCH GROUP
LEIDEN
The Department of Urology of the Leiden University Medical Center has a long
tradition of male sexual function related research started by Donker who after
his retirement described the surgical anatomy of the pelvic autonomic nerves in
detail in 1986. Earlier he published with Walsh the article on nerve-sparing radical
prostatectomy, as a result of a visit of Walsh to Donker in Leiden in 1981 (44). It is
of interest that in the same period Donker did a lot of neuroanatomical research
on female cadavers. We were unaware of these dissections until when recently the
anatomical archive was moved to a new building. A detail of one of these drawings,
is illustrating the cover of this thesis.
In 2004 the Department of Urology founded the Pelvic Floor & Sexuality
Research Group Leiden. The aspiration, mission, of the research group is
initiating pelvic oor and sexual function related research. In 2004 the rst
manuscript was published by the group (45) and in the same year Pzer and
“stichting Amsterdam 98” supported the research group by unrestricted grants.
Chapter 1
12
OUTLINE OF THE THESIS
The principle aim of the study was to investigate the prevalence of sexual (dys)
function in a urological clinic. Also the prevalence and detection of sexual abuse
are discussed as well as the impact of urological treatment on female sexual
function.
The study was initiated by the in 2004 founded Pelvic Floor & Sexuality Research
Group Leiden.
In chapter two we describe the results on the prevalence of female sexual function
in an outpatient urologic clinic related to dierent urological complaints.
Sexual abuse appeared to be a quite frequent problem in urological practice.
During a pelvic oor evaluation by our physiotherapist 32% of 141 female patients
with pelvic oor complaints had a history of sexual abuse. In chapter three sexual
abused patients are evaluated in relation to their pelvic oor complaints in order
to estimate which patients are prone to have a history of sexual abuse. Chapter
four reports an evaluation of a self-administered questionnaire versus a taken
questionnaire administered by a pelvic oor clinician in relation to sexual abuse
in patients with pelvic oor complaints. The reliability of a self-administered
questionnaire in detecting sexual abuse is discussed. Also the literature in relation
to pelvic oor complaints and sexual abuse is reviewed.
Research on the inuence of urological surgery on sexual function is relative rare
in female in contrast to male patients. In chapter ve we describe the inuence
of Tension-free Vaginal Tape (TVT) incontinence surgery on sexual function.
Whether the impact of surgical treatment of stress urinary incontinence (SUI)
on female sexual function is related to the procedure as such, in chapter six the
inuence of TransObturator suburethral Tape (TOT) or Tension Free Vaginal Tape
Obturator (TVT-O) is discussed. Also some novel questions are introduced to get
more neuro-sexuological specic information after the incontinence operation.
In chapter seven we evaluate the female sexual function and activity following
cystectomy. In this study the sexual function after cystectomy and continent
urinary tract diversion for benign indications is reported. In order to diminish
the impact of a cystectomy procedure on sexual function, the eect of a partial
cystectomy procedure of a 32-year-old woman with radiation cystitis is described
in chapter eight.
Finally, in chapter nine the results of the presented studies and future prospects
are discussed.
Female sexual function in urological practice
13
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Chapter 1
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16
17
CHAPTER 2
Evaluation of sexual function in
women attending an outpatient
urological clinic; a survey study of
326 patients
Based on:
Elzevier HW, Beck JJ, Putter H, Pelger RCM, Voorham- van der Zalm PJ,
Lycklama a Nijeholt AAB. Evaluation of sexual function in women attending an
outpatient urological clinic; a survey study of 326 patients
18
Chapter 2
INTRODUCTION
Well-designed, random-sample, community-based epidemiological investigations
of women with sexual dysfunction (SD) are limited. The most widely cited study
is based on the U.S. National Health and Social Life Survey of 1992 (1). Female
sexual function was evaluated before in the general population, SD is a highly
prevalent problem for 15% to 43% of women (1-5) and a result of multicausal
and multidimensional factors; emotional, physical, biological, psychological, and
interpersonal domains interfering with the sexual function of women (6). In this
respect, urogynecologic patients may even be at a higher risk of sexual complaints
(48%-64%) for multiple reasons, including advanced age and pelvic oor
dysfunction (7;8). Urogynecological complaints may lead to sexual dysfunction,
but are probably more due to prolapse and urinary symptoms. Our study is
expanding on prior literature by not only evaluating urogynecological complaints,
but also other urological complaints. To evaluate sexual function we used the
SD classication of sexual desire disorders, sexual arousal disorder, orgasmic
disorder and sexual pain disorders described by The International Consensus
Development Conference on Female Sexual Dysfunction (9).
The rst aim of this study was to evaluate sexual function in an outpatient
urological clinic related to a variety of urological complaints. Secondly we wanted
to know which urological complaints were most likely to be related to sexual
complaints.
MATERIALS AND METHODS
All female patients, aged 18-years and older, in a period of 2.5 years, who
presented at our outpatient urological university clinic for urological evaluation
for the rst time, were included in this study. All patients gave informed consent.
The patients were asked to ll out a self-administered questionnaire evaluating
referal indications including urological complaints (see Appendix); the Female
Sexual Function Index (FSFI) (10) and the Golombok Rust Inventory of Sexual
Satisfaction GRISS (11;12) , who are both validated for the Dutch language (13;14).
The FSFI is a validated instrument that characterizes six domains of female
sexual function. The FSFI consists of 19 items, assessing the extent to which
women experience sexual problems (19). There are six subscales: desire (2 items;
range, 1-5), arousal (4 items; range, 0-5), lubrication (4 items; range, 0-5), orgasm (3
items; range, 0-5), satisfaction (3 items; range, 0-5) and pain (3 items; range, 0-5).
The data were scored using the scoring system as described by Rosen et al. (10).
“Low FSFI score” was dened as an adjusted FSFI cut-o below 26.55 which could
be a sign of sexual complaints (15). FSFI score above 26.55 was dened as a “High
Female sexual function in urological practice
19
FSFI score”.
The GRISS is a, short 28-item, questionnaire for assessing the existence and
severity of sexual problems. It measures the most common psychosexual
complaints and has been chosen to assess the degree of bother as described before
by ter Kuile et al. (16), because no validated bother questionnaire was available in
the Dutch language at the start of the study. For this study, only seven items were
used for analyses. These items comprised the subscales for “non-communication”
(scoring ranges: 2-10) and female dissatisfaction (scoring ranges: 4-20), following
the question “do you enjoy sexual intercourse with your partner” (score between
1-5). Higher scores indicate more dissatisfaction. The subscales of the GRISS was
used to evalute the dierence in bother between the “Low FSFI score” and “High
FSFI score” group
All data were collected anonymously. The data were analysed using SPSS version
14. Dierences in quantitative variables and frequencies were evaluated using
Student’s t test and Pearson’s chi-square test, respectively. A two-sided P-value
<0.05 was considered statistically signicant. Our Institutional Review Board
approved the study.
RESULTS
Of a total of 1383 patients presenting at the clinic for the rst time, 410 (30%)
agreed to participate after reading the informed consent form. Of them 326 (80%)
completed and returned the questionnaires.
Of the remaining 326 patients 83.4% (n=272) had a partner, 119 (36.5%) were
sexually inactive and 207 (63.5%) patients were sexually active. The reasons for
sexual inactivity and the urological complaints (a patient could give more than
one complaint) of the inactive patients are listed in Table 1 and 2. In a few extra
questions we asked whether patients thought that there was an urological related
reason for their sexual inactivity. Incontinence during sexual activity was the main
reason for sexual inactivity in 7.6% (n=9) of the total inactive sample and in 13.2%
of the patients with incontinence (n=68). For 16.1% (n=18) of the 119 sexually
inactive patients, the main reason for sexual inactivity was pain during intercourse,
for 23.2 % (n=26) loss of libido. The mean age of the inactive population was 59.0
(sd 14.6) years, which is signicantly higher than the mean age of 45.6 (sd 13.7) of
the sexually active group (p<0.001). Dierences between active versus inactive
patients are listed in Table 3.
20
Chapter 2
Table 1
Reason for sexual inactivity (n=119)
No partner 52 42.9%
Partner-related issues like illness or Erectile Dysfunction 18 14.3%
Patient-related issues 10 8.9%
Combination of problems 36 32.1%
Unknown 3 1.8%
Total 119 100%
Table 2
Urological complaints of the sexually inactive patients (n=119)
Complaints n Percentage
Loin pain 16 13.4%
Heamaturia 26 21.8%
Urinary tract infection 54 45.4%
LUTS (urge and frequency) 76 63.9%
Incontinence 72 60.5%
Lower abdominal Pain 35 29.4%
Abnormality on X-ray 6 5.0%
Consult by other specialist 47 39.5%
Otherwise 20 16.8%
Female sexual function in urological practice
21
Table 3
Sexual active versus sexual inactive
Sexual active Sexual inactive n
Age 45.5 58.5 >0.001
Partner 97.6% 58.8% >0.001
Smoking 16.9% 22.0% 0.255
Alcohol 59.5% 44.4% 0.090
Cardio vascular disease 41.2% 53.8% 0.028
High blood pressure 39.7% 51.3% 0.044
Diabetes 39.2% 53.0% 0.017
Neurological complaints 39.2% 53.0% 0.017
Psychological complaints 36.8% 50.9% 0.014
Menstruation
Regular
Not regular
Few months not any more
Few years anymore
43.2%
13.6%
6.8%
36.4%
8.8%
6.8%
4.3%
70.1% >0.001
Sexual abuse 14% 22.0% 0.064
Note. Dierences between sexually active and inactive patients are also signicant in the subgroup of women
with a partner.
22
Chapter 2
Table 4
Female Sexual Function Index (n=207)
Domains Total
Complaints n Desire Arousal Lubrication Orgasm Satisfaction Pain
Loin pain 26 3.6
(1.8-6.0)
4.2
(1.8-6.0)
5.9
(2.7-6.0)
4.6
(1.2-6.0)
5.2
(1.2-6.0)
6.0
(0.0-6.0)
28.0
(13.1-36.0)
Haematuria 51 3.6
(1.2-6.0)
4.2
(0.0-6.0)
5.4
(0.0-6.0)
5.2
(0.0-6.0)
5.2
(1.2-6.0)
5.6
(0.0-6.0)
28.4
(3.9-36.0)
Urinary tract infection 93 3.6
(1.2-6.0)
4.5
(0.0-6.0)
5.4
(0.0-6.0)
5.2
(0.0-6.0)
4.8
(1.2-6.0)
4.8
(0.0-6.0)
28.2
(4.6-36.0)
LUTS (urge and frequency) 95 3.6
(1.2-6.0)
3.9
(0.0-6.0)
4.8
(0.0-6.0)
4.4
(0.0-6.0)
4.8
(0.8-6.0)
4.0
(0.0-6.0)
24.9
(5.4-36.0)
Incontinence 93 3.6
(1.2-6.0)
4.5
(0.0-6.0)
5.4
(0.0-6.0)
4.8
(0.0-6.0)
4.8
(0.8-6.0)
4.8
(0.0-6.0)
26.9
(4.6-34.5)
Lower abdominal Pain 62 3.6
(1.2-6.0)
3.9
(0.0-6.0)
4.8
(0.0-6.0)
4.4
(0.0-6.0)
4.4
(0.8-6.0)
4.0
(0.0-6.0)
25.3
(5.4-36.0)
Abnormality on X-ray 18 3.0
(1.2-5.4)
4.1
(1.8-5.7)
5.4
(1.2-6.0)
4.6
(1.2-6.0)
4.8
(2.8-6.0)
3.8
(0.0-6.0)
26.5
(11.4-34.5)
Consult other specialist 48 3.6
(1.2-4.8)
3.8
(0.0-6.0)
4.4
(0.0-6.0)
4.4
(0.0-6.0)
4.6
(1.2-6.0)
3.6
(0.0-6.0)
24.3
(4.8-34.4)
Otherwise 33 3.6
(1.2-6.0)
4.2
(0.0-6.0)
5.4
(0.0-6.0)
4.8
(0.0-6.0)
4.8
(1.2-6.0)
4.8
(0.0-6.0)
27.0
(3.9-34.5)
Female sexual function in urological practice
23
A total of 207 patients were sexually active and lled out the FSFI and the 7
items of the GRISS questionnaire. The total FSFI score was 28.3 (3.9-36), of these
41.7% had a low FSFI score. FSFI scores and domains of the dierent urological
complaints are listed in Table 4. Only age and menopause were signicantly
dierent between the Low FSFI score group versus High FSFI score group.The
mean age of the Low FSFI score group (48.2 years, sd 13.1) was signicantly higher
than the mean age of the High FSFI score group” (42.2 years, sd 13.2, p<0.005).
No signicantly dierence was seen in co-morbidity between both groups. Only
signicantly more patients were postmenopausal in the Low FSFI score group
(p<0.01).
When comparing sexually active patients in the Low FSFI score group with
the total sample, we found patients with complaints of LUTS (p<0.001), lower
abdominal pain (p<0.05) and “consultation by another specialist” group (p<0.01)
were more likely to have sexual complaints. Only 15 of the 48 patients of the
“consultation by another specialist” group had no urological complaints. Of the
rest of these patients (n=33) 45.5% had complaints of LUTS, and 33% reported
complaints of lower abdominal pain.
The mean score of GRISS noncommunication domain of the sexually active
patients was 4.9 (sd 1.7). The mean score of the Low FSFI score group was 5.3
(sd 1.7) versus 4.3 (sd 1.5) for the High FSFI score group (p<0.001). This nding
indicates that the Low FSFI score group found it more dicult to discuss sexual
issues with their partner.
The mean GRISS female dissatisfaction score was 7.7 (sd 3.2). The mean score of
the Low FSFI score group was 8.8 (sd 3.3) versus 6.0 (sd 2.1) for the High FSFI
score group (p<0.001). The mean score of the question “do you enjoy sexual
contact” was 1.9 (sd 1.0). The mean score of the Low FSFI score group was 2.3
(sd 1.1) versus 1.2 (sd 0.4) of the High FSFI score group (p<0.001). The Low FSFI
score group was more dissatised with the time devoted to sex and reported less
enjoyment with sexual contact with their partner.
The question “Did you have negative sexual experiences in the past” which could
indicate sexual abuse, was answered positive in 16.9% of the total population, no
signicant dierence was seen between the active versus inactive population.
DISCUSSION
This study was performed in a tertiary referral center of an outpatient urological
university clinic. In contrast to urogynecology clinic studies (8;17) also patients
without urogynaecological related complaints were included. In the total
sample we found sexual inactivity in 34.4% of patients, of them 46.9% was
incontinence, pain or libido related, and in the sexually active patients we found
24
Chapter 2
a low FSFI score (<26.55) in 41.7%. In total we found 42.6% sexual inactivity due
to incontinence,pain or loss of libido or low FSFI (which could be indicative of
sexual complaints). This was almost the same as the 50% sexual dysfunction in
the study by Geiss et al (7).
The reason of inactivity or Low FSFI score is multicausal; we discuss some
aspects in detail. Having a partner is probably the most important reason
for sexual inactivity (Table3). The mean age of the inactive population was
signicantly higher than the sexually active group. Declining sexual activity in the
elderly has been reported by others (18-21). Also the Low FSFI score group, who
might be at risk for female sexual dysfunction, was signicantly older.
The inuence of menopausal status on sexual function has recently been reviewed
(22-25). In our study 70.1% of the inactive patients were postmenopausal, in
contrast to 36.4% of the sexually active population (Table 3). Age and menopausal
status may inuence sexual activity and sexual dysfunction in this study although
recently Hayes et al. (26) concluded that relationship factors were more important
to low desire than age or menopause, whereas physiological and psychological
factors were more important to low genital arousal and low orgasmic function
than relationship factors.
There are several studies dealing with the negative eects of urinary problems
on an individual’s sexual life (27-30). Problems related to urinary incontinence,
especially leakage during intercourse, wetness at night, odor and bedwetting, have
been associated with sexual problems such as a decrease in frequency of coitus,
anorgasmia and dyspareunia. Temml et al. reported that 25.1% of incontinent
women had some form of impairment in sexual function, and the majority of
aected women reported that stress incontinence and urge incontinence during
coitus were the most bothersome (31). Incontinence complaints were the main
reason for sexual inactivity in 13.2%. In our patients who were sexually active,
incontinence was seen in 44.9%. The median FSFI score of these patients was
26.9 (4.6-34.5). A total of 51.2% had a Low FSFI score. In the total incontinence
complaint group 41% of the patients were sexual inactive due to incontinence
complaints or had a low FSFI score. This outcome is higher than Temml et al
reported.
Routine screening for sexual abuse was reported to be rare in a study of health
care practitioners and gynaecologists (respectively 1,3 and 0,5%) (32;33). In our
study 16.9 % of the patients reported to have experienced sexual abuse. The
prevalence of sexual abuse in relation to pelvic oor and urological related
problems was recently reviewed (34;35). Beck et al recently concluded that
patients with multiple pelvic oor complaints related to pelvic oor dysfunction
are more likely to have a history of sexual abuse than patients with isolated
complaints (36).
A response rate of 24% is low. We oer two reasons for this low response rate.
Female sexual function in urological practice
25
Firstly, subjects had to be actively recruited by the urologist or resident in that s/
he was to ask at any rst visit whether the patient had received a letter including
informed consent. Asking for participation was not always appreciated and so
not always done by all urologist and residents, so this may have led to a decreased
participation. The patients were required to return the questionnaire by mail
or to hand it in at the second visit. The latter again required active input of the
urologist or resident and could likely have resulted in not all patients handing in
the questionnaire in case she was not asked to. Secondly, a part of the patients
who wanted to participate may have been embarrassed by the content of the
questionnaire.
In the study of Pauls et al. the majority of sexually active patients completed
the FSFI questionnaire, while only a small group voiced embarrassment at the
questions (8). Based on these ndings, they felt comfortable incorporating this
questionnaire into their introductory patient packages. In our study, 20 % of
the patients who wanted to participate did not return the questionnaire. Also a
large part of the patients did not want to participate after reading the informed
consent. Although the FSFI was accepted as a sexual evaluation tool, probably the
evaluation with sexual function questionnaires in a standard urological practice
is not an option. More research is needed to select urological complaints were
standard sexual evaluation of sexual function is an option. Voorham et al. has given
some good advice in relation to pelvic oor complaints evaluation (37;38).
On the other hand, a few sexual function questions like “do you have sexual
problems” and “do you have a history of sexual abuse” or “have you had any
negative sexual experiences in the past” before vaginal examination is performed,
is in our opinion necessary. Important in this matter is the physician’s attitude
towards female sexual complaints like Berman et al. described in relation to
seeking help for sexual function complaints in gynecological practice (39). This
attitude is not only gynecological related only, but is needed in the medical
profession in general. Female sexual problems are frequent in many clinical
conditions, but are not yet a routine part of diagnostic workup and therapeutic
planning. It is crucial, as Berman at al. suggested, that further research is carried
out in this area, as well as more timely evaluations of what is actually going on in
medical schools and postdoctoral professional training around sexual topics. With
potential treatments available, women are going to come forward seeking help
more than ever and, it is hoped, will feel more and more entitled to full sexual
lives.
Tools are needed, like Bitzer et al. have developed, to help physicians in dierent
clinical settings to evaluate sexual problems of the female patients (40). We
noticed in our study that physicians (residents and urologists) had diculties in
asking about sexual function or participation in this study even though we had
informed patients about the study by mail before the rst visit of our outpatient
Chapter 2
26
clinic. Although we did not evaluate this diculties by a questionnaire some
remarks can be made related to this subject. First patients were not reered
for sexual problems, so in some cases ( for example; stones in the kidney or
kidney tumor on radiological examination) the relation between sexual and
urological complaint is dicult to make and makes it more dicult to explain
the importancy of participation in this study. Secondly female sexual function is
not a subject in wich urologist are educated in contrast to erectile dysfunction.
Probably also the sexual attitude of the physician it self plays an important role in
asking sexual questions.
A few other limitations of the study have to be discussed. Personal distress in
relation to sexual dysfunction in the inactive patient group was not evaluated.
Another limitation of the study could be the potential for selection bias as a
substantial proportion of patients refused to ll in the questionnaire. Those that
responded may be dierent from the non-responders.
Lastly, the university clinic patient population may have more co-morbidity, which
could negatively inuence the the prevalence of sexual function complaints.
Nevertheless, we believe that this rst study performed in a urological clinic
shows, that female sexual function is an important issue in urological practice.
CONCLUSION
In urological practice female sexual function is a common problem, therefore
we recommend integrating female sexual function questionnaires in standard
urological care.
Female sexual function in urological practice
27
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30
Chapter 2
APPENDIX
QUESTIONNAIRES
1 Date of Birth
2 Do you have a partner? n yes n no
3 How many children do you have?
4 Do you smoke? n yes n no
5 Do you have
Vascular or heart problems n yes n no
High blood pressure
n yes n no
Diabetes
n yes n no
Neurological complaints n yes n no
Psychiatric complaints n yes n no
6 Do you menstruate?
n Yes, regularly
n Yes, but not regularly
n No, I haven’t had a period since a few months
n No, I haven’t had a period for more than a year
7 Did you have negative sexual experiences in the past n yes n no
Would you be willing to provide some more information about this?
8 What medication do you use currently?
9 Did you have any operations in the past, if yes, please list them here
31
Female sexual function in urological practice
Urological complaints (more than one urological complaint can be
entered)
10 Do you experience pain in the region of the kidney? n yes n no
11 Do you have blood in your urine? n yes n no
Microscopic n yes n no
Macroscopic n yes n no
12 Urinary tract infection n yes n no
13 Urinating complaints n yes n no
14 Incontinence n yes n no
15 Abdominal pain n yes n no
16 Abnormalities on radiological examination n yes n no
17 Consultation by other specialist but I have no
urological complaints n yes n no
18 Other, please explain n yes n no
19 This question refers to the reason, why you weren’t sexually active
Was this the result of:
n Not having a partner
n Partner related problems as, for example, illness, impotence, age
n Patient related problems as, for example illness, age
n A combination of these factors
If you would like to give an explanation, you can write it underneath
The reason for not being sexually active anymore was due to the next problems?
20 Incontinence during sexual intercourse n yes n no
32
Chapter 2
21 Pain during sexual intercourse n yes n no
22 No sexual desire n yes n no
Next FSFI and GRISS
33
Female sexual function in urological practice
34
35
CHAPTER 3
Multiple pelvic oor complaints are
correlated with sexual abuse history
Based on:
Beck JJ, Elzevier HW, Pelger RCM, Putter H, Voorham – van der Zalm PJ.
Multiple pelvic oor complaints are correlated with sexual abuse history.
J Sex Med 2008 accepted
36
Chapter 3
INTRODUCTION
International estimates of the prevalence of sexual abuse are high. In a review
from Kellogg and the Committee on Child Abuse and Neglect in 2005, it is
suggested that each year, approximately 1% of children experience some form of
sexual abuse, resulting in the sexual victimization of 12 - 25% of girls and 8 - 10%
of boys by 18 years of age (1).
Results of a national telephone survey conducted in 2001-2003 in the United
States indicate that 1 in 59 U.S. adults (2.7 million women and 978,000 men)
experienced unwanted sexual activity in the 12 months preceding the survey and
that 1 in 15 U.S. adults (11.7 million women and 2.1 million men) have been forced
to have sex during their lifetime (2).
The relationship between sexual abuse and urinary tract symptoms, sexual
abuse and gastrointestinal symptoms, or sexual abuse and sexual dysfunction
has been described in many articles, but it has not been quantied statistically
(3-11). The pelvic oor controls isolated and integrated functions, sustains proper
anatomic relationships between pelvic visceral organs and its outlets, and shares
the basic mechanism with various visceral organs that control their function.
The pelvic oor, consisting of muscular and fascial components, is the binding
element between these organs. It is also considered to be an inuential factor
in dysfunction and subsequently behavior of the genital system in both men
and women (12). However, literature is scarce on the topic of the diagnostic
investigation of pelvic oor, and there is a lack of uniformity in the description of
the anatomy per se and the nomenclature of the pelvic oor (13-15). A relationship
between the complaints of micturition, defecation, and sexual dysfunction related
to the pelvic oor dysfunction and a history of sexual abuse has been suspected,
but has not been previously examined or reported upon to date.
The rst aim of this study was to document the prevalence rates of reported
sexual abuse in a large sample of female patients with complaints of the pelvic
oor. The second aim was to evaluate the frequency of complaints in the dierent
domains of the pelvic oor, such as complaints of micturition, defecation, and
sexual function, in female patients reporting sexual abuse, and comparing these
data with female patients without a history of sexual abuse.
Our hypothesis was that patients referred to a tertiary center with complaints
of micturition, defecation, and/or sexual dysfunction related to the pelvic oor
dysfunction are more likely to have of a history of sexual abuse than women with
complaints in fewer domains of the pelvic oor.
Female sexual function in urological practice
37
METHODS
All female patients referred between January 2004 and November 2007 by
urologists, gynecologists, surgeons, or gastroenterologists to our out patient pelvic
oor center for pelvic oor evaluation because of complaints of micturition,
defecation, and /or sexual dysfunction possibly related to pelvic oor dysfunction
were included.
The pelvic oor clinician assessed the medical history of the patients. This
consisted of a pelvic oor questionnaire in which dierent domains of the pelvic
oor (micturition, defecation and sexual function) were structurally evaluated.
The Pelvic Floor Inventories Leiden (PelFIs), a validated questionnaire, was used
(16). At the start of the development of the PelFIs, the type of sexual abuse was
not specied, only a history of sexual abuse was recorded. Later on, the PelFIs was
improved addressing the nature of sexual abuse: incest, sexual intimidation, rape,
marital rape, sexual harassment, including forcible fondling, or not (otherwise)
specied. The PelFIs is only validated in Dutch. An English version is currently
validated in several English native speaking countries. A retrospective search was
performed to evaluate if the referring physician has documented the type of sexual
abuse in the patients' medical record.
For the analysis, patients were divided in two groups: patients with a history of
sexual abuse (Group I) and patients without a history of sexual abuse (Group II).
If a patient had at least one of the following complaints related to the dierent
domains of the pelvic oor, we dened her as positive for that domain. The
domains are the urological domain, gastrointestinal domain, and sexual domain
(Table 1). The data were analysed using SPSS version 14 (SPSS Inc., Chicago, IL.,
USA). Dierences in frequencies were evaluated using Pearson’s chi-square test or
Fisher’s exact test when cells with less than 5 expected subjects were present.. A
two-sided P-value <0.05 was considered statistically signicant.
RESULTS
A total of 185 female patients were retrospectively included and evaluated by a
pelvic oor physiotherapist. No patients were excluded. The mean age of the
population was 47.1 years (standard deviation, 15.5 years). Twenty-three percent
of the patients (42/185) reported a history of sexual abuse. In the total group
of patients, the mean age of the sexually abused patients (Group I) was not
signicantly dierent from the not sexually abused patients (Group II) (43.7 vs.
48.1 ; p= 0.106).
The type and frequency of sexual abuse are listed in Table 2. The type of abuse
could not be determined in 23.8% of the abused patients (10/42). Questions
38
Chapter 3
regarding sexual abuse were added in a follow-up version of the PelFIs. In an
earlier version sexual abuse was not specied by the patient, pelvic oor clinician
or documented in the patients’ medical record by the referring physician.
In the sexually abused group 7.2% (3/42) of the patients had complaints in one
domain of the pelvic oor vs. 17.5% (25/143) in the nonabused group. Dierences
in two and three domains are 9.5% (4/42) in the abused group vs. 34.2% (49/143)
in de nonabused group, and 83.3% vs. 48.3 % (69 /143), respectively (p<0.0001)
(Table 3).
Table 1: Specication of complaints in the three domains of the questionnaire.
Urological Domain Gastro-intestinal Domain Sexual Domain
Urgency / frequency Frequency Dyspareunia
Hesitation Blood loss
Weak urinary stream Inappropriate emptying
Intermittent urinary stream Defecation in tempi
Straining when urinating Straining
Residual awareness Peri-anal skin complaints
Urinary tract infections Soiling
Painful voiding Incontinence of stool or flatus
Peri-anal pruritus
Painful emptying
Female sexual function in urological practice
39
Table 2: Frequency and percentage of reported sexual abuse.
Type of abuse N %
Incest 11 26,2
Sexual intimidation 4 9,5
Rape 3 7,2
Marital rape 9 21,4
Sexual harassment 5 11,9
Unknown 10 23,8
Total 42 100.0
Tabel 3: Number of domains with complaints of patients with or without sexual abuse.
Domains
Group I
(Abused +)
Group II
(Abused -) n p-value
1
3
(7.2 %)
25
(17.5 %)
28
(15.1 %)
2
4
(9.5 %)
49
(34.2 %)
53
(28.7 %)
3
35
(83.3 %)
69
(48.3 %)
104
(56.2 %)
Total
42
(100 %)
143
(100%)
185
(100%)
<0.001
Domains: number of domains of the pelvic oor with complaints
Abused +: number of patients with a history of sexual abuse
Abused -: number of patients without a history of sexual abuse
40
Chapter 3
DISCUSSION
A sexual abuse prevalence of 23% at our outpatient academic pelvic oor center
is comparable to earlier published data, in which a prevalence of 4 - 38% has
been described (3;17-24). Kellogg reported a child sexual abuse prevalence of 12 -
25% (1). In a prevalence study in a gynecologic outpatient clinic of a large urban
teaching hospital, Peschers et al. reported that one fth of the patients (20.1%)
had been forced to engage in sexual activities (21).
Many studies have shown that sexual abuse might lead to a variety of symptoms
in one domain of the pelvic oor (3-6;9-11;17;21;22;25-30). To our knowledge,
this is the rst publication about the relationship of complaints of micturition,
defecation and sexual dysfunction related to the pelvic oor dysfunction and a
history of sexual abuse. Our study demonstrated a signicantly higher rate of
sexually abused women with complaints in the three domains of the pelvic oor
compared to women with complaints in fewer domains. One of the limitations
of this study is that we only included dyspareunia as a sexual dysfunction
issue. In 2005 the Pelvic Floor Clinical Assessment Group of the International
Continence Society described the domains of the pelvic oor including also
pelvic pain and pelvic organ prolaps (31). Our study was started in 2004, so we
did not include pelvic pain and a more specic denition of sexual dysfunction.
Nor did we specify the type of sexual behavior that occurred during the abuse in
genital penetration vs. touch or forced oral sex. Another limitation of our study
is that our sample is self-selected. Therefore more patients with complaints of
micturition, defecation and/or sexual dysfunction related to the pelvic oor
dysfunction can be found in our research population. We believe that if this
study would be performed in a urological, gynaecological, gastroenterological, or
surgical outpatient oce, the dierence may be even more signicant, because
the probability of selection is much lower.
The fact that only 28 out of 185 of the women had only a single complaint could
indicate that having only a single complaint is rare. We believe that this is the
result of a selection bias, because referrers think of a pelvic oor dysfunction
sooner in patients with multiple pelvic oor complaints. Certainly, we have not
demonstrated that women with pelvic oor problems have a higher prevalence
of sexual abuse than women in the general population, based on our small self-
selected sample. Another limitation is that instead of studying two large cohorts,
one of sexual abused women and non abused controls, and then looking at pelvic
oor domains, we used two groups which are already a pathological sample —
women who went to a pelvic oor clinic with at least one pelvic oor problem.
There is no real control group since both groups have already pathology.
Women forced to engage in oral sex with a perpetrator may have very dierent
sexual problems compared to women who had forced intercourse. Additionally, a
Female sexual function in urological practice
41
sexual abuse experience that includes fondling is very dierent from a sexual abuse
that includes intercourse, and can have a dierent impact for the functioning
of the pelvic oor. So, analyzing sexual abuse as a homogenous experience can
inuence the outcome of the study. The importance of discussing abuse before
performing a gynaecological examination is clear. Survivors of sexual abuse rated
the gynaecological care experience more negatively than the controls, experienced
more intensely negative feelings, and reported being more uncomfortable during
almost every stage of the gynaecological examination than the controls. Survivors
also reported more trauma-like responses during the gynaecological examination,
including overwhelming emotions, intrusive or unwanted thoughts, memories,
body memories, and feelings of detachment from their bodies (32-36). Physicians
should also consider that any kind of gynaecological examination in these women
may trigger a ashback of the primary situation and retraumatize the concerned
women (37). Farley et al. demonstrated a decreased probability of screening for
cervical cancer at women who have been sexually abused, indicating that women
who have been sexually abused tend to avoid routine gynaecological care (38).
The clinical signicance of the ndings in this study suggests that a holistic view
is needed in the treatment of pelvic oor dysfunction treatment and all domains
need to be assessed in a questionnaire as early as possible during history taking,
as was already described by Devroede (39). A hypothesis for complaints in more
domains in the abused group could be that they are related to a general pelvic
oor disorder. This disorder is probably related to a overactive rest tone of the
pelvic oor (15;40).
For example, Leroi et al. reported that patients with a history of sexual abuse have
a signicantly more disturbed anorectal motility and a increased resting pressure
at the lower part of the anal canal compared to non-abused patients with anismus
(7).
The pelvic oor comprises several layers: from supercial to deep, the supportive
connective tissue of the endopelvic fascia, the pelvic diaphragm (levator ani
and coccygeus muscle), the perineal membrane (urogenital diaphragm) and the
supercial layer (bulbospongiosus, ischiocavernosus and supercial transverse
perineal muscles) (12;40). The iliococcygeus, pubococcygeus, and puborectal
muscles make up the levator ani muscle and play an important role in prevention
of pelvic organ prolapse and incontinence. The perineal membrane is a brous
muscular layer directly below the pelvic diaphragm. The current concept is that
the muscular contents of this layer are formed by the distal part of the external
urethral sphincter muscle (compressor urethra and urethrovaginalis part of the
external urethral sphincter). The bulbospongiosus and ischiocavernosus muscles
of the supercial layer also have a role in sexual function, while the supercial
transverse perineal muscle has a supportive role. Pelvic oor muscle contraction
presumably involves contraction of these muscles groups (41-43). We conclude that
42
Chapter 3
sexual abuse survivors may have a dysfunction of the aforementioned muscles,
giving rise to urological complaints, gastro-intestinal complaints and/ or sexual
dysfunction. Perhaps pelvic oor hypertonus may be related to state or trait
anxiety, developed as a holding pattern or defense mechanism. However, there
is no literature to support this idea. This issue should be explored further in the
future, and investigators should assess and describe their ndings in both women
and men, with pelvic oor dysfunction and sexual abuse, in relation to complaints
of micturition, defecation, sexual dysfunction and/or pelvic pain syndrome.
CONCLUSIONS
Twenty-three percent of the female patients in a pelvic oor center reported
a history of sexual abuse. In our sample, patients with multiple pelvic oor
complaints related to pelvic oor dysfunction are more likely to have a history of
sexual abuse than patients with isolated complaints. Further research is needed
to assess the impact of pelvic oor dysfunction and sexual abuse in relation to
complaints of micturition, defecation and/or sexual dysfunction.
43
Female sexual function in urological practice
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Recognition and Management. J Reprod.Med. 1995;40(1):13-8.
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40. Bartram, C. I., Knolmayer, G. O. L, and Delancey, J. O. L., Imaging Pelvic Floor
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46
47
CHAPTER 4
How reliable is a self administered
questionnaire in detecting sexual
abuse: a retrospective study in
patients with pelvic oor complaints
and a review of literature
Based on:
Elzevier HW, Voorham- van der Zalm PJ, Pelger RCM: How reliable is a self
administered questionnaire in detecting sexual abuse: a retrospective study
in patients with pelvic-oor complaints and a review of literature. J Sex Med
2007;4:956-963
48
Chapter 4
INTRODUCTION
Female Sexual Dysfunctions (FSDs) are very prevalent and multifaceted
problems, but are under-recognized and under treated (1). Sexual abuse, a
signicant contributing factor to sexual dysfunction, may even be more dicult
to discuss with patients than the sexual problem itself. It is of utmost importance
to recognize sexual abuse because of its impact not only on gynaecological
complaints but on pelvic oor complaints in general. However, there is little data
available regarding the superiority of one method over another in detecting sexual
abuse. We wondered if a self-administered questionnaire designed for pelvic
oor complaints would be comparable in terms of suitability and reliability to a
questionnaire administered by a dedicated clinician to detect sexual abuse in daily
practice.
In a study of health care practitioners and gynaecologist routine screening for
sexual abuse was mentioned to be rare (respectively 1,3 and 0,5%) (2;3).
The prevalence of sexual abuse depends on the underlying denition and research
population. The incidence in general population of child sexual abuse is 8-32%
(4-15), in gynaecological and obstetric care 10-20% (3;14;16-18) and 19,4-27,5%
in pelvic pain patients (19-21). One of the major problems in studies on sexual
abuse is the lack of agreement on the denition and description of sexual abuse,
like child abuse, rape or intimate partner abuse. Child abuse can be dened as
any activity with a child before the age of legal consent that is for the sexual
gratication of an adult or a substantially older child (22). These activities include
oral-genital, genital-genital, genital-rectal, hand-genital, hand-rectal, or hand-
breast contact; exposure of sexual anatomy; forced viewing of sexual anatomy; and
showing pornography to a child or using a child in the production of pornography.
In a recent study of Banyard et al child sexual abuse victims reported a lifetime
history of multiple exposures to various trauma and higher levels of mental
health symptoms (23). The distress outcome may be diverse. Sexual violence is
associated with lower rates of cervical cancer screening (24) and increased risk of
posttraumatic stress disorder (PTSD) (25;26) and depression (27). Already in 1993
a good overview of the problems related to this subject was given by The Panel on
Research on Child Abuse and Neglect (28).
The interest in sexual dysfunction also increases the focus on symptoms and
patterns associated with sexual problems in relation to pelvic oor complaints.
Klevan et al conclude that urinary tract symptoms following sexual abuse are
common (29). In this study 20% of the victims of sexual abuse complained of
one or more genitourinary symptoms. Davilla et al conclude that sexual abuse
survivors have a signicantly higher incidence of genitourinary dysfunction
symptoms, including stress and urge incontinence, and voluntary urinary
retention (30). In this study 72% of the survivors of abuse reported ever
Female sexual function in urological practice
49
experiencing urinary incontinence symptoms. Recently Jundt et al reported
signicantly more women (30.6%) with overactive bladder had been previously
physically and/or sexually abused than women with stress urinary incontinence
(17.8%) and of the control group (17.5%) (31). Also women with chronic pelvic pain
were found to have a higher lifetime prevalence of sexual abuse (19;32-34). The
inuence of early sexual abuse on later adult sexual functioning has been found
to pertain in particular to problems in desire, sexual arousal and orgasm (35-37).
Sarwer et al, found that childhood abuse involving sexual penetration or the use
of physical force, was related to adult sexual dysfunction (38). Meston et al showed
that the relationship between child sexual abuse and negative sexual aect was
independent from symptoms of depression and anxiety, suggesting that the impact
of child sexual abuse on sexual self-schemas may be independent from the impact
that the abuse may have in other areas of the survivor’s life (39). In a review article
on factors predisposing women to chronic pelvic pain by Latthe et al, sexual abuse
was associated with dyspareunia and also to non-cyclical pelvic pain (40).
The importance of discussing abuse before performing a gynaecological
examination is clear. Survivors of sexual abuse rated the gynaecological care
experience more negatively than the controls, experienced more intensely
negative feelings, and reported being more uncomfortable during almost every
stage of the gynaecological examination than the controls. Survivors also reported
more trauma-like responses during the gynaecological examination, including
overwhelming emotions, intrusive or unwanted thoughts, memories, body
memories, and feelings of detachment from their bodies (41-45). In the study of
Robohm et al, eighty-two percent of the survivors had never been asked about
a history of sexual abuse or assault by the gynaecological care provider (41). The
importance of asking about sexual abuse was clearly illustrated by Davy in relation
to endoscopic procedures (46) and Schachter et al in relation to physical therapists
(47). It should be pointed out that her work refers to general physiotherapy and
not pelvic oor practice suggesting how much more relevant it is in pelvic oor
physiotherapy practice.
Physicians should also consider that any kind of gynaecological examination in
these women may trigger a ashback of the primary situation and retraumatize
the concerned women (48).
Our institute has recently developed and validated the Pelvic Floor Leiden
Inventories (PelFIs), a 144 items new condition-specic pelvic oor assessment
questionnaire, in an attempt to increase the quality of care and to get more
uniformity in pelvic oor physiotherapy practice. During the validation of the
PelFIs in the total population with and without pelvic oor complaints a high
percentage (13,3%) of sexual abuse was reported .
A selection of patients has been evaluated in our Pelvic Floor Center. This
outpatient Pelvic Floor Center is a specialized part of our Urological department
50
Chapter 4
and consist a surgeon, gynecologist, urologist and a pelvic oor physiotherapist.
Routinely all new patients were sent in advance a voiding dairy and a
questionnaire on pelvic oor complaints to be completed at home and discussed
at the rst visit of our Pelvic Floor Center. This questionnaire contains questions
on defecation, lower urinary tract symptoms, obstetric information and also
sexual complaints. One of the questions is about sexual abuse.
We were interested how reliable this standard self-administered questionnaire is
in detecting the number of patients admitting sexual abuse.
MATERIALS AND METHODS
From June 2005 to August 2006 during the validation of a new administered
questionnaire (PelFIs) by a pelvic oor physiotherapist 26 out of 81 patients (32%)
admitted sexual abuse.
We retrospectively evaluated if these patients had visited our Pelvic Floor Center
in an earlier phase. In this center a self-administered pelvic oor questionnaire is
standard of care before visiting our Pelvic Floor Center. The questionnaire is sent
by mail and returned by the patient on its rst visit. It appeared that 20 out of 26
patients had completed this standard self-administered pelvic oor questionnaire.
The other 6 abused female patients that had completed the PelFIs were excluded
because they had not been evaluated at the Pelvic Floor Center before, but had
been evaluated at the department of Urology.
This self-administered questionnaire is not a validated pelvic oor questionnaire,
but is used for eciency and consists out of ve parts. Part 1 contains nine
questions on lower urinary tract symptoms (urgency, frequency, incontinence,
urinary tract infections), part 2 four questions on gynecological complaints
(prolaps, abdominal pain, delivery), part 3 two questions on defecation, part 4
questions on medical and surgical history related to pelvic oor complaints and
part 5 four questions on sexual function (Table 1).
The PelFIs is a 144 item questionnaire administered by a pelvic oor
physiotherapist and consists of 6 parts. Part 1 contains thirty-seven questions on
general health, part 2 thirty-seven questions on lower urinary tract symptoms,
part 3 thirty-three questions on defecation, part 4 nineteen questions on
gynaecological complaints, part 5 nine questions on pelvic pain and part 6 nine
questions on sexual function (Table 1).
Female sexual function in urological practice
51
Table 1: summery of described questions
Domain self-administered questionnaire PeLFIs
Questionnaire
Time
General Health
LUTS
Gynecology/
prolaps
Defecation
Pain
Sex
Total
5-10 min
7
9
3
2
3
1. Do you have a sexual partner?
(Male, Female, None)
2. Do you have sexual complaints? (Yes, No)
3. If yes,
- do you experience urine lost during intercourse?
(Yes, No)
- do you experience pain during intercourse? (Yes,
No)
4. Did you have negative sexual experience in the
past?
- if you would like to give a comment, you can
write it underneath
28
20-30 min
37
37
19
33
9
1. Do you have sexual intercourse? (Yes, No)
2. Pain during intercourse? (Yes, No)
3. If yes,
- during introduction of the penis
- deep penetration of penis
4. Do you have sexual problems because of your
pelvic floor complaint? (Yes, No)
5. If yes,
- urine lost during intercourse
- urine lost during orgasm
- stools during intercourse
6. Did you have negative sexual experience in the
past? (Yes, No)
7. If yes, did you have therapy for it? (Yes, No)
8. Can you deal with it now? (Yes, No)
9. If not, do you want therapy? (Yes, No)
144
PeLFIs = Pelvic Floor inventories Leiden; LUTS = Lower Urinary Tract Symptoms
52
Chapter 4
At our Pelvic Floor Center one single physiotherapist with almost two decades
of experience on pelvic oor treatment and skills in recognizing sexual abuse has
been administering the PelFIs. We reviewed the self-administered questionnaires
of all patients who admitted sexual abuse during the PelFIs by the pelvic oor
physiotherapist. Patients with sexual abuse were oered sexual treatment by an
urologist with a sexual education.
We tried to evaluate the reliability of the self-administered questionnaire
in detecting sexual abuse using the PelFIs as “gold standard”. Because both
questionnaires are used routinely in our clinic we did not need institutional
review board approval for this evaluation.
RESULTS
20 Patients admitting sexual abuse during administration of the PelFIs had
visited our Pelvic oor Center in earlier phase and completed a self-administered
questionnaire. At rst consultation the mean age of these 20 patients was 44,5
year (range 19-68 years). Only 6 of them (30%) with a mean age of 50,2 year (range
38-68 years) noted in the self-administered questionnaire they did not have a
history of sexual abuse, but later on admitted sexual abuse during administration
of the PelFIs. Sexual child abuse was reported in 13 out of the 20 patients, 6
patients reported a history of rape and 1 intimate partner abuse. 13 Out of the 14
patients, with a mean age 42,1 year (range 19-63years), who completed the self-
administered questionnaire described the type of sexual abuse: sexual child abuse
(8), rape (4) or intimate partner abuse (1). The only patient who did not describe
the kind of sexual abuse later admitted she had been the victim of sexual child
abuse.
DISCUSSION
A history of sexual abuse is a common problem in pelvic oor practice (18;29-
31;49-56). The pelvic oor not only contains pelvic visceral organs within the
pelvic cavity; it also controls individual and integrated functions, sustains proper
anatomic relationships, and shares the basic mechanism with various visceral
organs that control their function. The pelvic oor is the binding element
between these organs. Although pelvic oor dysfunction has long been related
to the lower urinary tract and, more recently to lower gastrointestinal symptoms
also, it is now considered to be an inuential factor in the normal function and
behavior of the genital system in both men and women (57). Devroede described
the pelvic oor as a muscular structure, pierced by the urological, genital and
Female sexual function in urological practice
53
distal intestinal tract (58). Normal function can be replaced by dysfunctions of
several kinds, overlapping voiding, sexual, genital and defecatory behaviour. He
already mentioned that if the pelvic oor was not considered as an integrated
muscular structure, unsuspected pathology would lie outside the spectrum of
activities of the given speciality. Thus, in relation to pelvic oor complaints, it is
important to evaluate sexual function in general (59), including abuse,. Bachmann
(60) recently published a study to obtain pilot data on physicians’ knowledge,
perceptions, and practices regarding FSDs, which may help uncover means
of facilitating future dialog between physicians and patients. A total of 1,946
survey physicians and other health professionals used a self-administered reply
questionnaire. Most respondents (60%) estimated that one- to three-quarters of
their patients had FSDs. Low sexual desire was the most prevalent FSD observed.
A total of 58% of participants reported initiating the rst discussion of FSDs in
one-quarter or less of patients. Obstacles to discuss sexual health included limited
time and training, embarrassment, and absence of eective treatment options. She
concluded that healthcare professionals are aware of the high prevalence of FSDs
but infrequently initiate a discussion of sexual function with their female patients
or fail to conduct a comprehensive evaluation for FSDs. In discussing sexual
dysfunction sexual abuse is probably a more delicate topic to address.
A study of MacMillan et al about a maltreatment history in childhood using
a self-administered questionnaire , concluded that child abuse may be more
prevalent in younger women compared with older women, or there may be a
greater willingness among younger women to report abuse (12). The women in our
study who admitted abuse in the self-administered questionnaire had a mean age
of 42,1 year. The patients who did not report sexual abuse in the questionnaire
had a mean age of 50,2 year. Although the number of patients (n=20) is too small
to make conclusions on age dierence between the two groups. It might indicate
the older the patient the less sexual abuse is reported in a self-administered
questionnaire. Marital status (in both groups 50% was maried), history of
psychological counseling in the past did not inuence the womens decision to ll
in the self-administered questionnaire.
“Did you have negative sexual experiences in the past” used in the questionnaire
is of course not equal to “did you experiences sexual abuse in the past” but in
the Dutch language it is considered to be almost similar. This is conrmed by
the responses of patients: all patients admitted abuse and 13 out of 14 patients
described the type of negative sexual experience as sexual abuse.
How forthcoming a patient is about his or her medical, sexual, and sexual
abuse history may strongly be inuenced by the level of comfort created by the
physician taking the history. Particularly, discussing a history of sexual abuse
or sexual assault with a patient is usually emotionally very dicult. This raises
the question whether patients are more forthcoming when completing a self-
54
Chapter 4
administered questionnaire or talking to a physician. In this study 20 patients
reported sexual abuse during administration of the PelFIs by a physiotherapist.
14 Out of these 20 patients (70%), completed the sexual abuse question admitting
sexual abuse in the routine questionnaire before visiting our outpatient Pelvic
Floor Center and talking to a physician. This high percentage of patients
admitting sexual abuse during the self-administered “screening” questionnaire
raises the question: “is a concerned physician needed in detecting abuse?” Or is
the anonymous self-administered questionnaire avoiding a face to face contact
with a physician “safer” and less embarrassing for the patient reporting sexual
abuse.
This is in contrast to the conclusion of the study of Nusbaum et al describing
women to be more prone to discuss sexual issues with physicians who appear to
be concerned, comfortable, and informed about FSDs (61). The rate of women
reporting sexual abuse to a physician varies between less than 2% (62) to 28% (63).
Although the response to the question on sexual abuse was 70% in the self-
administered questionnaire compared to the administered questionnaire by a
female physiotherapist, it still may be very helpful in daily practice in order to
detect sexual abuse.
This raises the question if gender of the therapist inuences the outcome of the
study. In literature regarding this subject “the sex of the therapist” the gender of
the therapist was not a major problem (64-66). Kaplan stated that: “the question
of therapist gender and its eect on therapy with women highlights an issue of
therapist self-awareness and growth rather than one of the patient’s selection
process” (64). Probably, the therapist’ sensitivity and value system regarding the
sexual abuse issue, is the most important factor.
In general physicians cite many barriers to ask women about sexual abuse,
including lack of time and resources of support, fear of oending women, lack of
training, fear of opening the “Box of Pandora”.
It is clear considering the impact of sexual abuse on the pelvic oor; sexual abuse
is an import issue in routine pelvic oor care. However, the practice of a universal
screening warrants further investigation. As Garcia-Moreno indicated it is not
feasible in certain settings and may even be dangerous if caregivers lack sucient
training to ensure women’s safety during and after disclosure (67).
Physicians that are uncomfortable with this topic and do not feel qualied
enough to deal with the responses they might receive or observe ongoing distress
in there patients should refer these women to clinicians that are familiar with
these issues (68).
Essential is appropriate medical education and training in order to improve in
women the identication and management of FSDs including sexual abuse,
realizing we still have a long way ahead of us (60;69-73).
We acknowledge several limitations of our study. This study relies exclusively
Female sexual function in urological practice
55
on data of women evaluated in an outpatient Pelvic Floor Center. Moreover,
it is unclear if our sample is representative for other Pelvic Floor Centers. We
know that the percentage of 32% of sexual abuse is higher than was seen at
our Department of Gynaecology. In a study of 325 patients at our outpatient
Gynaecology Department in 1996, 15.4% reported sexual abuse and 7.4% physical
molestation (74).
Also is important to mention the cultural context in which the study took place.
Only patients who were able to understand and read the Dutch language could
be included. This excludes a part of the not Dutch-speaking immigrants. In that
matter we need more questionnaires in dierent language to optimizing the
likelihood of disclosure.
How forthcoming a patient is about his or her medical history, history of sexual
and sexual abuse may strongly be inuenced by the level of comfort provided by
the physician taking the history. Our physiotherapist with almost two decades
of experience on pelvic oor treatment and skills in recognizing sexual abuse has
been administering the PelFIs. This could have had a positive impact on the level
of detection. Also the impact of screening needs to be addressed. Screening is
only possible in a setting with caregivers with sucient sexual training. Although
screening may be a helpful tool in detecting abuse and may give both patients and
physicians comfort as illustrated in the studies of Brown et al describing abuse
screening in the family practice setting (75;76).
Further research is needed to conrm our ndings in other patient groups and
to determine the threshold for admitting sexual abuse during interviews or self-
administered questionnaires. Another important issue that needs to be addressed
is the explanation of the relationship between sexual abuse and pelvic oor
complaints.
CONCLUSION
In our opinion the interaction of a patient and clinician during the administration
of a questionnaire is essential in order to gain the patients’ trust and thus acquire
a true perspective of past or prevalent sexual abuse and FSDs. We believe
that a questionnaire administered by a clinician should be preferred to a self-
administered questionnaire. However, in order to recognize sexual abuse a self-
administered questionnaire can still be helpful and thus may oer healthcare
physicians a helping hand in dealing with sexual abuse of their female patients in
daily practice.
56
Chapter 4
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64. Kaplan, A. G. Female or Male Therapists for Women Patients: New Formulations. Psychiatry
1985;48(2):111-21.
65. Mogul, K. M. Overview: the Sex of the Therapist. Am.J.Psychiatry 1982;139(1):1-11.
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Chapter 4
66. Zlotnick, C., Elkin, I., and Shea, M. T. Does the Gender of a Patient or the Gender of a
Therapist Aect the Treatment of Patients With Major Depression? J.Consult Clin.Psychol.
1998;66(4):655-9.
67. Garcia-Moreno, C. Dilemmas and Opportunities for an Appropriate Health-Service
Response to Violence Against Women. Lancet 4-27-2002;359(9316):1509-14.
68. Bachmann, G. A., Moeller, T. P., and Benett, J. Childhood Sexual Abuse and the
Consequences in Adult Women. Obstet.Gynecol. 1988;71(4):631-42.
69. Rosen, R., Kountz, D., Post-Zwicker, T., Leiblum, S., and Wiegel, M. Sexual Communication
Skills in Residency Training: the Robert Wood Johnson Model. J.Sex Med. 2006;3(1):37-46.
70. Marwick, C. Survey Says Patients Expect Little Physician Help on Sex. JAMA 6-16-
1999;281(23):2173-4.
71. Metz, M. E. and Seifert, M. H., Jr. Men’s Expectations of Physicians in Sexual Health
Concerns. J.Sex Marital Ther. 1990;16(2):79-88.
72. Tsimtsiou, Z., Hatzimouratidis, K., Nakopoulou, E., Kyrana, E., Salpigidis, G., and
Hatzichristou, D. Predictors of Physicians’ Involvement in Addressing Sexual Health Issues.
J.Sex Med. 2006;3(4):583-8.
73. Bitzer, J., Platano, G., Tschudin, S., and Alder, J. Sexual Counseling for Women in the
Context of Physical Diseases-a Teaching Model for Physicians. J.Sex Med. 2007;4(1):29-37.
74. van Lankveld, J. J., ter Kuile, M. M., Kenter, G. G., van Hall, E. V., and Weijenborg, P. T.
[Sexual Problems and Experiences With Sexual and Physical Violence in Gynecological
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903.
61
Female sexual function in urological practice
62
63
CHAPTER 5
Sexual function after
tensionfree vaginal tape (TVT) for
stress incontinence: results of a
mailed questionnaire
Based on:
Elzevier HW, Venema PL, Lycklama à Nijeholt AAB. Sexual function after
tension-free vaginal tape (TVT) for stress incontinence: results of a mailed
questionnaire. Int Urogynecol J 2004; 15: 313-318
64
Chapter 5
INTRODUCTION
The tension-free vaginal tape (TVT) is a relatively new procedure to correct
stress incontinence (1). Recent data indicate that its ecacy and untoward eects
are similar to those of the best of other commonly performed anti-incontinence
procedures, such as retropubic urethropexy (Burch) and suburethral sling
procedures (2;3). Genuine stress urinary incontinence (SUI) is dened as urinary
leakage due to a sudden increase in the intra-abdominal pressure through some
kind of physical stress, without evidence of bladder contractions and/or an
unstable urethra. Urinary incontinence during sexual intercourse is a common
symptom in patients with SUI (4-11). Sutherst et al. found that sexuality was
negatively aected in nearly half of women attending an incontinence clinic.
Women with genuine stress incontinence had signicantly fewer sexual problems
than those with bladder instability (9).
Studies on the eect of vaginal surgery for benign conditions on sexual function
are rare. The anatomical explanation for sexual dysfunction after vaginal surgery
may be due to the relation of the female urethra and the clitoris. The clitoris
consist of two corporal bodies and the glans clitoris, with a neurovascular bundle
dorsally and wide urethral plate ventrally. The distribution and course of the
neurovascular bundle of the clitoris is similar to that of the penis. The wide
urethral plate is adherent to the corporal bodies, causing ventral chordee (12).
OConnell et al. described the urethra as a pelvic and perineal conduit embedded
in the anterior vaginal wall but in all other directions surrounded by the erectile
tissue of the clitoris (13).
It is expected that sexuality would improve after TVT, particularly among those
patients who had either dyspareunia or leakage during intercourse. However, it is
also possible that TVT could be detrimental to sexual activity owing to surgical
damage. This retrospective study was undertaken to assess the eect on sexual
function of TVT procedures for stress urinary incontinence.
MATERIALS AND METHODS
From January 1999 to November 2002, 128 patients had a TVT inserted for the
treatment of SUI. Genuine stress incontinence was conrmed objectively by
urodynamic assessment. None of the women presented with detrusor or urethral
instability. On cystoscopy no pathological ndings were observed in the urethra
and/or bladder. Patients with a pelvic organ prolapse who needed more extensive
surgical treatment were excluded. All patients had had surgery at least 3 months
prior to this follow-up study, with a maximum of 1 year.
In the absence of a conventionally accepted sexual function index for women
Female sexual function in urological practice
65
with incontinence we evaluated our patients with the questionnaire developed by
Lemack et al. (14) (see Appendix). The questionnaire, as well as an introduction
letter stating the goal of the study, was mailed to all 128 patients. The McNemar
test was used for statistical analysis.
RESULTS
Of the 96 women who responded to the mailing, 69 were sexually active and 27
were not. Four sexually active patients were excluded, two had had no partner
before, and another had no partner after the TVT operation. One patient sent an
incomplete questionnaire. The reason for sexual inactivity in 27 patients is shown
in Table 1. The mean age of the 65 sexually active women was 50.5 years (range
36–77).
Table 1 Reason for sexual inactivity
n=27
No partner 12 (44%)
Partner-related issues 6 (22%)
Patient-related issues 3 (11%)
Both 4 (15%)
Not specified 2 (8%)
Mean age of sexually inactive women (yrs) 63 (46–77)
66
Chapter 5
Table 2 presents the surgical history of the sexually active women. Preoperative
characteristics are presented in rst column of Table 3. Most women had
intercourse once or twice a week (51%), or one to three times per month (30%).
Overall, 75% of women described intercourse before the operation as pleasurable.
Only three women reported dyspareunia preoperatively (5%). Thirty-ve women
reported preoperative leakage at some point during intercourse (54%).
Table 2 Abdominal or vaginal surgery before TVT in sexually active women
n=65
No surgery 38 (58%)
Surgery 17 (26%)
Abdominal hysterectomy 7
Vaginal hysterectomy 1
Stamey procedure 2
Raz procedure 1
Burch procedure 4
Caesarean section 5
Colporraphia anterior 1
Unknown 10 (16%)
Female sexual function in urological practice
67
Table 3 Results of questionnaire on intercourse before and after TVT in sexually active women
n= 65
Preoperative Postoperative
Frequency of
intercourse
More than twice/week 5 (8%) 5 (8%)
1–2 times/week 33 (51%) 32 (50%)
1–3 times/month 20 (30%) 20 (30%)
less than once/month 7 (11%) 8 (13%)
Sexual intercourse is
Pleasurable 49 (75%) 50 (78%)
Neither pleasurable nor
painful
13 (20%) 12 (17%)
Painful 3 (5%) 3 (5%)
Other 0 (0%) 0 (0%)
Do you experience
leakage during
intercourse?
No 30 (46%) 57 (88%)
Yes, rarely 4 (6%) 6 (9%)
Yes, occasionally 21 (32%) 0 (0%)
Yes, frequently 5 (8%) 1 (1,5%)
Yes, always 5 (8%) 1 (1,5%)
Postoperative data (Table 3) showed almost no dierence in frequency or
appreciation of intercourse. Dyspareunia remained in three women. One of them
noticed that pain was reduced after operation. Only six women (9%) reported
occasional leakage during intercourse. One patient had no benet from the TVT
operation and remained incontinent frequently during intercourse. One woman
described worsening of intercourse after the operation, describing an increase
in incontinence after TVT. The other women were postoperatively dry during
intercourse (88%). Overall, 17 women (26%) described intercourse as being better
than prior to surgery (Table 4). Seven of them stated that the absence of leakage
made intercourse more pleasurable. One of them reported vaginal narrowing as
the reason for better sexual intercourse.
68
Chapter 5
Table 4 Overall sexual appreciation after TVT in sexually active woman
n= 65
Overall, how would you
describe intercourse
postoperatively
Better than prior to surgery 17 (26%)
Worse than prior to surgery 1 (1%)
No different than prior to surgery 47 (73%)
Other 0 (0%)
Does your sexual partner
postoperatively report
a
Pain due to vaginal narrowing 3 (5%)
Narrowing but no pain 2 (3%)
Pain due to dryness or other 10 (15%)
Both narrowing and dryness 1 (1%)
None of the above 46 (71%)
Unknown 3 (5%)
a
Because these aspects were not well documented preoperatively, they are not compared with the preoperative
situation
The questionnaire contained also questions on the discomfort of the partner
postoperatively. Three women reported that their partner reported pain due
to vaginal narrowing. Pain due to dryness was described in 16%. Half of them
had mentioned complaints of dryness before the operation. These problems
subsided after using gel. One woman reported that her partner noted both vaginal
narrowing and dryness.
The McNemar test was used for statistical analysis and showed that the
improvement in sexual intercourse is highly signicant.
DISCUSSION
One of the rst publications on the eect of vaginal surgery for benign conditions
on sexual function was made by Iosif, who interviewed 156 patients before
and after colpocystourethropexy (7). Thirty-two percent of women with stress
incontinence had sexual problems before surgery. This proportion decreased after
surgery to 10%. Iosif had already stated that change of self-image, because of the
absence of urinary leakage during intercourse after the operation, might explain
Female sexual function in urological practice
69
the decrease in sexual dysfunction. Lemack et al. published a nice overview of
studies related to vaginal surgery and sexual function (15). In this study, 10 patients
underwent a modied four-corner bladder neck suspension, or anterior vaginal
wall suspension (AVWS), for the treatment of stress incontinence with or without
a mild to moderate cystocele. Overall, 20% of patients described intercourse
postoperatively better than prior to surgery. However, another 20% described it
as worse than prior to surgery. Although the number of patients is small, it points
to the potential of sexual problems related to vaginal surgery.
TVT was introduced into clinical practice in 1994–95. More than 150 000 TVT
operations have been carried out so far (1). Recently, Maaita et al. published the
rst retrospective results of TVT in relation to sexual function. Worsening of
sexual function after surgery was reported in 14% (16). In this study some patients
underwent combined procedures, and it could be that these patients had more
sexual problems after surgery. However, other studies showed that overall sexual
satisfaction appeared to be independent of diagnosis or therapy for urinary
incontinence or prolapse (17;18).
Only after specic operations, such as Burch colposuspension and posterior
colporrhaphy, did Weber et al. (19) nd an increased risk of dyspareunia.
In our study 26% of women described intercourse as better than prior to surgery.
Because the existence of the partners discomfort was scored only postoperatively,
we have no information on partners discomfort preoperatively. A relatively high
percentage of partner discomfort was mentioned in our study (24%).
Only a few patients stated that narrowing and dryness were due to the operation.
It is obvious that these aspects need to be addressed properly in a prospective
way to obtain a clear picture of partner discomfort.
Bearing in mind the anatomical relation of the erectile tissue of the clitoris
and the urethra, described by OConnell et al., operations in the vicinity of the
urethra, such as AVWS, may damage erectile tissue, which may explain up to
20% of sexual dysfunction after operation (20). The clitoris was well visualized
in an MRI study by Suh et al. (21). It looks as though the clitoral crus is the only
part of the clitoris that can be perforated during a TVT procedure. It is unlikely
that such interference occurs between the tape and the body of the clitoris,
because the tape is placed paraurethrally. This could explain the absence of sexual
dysfunction after TVT in this study.
Another issue in this respect might be the G-spot, a small area of erotic
sensitivity in the ventral vaginal wall, previously mentioned by Maaita et al.
In a recent study on vaginal electric activity by Shak et al., a pacemaker was
postulated to exist in the upper vagina. Thiswould seem to represent the G-spot
(22). If the G-spot is localized ventrally in the upper vagina it is not expected that
a TVT procedure would have any inuence on it.
Interesting is the presence and tissue distribution of PDE5 in the human vagina,
70
Chapter 5
recently published by DAmati et al. (23). This suggests the existence of an
integrated system of nitric oxide synthase-PDE5, which may play a physiological
role in female sexuality. Damage to this system could be an explanation for loss of
arousal after vaginal surgery, as reported by Maaita et al. (24).
It is clear that further investigation on the relation of AVWS or TVT to the
erectile tissue of the clitoris, as well as research into the role of PDE5, is needed.
CONCLUSION
This study highlights sexual function after TVT placement for genuine stress
incontinence. The majority of women described intercourse as better than
before the operation. In contrast to AVWS, no women reported intercourse to
be worse postoperatively, except for one patient with increased incontinence
postoperatively. Of the women 26% found intercourse better than prior to
surgery. This in contrast to the study of Maaita et al., who reported 14% sexual
dysfunction after TVT. Improvement often resulted from cessation of urinary
incontinence. It is clear that in studies like these, improvement in incontinence
and local surgical eects as potential opposing aspects need to be addressed
separately for their eects on sexual function. The potential impact of these
two aspects is dicult to distinguish. Also, proper attention should be paid
to the partner. Partner discomfort due to vaginal narrowing and dryness has
been reported in 25%. The possible causes for vaginal narrowing and dryness
require further investigation. In relation to urogynecologic surgery such as
TVT, prospective studies need to be done with validated global sexual function
questionnaires.
Acknowlegments
A special thanks to the following hospitals for including patients in our study:
Department of Urology and Gynaecology, Gemini Hospital Den Helder,
Department of Urology Medical Centre Alkmaar, and Department of Urology,
Ikazia Hospital, Rotterdam.
EDITORIAL COMMENT
The impact of urogynecologic surgery on sexual function is unclear. For those
who are incontinent with intercourse, cure of incontinence may improve sexual
activity at the price of potential damage to the vaginal anatomy. In this study
sexual function following the TVT procedure was evaluated. The authors
report that sexual frequency was overall unchanged, and many patients felt that
Female sexual function in urological practice
71
intercourse improved. It appears that much of this improvement is probably
related to cure of the incontinence rather than any specic features of the TVT.
Although the study is awed by its retrospective design and a long interval
between the procedure and the questionnaire, the results overall are reassuring.
72
Chapter 5
REFERENCES
1. Ulmsten, U. An Introduction to Tension-Free Vaginal Tape (TVT)--a New Surgical Procedure
for Treatment of Female Urinary Incontinence. Int.Urogynecol.J.Pelvic.Floor.Dysfunct.
2001;12 Suppl 2:S3-S4.
2. Liapis, A., Bakas, P., and Creatsas, G. Burch Colposuspension and Tension-Free Vaginal Tape
in the Management of Stress Urinary Incontinence in Women. Eur.Urol. 2002;41(4):469-73.
3. Nilsson, C. G., Kuuva, N., Falconer, C., Rezapour, M., and Ulmsten, U. Long-Term Results
of the Tension-Free Vaginal Tape (TVT) Procedure for Surgical Treatment of Female Stress
Urinary Incontinence. Int.Urogynecol.J.Pelvic.Floor.Dysfunct. 2001;12 Suppl 2:S5-S8.
4. Berglund, A. L. and Fugl-Meyer, K. S. Some Sexological Characteristics of Stress Incontinent
Women. Scand.J.Urol.Nephrol. 1996;30(3):207-12.
5. Clark, A. and Romm, J. Eect of Urinary Incontinence on Sexual Activity in Women.
J.Reprod.Med. 1993;38(9):679-83.
6. Hilton, P. Urinary Incontinence During Sexual Intercourse: a Common, but Rarely
Volunteered, Symptom. Br.J.Obstet.Gynaecol. 1988;95(4):377-81.
7. Iosif, C. S. Sexual Function After Colpo-Urethrocystopexy in Middle-Aged Women. Urol.Int.
1988;43(4):231-3.
8. Shaw, C. A Systematic Review of the Literature on the Prevalence of Sexual Impairment in
Women With Urinary Incontinence and the Prevalence of Urinary Leakage During Sexual
Activity. Eur.Urol. 2002;42(5):432-40.
9. Sutherst, J. and Brown, M. Sexual Dysfunction Associated With Urinary Incontinence. Urol.
Int. 1980;35(6):414-6.
10. Sutherst, J. R. Sexual Dysfunctional and Urinary Incontinence. Br.J.Obstet.Gynaecol.
1979;86(5):387-8.
11. Walters, M. D., Taylor, S., and Schoenfeld, L. S. Psychosexual Study of Women With
Detrusor Instability. Obstet.Gynecol. 1990;75(1):22-6.
12. Baskin, L. S., Erol, A., Li, Y. W., Liu, W. H., Kurzrock, E., and Cunha, G. R. Anatomical
Studies of the Human Clitoris. J.Urol. 1999;162(3 Pt 2):1015-20.
13. O’Connell, H. E., Hutson, J. M., Anderson, C. R., and Plenter, R. J. Anatomical Relationship
Between Urethra and Clitoris. J.Urol. 1998;159(6):1892-7.
14. Lemack, G. E. and Zimmern, P. E. Sexual Function After Vaginal Surgery for Stress
Incontinence: Results of a Mailed Questionnaire. Urology 8-1-2000;56(2):223-7.
15. Lemack, G. E. and Zimmern, P. E. Sexual Function After Vaginal Surgery for Stress
Incontinence: Results of a Mailed Questionnaire. Urology 8-1-2000;56(2):223-7.
16. Maaita, M., Bhaumik, J., and Davies, A. E. Sexual Function After Using Tension-Free Vaginal
Tape for the Surgical Treatment of Genuine Stress Incontinence. BJU Int. 2002;90(6):540-3.
17. Barber, M. D., Visco, A. G., Wyman, J. F., Fantl, J. A., and Bump, R. C. Sexual Function
in Women With Urinary Incontinence and Pelvic Organ Prolapse. Obstet.Gynecol.
2002;99(2):281-9.
Female sexual function in urological practice
73
18. Weber, A. M., Walters, M. D., and Piedmonte, M. R. Sexual Function and Vaginal Anatomy
in Women Before and After Surgery for Pelvic Organ Prolapse and Urinary Incontinence.
Am.J.Obstet.Gynecol. 2000;182(6):1610-5.
19. Weber, A. M., Walters, M. D., and Piedmonte, M. R. Sexual Function and Vaginal Anatomy
in Women Before and After Surgery for Pelvic Organ Prolapse and Urinary Incontinence.
Am.J.Obstet.Gynecol. 2000;182(6):1610-5.
20. Lemack, G. E. and Zimmern, P. E. Sexual Function After Vaginal Surgery for Stress
Incontinence: Results of a Mailed Questionnaire. Urology 8-1-2000;56(2):223-7.
21. Suh, D. D., Yang, C. C., Cao, Y., Garland, P. A., and Maravilla, K. R. Magnetic Resonance
Imaging Anatomy of the Female Genitalia in Premenopausal and Postmenopausal Women.
J.Urol. 2003;170(1):138-44.
22. Shak, A., El Sibai, O., Shak, A. A., Ahmed, I., and Mostafa, R. M. The Electrovaginogram:
Study of the Vaginal Electric Activity and Its Role in the Sexual Act and Disorders. Arch.
Gynecol.Obstet. 2004;269(4):282-6.
23. D’Amati, G., di Gioia, C. R., Bologna, M., Giordano, D., Giorgi, M., Dolci, S., and Jannini, E.
A. Type 5 Phosphodiesterase Expression in the Human Vagina. Urology 2002;60(1):191-5.
24. Lemack, G. E. and Zimmern, P. E. Sexual Function After Vaginal Surgery for Stress
Incontinence: Results of a Mailed Questionnaire. Urology 8-1-2000;56(2):223-7.
74
Chapter 5
APPENDIX
QUESTIONNAIRES
The next questions refer to the situation one year before operation
1 Were you last year sexually active? n yes n no
If you answered this question with no please answer next question.
If you answered yes, you can skip answer 2
2 This question refers to the reason why you werent sexually active before operation.
Was this the result of:
n Not having a partner
n Partner related problems as, for example, illness, impotence, age
n Patient related problems as, for example illness, age
n A combination of these factors
If you would you like to give an explanation, you can write it underneath
The reason for not being sexually active anymore was due to the next problems?
Incontinence during sexual intercourse n yes n no
Pain during sexual intercourse n yes n no
3 The next questions refer to sexual activity before the operation
A. Frequency of sexual activity with penetration
n More than 2 times a week
n 1–2 times a week
n 1–3 times a month
n less than once a month
B. Sexual activity with penetration is?
n Enjoyable
n Neither enjoyable nor painful
n Painful
75
Female sexual function in urological practice
C. Was there a question of incontinence, loss of urine during sexual intercourse?
n No
n Yes, but rarely
n Yes, occasionally
n Yes, frequently
n Yes, always
The next questions refer to the situation after the operation
4 Were you sexually active after operation?
n yes n no
If you answered this question with no please answer next question.
If you answered yes, you can skip answer 5
5 This question refers to the reason why you werent sexually active after operation
Was this the result of?
n Not having a partner
n Partner-related problems, for example illness, impotence, age
n Patient-related problems, for example illness, age
n A combination of these factors
If you would you like to give an explanation, you can write it underneath
The reason for not being sexually active anymore was due to the next problems?
Incontinence during sexual intercourse n yes n no
Pain during sexual intercourse
n yes n no
6 The next questions refer to sexual activity after the operation
A. Frequency of sexual activity with penetration
n More than 2 times a week
n 1–2 times a week
n 1–3 times a month
n less than once a month
B. Sexual activity with penetration is?
n Enjoyable
n Neither enjoyable nor painful
n Painful
76
Chapter 5
C. Was there a question of incontinence, loss of urine during sexual intercourse?
n No
n Yes, but rarely
n Yes, occasionally
n Yes, frequently
n Yes, always
7. How would you describe having sexual intercourse after the operation?
n Better than before the operation
n Worse than before the operation
n No dierence between before or after the operation
If you would you like to give an explanation, you can write underneath.
8. At last some questions for your partner (if applicable) concerning penetration
Did you experience pain during sexual intercourse
due to vaginal narrowing
n yes n no
There is question of narrowing but this is not painful
n yes n no
Pain because of dryness n yes n no
None of the above n yes n no
If there are other problems after the operation you can write it underneath.
9. Did you have other abdominal operations before this one? n yes n no
When the answer is yes would you write down which operations you had in the
past
77
Female sexual function in urological practice
78
79
CHAPTER 6
Female sexual function after surgery
for stress urinary incontinence:
Transobturator Suburethral Tape
(TOT) versus Tension-free Vaginal
Tape Obturator (TVT-O)
Based on:
Elzevier HW, Putter H, Pelger RCM, Delaere KPJ, Venema PL, Lycklama
à Nijeholt AAB Female sexual function after surgery for stress urinary
incontinence: Transobturator Suburethral Tape (TOT) versus Tension-free Vaginal
Tape Obturator (TVT-O) J sex Med 2008;5:400-406
80
Chapter 6
INTRODUCTION
The surgical treatment of female stress urinary incontinence (SUI) due to
urethral hypermobility has been profoundly changed a few years ago when
Ulmsten described a new concept in 1995: the Tension-free Vaginal Tape (TVT)
(1). To reduce the complications of the TVT, particularly with high-risk patients
like those who have been operated on before in the lower pelvis, an alternative
approach with a transobturator passage of the tape has been developed, the
transobturator suburethral tape (TOT) (2) not long there after the Tension Free
Vaginal Tape Obturator (TVT-O) (3).
TOT and TVT-O appear to be equally ecient as TVT for surgical treatment of
stress urinary incontinence in women at 1-year follow-up (4-7).
There are several studies dealing with the negative eects of urinary problems
on an individual’s sexual life (8-11). Problems related to urinary incontinence,
especially leakage during intercourse, wetness at night, odor and bedwetting,
have been associated with sexual dysfunction such as decrease in frequency of
coitus, anorgasmia and dyspareunia. The inuence non surgical (12;13) and surgical
treatment like TVT on sexual function has described before (14-20). Also the rst
results in relation to the TOT has been published (21;22). Only sexual function in
both TOT studies is a minor part of the Qol evaluation.
The aim of the present study was to assess the inuence of outside-in TOT
procedure and inside out TVT-O procedure for the surgical treatment of SUI, on
female sexual function.
MATERIALS AND METHODS
From January 2005 to December 2005, 78 sexual active patients had a TOT and
TVT-O inserted for treatment of SUI. Patients with a pelvic organ prolapse who
needed more extensive surgical treatment were excluded. The procedure was
performed according to the technique of Delorme or de Leval in two dierent
clinics with a long experience on incontinence surgery. We used a non-validated
sexual questionnaire developed by Lemack (23) translated in Dutch and a few
novel neuroanatomical questions (Appendix). The questionnaire, as well as an
introduction letter stating the goal of the study was mailed 3 to 4 months after
the procedure to the patients. The study was approved by our institutional review
board.
Dierences in percentages were evaluated using Pearson’s chi-square test. A two-
sided P-value of <0.05 was considered statistically signicant.
Female sexual function in urological practice
81
RESULTS
Introduction:
We evaluated 102 TVT-O and TOT patients. Only 78 of them (76,4%) were sexual
active. A total of 44 TOT (OB-TAPE Porges) patients (n=44, mean age 52.0 yr)
and 34 TVT-O patients (n=34, mean age 53.2 yr) could be included. All patients
completed the questionnaire 3 to 4 months after placement of the tape.
Postoperative TOT and TVT-O:
Almost no dierence in frequency of sexual intercourse and an improvement
of the continence during intercourse: continence was reported in 33 patients
(42,3%) before and 67 patients (78,4%) after operation. The appreciation of
sexual intercourse was improved in 15 patients (19.2%) and worsened in 8 patients
(10,3%). The appreciation of sexual intercourse was improved in 7 patients (20,6%)
and worsened in 2 patients (5,9%) in the TVT-O procedure and improved in 8
patients (18,2%) and worsened in 6 patients (13,6%) in the TOT procedure
(Table 1,2).
Postoperative TVT-O vs TOT:
Due to the operation, no dierence was seen in loss of lubrication, clitoral
tumescence reduction and clitoral sensibility reduction between both procedures.
Pain because of vaginal narrowing was seen signicantly more in the TOT
procedure group (Table 3).
82
Chapter 6
Table 1 Results of questionnaire on intercourse before and after TOT and TVT-O procedures in sexually active
women
N = 78
Preoperative Postoperative
Frequency of
intercourse
More than twice per week 10 (12.8%) 8 (10.3%)
One to two times per week 30 (38.5%) 28 (35.9%)
One to three times per month 31 (39.7%) 33 (42.3%)
Less than once per month 7 (9.0%) 9 (11.5%)
Sexual
intercourse
is
Pleasurable 64 (82.1%) 58 (74.4%)
Neither pleasurable nor painful 8 (10.3%) 10 (12.8%)
Painful 6 (7.7%) 10 (12.8%)
Do you
experience
leakage
during
intercourse?
No 33 (42.3%) 69 (78.4%)
Yes, rarely 11 (14.1%) 4 (5.1%)
Yes, occasionally 21 (26.9%) 4 (5.1%)
Yes, frequently 8 (10.3%) 0 (0%)
Yes, always 5 (6.4%) 1 (1.3%)
Table 2 Overall sexual appreciation after TOT and TVT-O procedures
Overall, how would you describe intercourse postoperatively?
OT TVT-O TOT
Frequency Percent Freq. Percent Freq. Percent
Better than prior
to surgery
15 19.2% 7 20.6% 8 18.2%
Worse than prior
to surgery
8 10.3% 2 5.9% 6 13.6%
No different than
prior to surgery
55 70.5% 25 73.5% 30 68.2%
Total (N) 78 34 44
OT = obturator tape; TVT-O = tension-free vaginal tape obturator; TOT = transobturator suburethral tape.
Female sexual function in urological practice
83
Table 3 Sexual function and vaginal anatomical changes after operation TVT-O vs. TOT
TVT-O TOT
P
N % N %
My lubrication during sexual activity is
less since the operation.
Yes 6 18.2 7 18.4
0.612
No 27 81.8 31 31
The sensibility of my clitoris is less since
the operation.
Yes 3 9.1 6 15
0.346
No 30 90.9 34 85
The tumescence (swelling) of my clitoris is
decreased by the operation.
Yes 2 6.1 6 15.8
0.181
No 31 93.9 32 84.2
Do you experience pain because of vaginal
narrowing due to the operation?
Yes 1 3 8 20.5
0.026
No 31 97 31 79.5
Since the operation, I don’t like to have
sex anymore. Is that true?
Yes 0 0 3 7.9
0.148
No 33 100 35 92.1
TVT-O = tension-free vaginal tape obturator; TOT = transobturator suburethral tape.
Partner evaluation
42 Of the TOT partners completed the partner questionnaire. No dierence
was seen in pain due to vaginal dryness pre and postoperative. 4 Partners (9.5%)
experienced vaginal narrowing after the operation. A total of 3 patients were able
to have intercourse without pain in spite of feeling the tape.
33 Of the TVT–O partners completed the partner questionnaire. No dierence
was seen in pain due to vaginal dryness. A total of 2 partners (6.1%) complained
about vaginal narrowing without pain. Only one partner noticed the tape during
intercourse and complained about pain due to the tape.
84
Chapter 6
DISCUSSION
Female sexual dysfunction (FSD) as a clinical term includes a variety of sexual
problems. Although 30%–50% of women suer from sexual dysfunction, only
recently has more medical and clinical research been focused on the problems
related to urological and gynecological operations (24;25).
During a TVT procedure theoretically the pelvic plexus branches, which
supply the blood vessels of the internal genitals and are involved in the neural
control of vasocongestion and, consequently, the lubrication-swelling response,
can be damaged. Also the pudendal nerve branches can be injured during this
procedure. In contrast, the TOT and TVT-O procedure have no relation to the
pelvic plexus branches. But there could be a relation to the pudendal nerve. As a
consequence, if there is an alteration of sexual function it probably will aect the
somatosensory pathway of the vulva. However, during recent anatomical studies
the tape was not disturbing the pudendal nerve (26;27).
In contrast to the anatomical studies we nd in our study detoration in
tumescence of the clitoris in 6.1% in TVT-O patients and 15.8% in TOT patients.
This outcome and also the changes in clitoral sensibility should be an important
issue for future studies.
Not only the innervation of the clitoris can be disturbed but the vaginal anatomy
as well. An altered vaginal anatomy as a result of vaginal surgery has described
before. Vaginal narrowing/shortening following posterior repair has been
reported to result in sexual dysfunction in 17% of the women surveyed (28). Also
colpoperineorrhaphy may result in dyspareunia due to narrowing of the vagina
(29).
The localization of the TOT or TVT-O tape could result in vaginal narrowing. In
this study vaginal narrowing was signicantly seen more in the TOT procedure
compared to the TVT-O procedure. The reason could be that more vaginal tissue
(perineal membrane) in the outside-in procedure is included and therefore more
vaginal narrowing is seen. Because of the question “Is sexual intercourse better
because of the reduction of urine loss during sexual intercourse” we know the
positive inuence of incontinence treatment on sexual function was 100% related
to the reduction of incontinence during intercourse. In the TOT study of Lukban
(30), 6% (n=33) of the patients concluded that they were less able to have a sexual
relationship. Also 14,9% of the patients experienced vaginal pain, pressure or
protrusion. These results are comparable with our study results of 12.5% pain
due to vaginal narrowing in the total population. It is interesting that in Lukban’s
study 33% of the patients was better able to have a sexual relationship and in 61%
it was about the same. In our study 19.2% described an improvement and 70.5%
no dierent than prior to surgery.
Compared to our TVT-study (31) more sexual problems were seen after TVT-O
Female sexual function in urological practice
85
and TOT procedures. In that TVT-study only 1 patient of 65 (1.5%) had more
problems during sexual intercourse because of increase of incontinence.
Some of the limitations of this study have to be discussed. The translated Lemack-
questionnaire and the neuroanatomical sexual questions we used are not validated.
One of the reasons was we wanted to compare the TOT/TVT-O data with our
TVT-study. On the other hand at this moment we do not have neuroanatomical
sexual questionnaires or questionnaires related to vaginal anatomy changes due
to vaginal surgery. Therefore we tried to introduce some more specic clitoral
function and vaginal anatomy questions. In our study vaginal narrowing was seen
in 19,5% of the TOT patient population. In the study of Weber et al the dierence
between patients’ perception and objective measures of vaginal dimensions after
prolaps or incontinence surgery is intriguing.
However, they could not correlate symptoms with objective changes in vaginal
length/caliber in those with sexual dysfunction after surgery. It is remarkable that
in our study 9.8% of the partners of the TOT group and 6.7% of the TVT-O
group also experience vaginal narrowing and a few noticed the tape during
intercourse.
The operations were performed in 2 dierent hospitals by 2 dierent surgeons,
this could give a bias. Therefore we asked two surgeons with a long experience
in incontinence surgery to perform the operation they prefered. The best way
to study female sexual function in relation to both procedures is a randomized
multicenter study, with enough power, as initiated by clinicaltrials.gov in relation
to TVT and TOT; the TOMUS study (Trial of Mid-urethral Slings - comparing
TVT to TOT).
The retrospective design, without baseline measurement, could be qualied
as limitation of the study as well, though we do not know the inuence of
prospective sexual function study itself on sexual behavior of the patients. Maybe
the questionnaire could have a positive input on sexual function. In the study
of Ghezzi et al (32), frequency of sexual intercourse signicantly increased in
contrast to other TVT studies. Maybe the frequency was increased to please the
investigating doctor in order to know if leakage during intercourse was still there
after the TVT procedure? The inuence of questionnaires itself on sexual behavior
has not been investigated before.
CONCLUSION
In this descriptive non-randomized cohort study 3-4 months postoperatively the
technique of TOT (outside-in) gave rise to more sexual dysfunction than TVT-O
(inside-out). However, because of the successful outcome on incontinence,
both procedures have overall a positive eect on sexual function. The possible
86
Chapter 6
cause of signicant more pain during intercourse after the TOT procedure as
a result of vaginal narrowing requires further investigation. In short, this study
demonstrated that TOT and TVT-O could have both a positive and a negative
outcome on sexual function and that it is of importance to discuss this issue in
the informed consent.
Female sexual function in urological practice
87
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4. Debodinance, P. Trans-Obturator Urethral Sling for the Surgical Correction of Female Stress
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Am.J.Obstet.Gynecol. 2004;190(3):602-8.
6. Dietz, H. P., Barry, C., Lim, Y., and Rane, A. TVT Vs Monarc: a Comparative Study. Int.
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7. Fischer, A., Fink, T., Zachmann, S., and Eickenbusch, U. Comparison of Retropubic and
Outside-in Transoburator Sling Systems for the Cure of Female Genuine Stress Urinary
Incontinence. Eur.Urol. 2005;48(5):799-804.
8. Sen, I., Onaran, M., Aksakal, N., Acar, C., Tan, M. O., Acar, A., and Bozkirli, I. The Impact of
Urinary Incontinence on Female Sexual Function. Adv.Ther. 2006;23(6):999-1008.
9. Shaw, C. A Systematic Review of the Literature on the Prevalence of Sexual Impairment in
Women With Urinary Incontinence and the Prevalence of Urinary Leakage During Sexual
Activity. Eur.Urol. 2002;42(5):432-40.
10. Coyne, K. S., Margolis, M. K., Jumadilova, Z., Bavendam, T., Mueller, E., and Rogers,
R. Overactive Bladder and Women’s Sexual Health: What Is the Impact? J Sex Med.
2007;4(3):656-66.
11. Coyne, K. S., Margolis, M. K., Brewster-Jordan, J., Sutherland, S. E., Bavendam, T., and
Rogers, R. G. Evaluating the Impact of Overactive Bladder on Sexual Health in Women:
What Is Relevant? J Sex Med. 2007;4(1):124-36.
12. Giuseppe, P. G., Pace, G., and Vicentini, C. Sexual Function in Women With Urinary
Incontinence Treated by Pelvic Floor Transvaginal Electrical Stimulation. J Sex Med.
2007;4(3):702-7.
13. Rosenbaum, T. Y. Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the
Role of Pelvic Floor Rehabilitation in Treatment: a Literature Review. J Sex Med. 2007;4(1):4-
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14. Elzevier, H. W., Venema, P. L., and Nijeholt, A. A. Sexual Function After Tension-Free
Vaginal Tape (TVT) for Stress Incontinence: Results of a Mailed Questionnaire. Int.
Urogynecol.J.Pelvic.Floor.Dysfunct. 2004;15(5):313-8.
15. Ghezzi, F., Serati, M., Cromi, A., Uccella, S., Triacca, P., and Bolis, P. Impact of Tension-Free
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Vaginal Tape on Sexual Function: Results of a Prospective Study. Int.Urogynecol.J.Pelvic.
Floor.Dysfunct. 6-23-2005.
16. Glavind, K. and Tetsche, M. S. Sexual Function in Women Before and After Suburethral
Sling Operation for Stress Urinary Incontinence: a Retrospective Questionnaire Study. Acta
Obstet.Gynecol.Scand. 2004;83(10):965-8.
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Tape for the Surgical Treatment of Genuine Stress Incontinence. BJU.Int. 2002;90(6):540-3.
18. Marszalek, M., Roehlich, M., Racz, U., Metzenbauer, M., Ponholzer, A., Rauchenwald, M.,
and Madersbacher, S. Sexual Function After Tension-Free Vaginal Tape Procedure. Urol.Int.
2007;78(2):126-9.
19. Mazouni, C., Karsenty, G., Bretelle, F., Bladou, F., Gamerre, M., and Serment, G. Urinary
Complications and Sexual Function After the Tension-Free Vaginal Tape Procedure. Acta
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20. Yeni, E., Unal, D., Verit, A., Kafali, H., Ciftci, H., and Gulum, M. The Eect of Tension-
Free Vaginal Tape (TVT) Procedure on Sexual Function in Women With Stress Urinary
Incontinence. Int.Urogynecol.J.Pelvic.Floor.Dysfunct. 2003;14(6):390-4.
21. Lukban, J. C. Suburethral Sling Using the Transobturator Approach: a Quality-of-Life
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22. Roumeguere, T., Quackels, T., Bollens, R., de Groote, A., Zlotta, A., Bossche, M. V., and
Schulman, C. Trans-Obturator Vaginal Tape (TOT) for Female Stress Incontinence: One
Year Follow-Up in 120 Patients. Eur.Urol. 2005;48(5):805-9.
23. Lemack, G. E. and Zimmern, P. E. Sexual Function After Vaginal Surgery for Stress
Incontinence: Results of a Mailed Questionnaire. Urology 8-1-2000;56(2):223-7.
24. Ghielmetti, T., Kuhn, P., Dreher, E. F., and Kuhn, A. Gynaecological Operations: Do They
Improve Sexual Life? Eur.J.Obstet.Gynecol.Reprod.Biol. 6-23-2006.
25. Elzevier, H. W., Nieuwkamer, B. B., Pelger, R. C., and Nijeholt, A. A. Female Sexual Function
and Activity Following Cystectomy and Continent Urinary Tract Diversion for Benign
Indications: a Clinical Pilot Study and Review of Literature. J Sex Med. 2007;4(2):406-16.
26. Achtari, C., McKenzie, B. J., Hiscock, R., Rosamilia, A., Schierlitz, L., Briggs, C. A., and
Dwyer, P. L. Anatomical Study of the Obturator Foramen and Dorsal Nerve of the Clitoris
and Their Relationship to Minimally Invasive Slings. Int.Urogynecol.J.Pelvic.Floor.Dysfunct.
10-7-2005;1-5.
27. Bonnet, P., Waltregny, D., Reul, O., and de Leval, J. Transobturator Vaginal Tape Inside
Out for the Surgical Treatment of Female Stress Urinary Incontinence: Anatomical
Considerations. J.Urol. 2005;173(4):1223-8.
28. Holley, R. L., Varner, R. E., Gleason, B. P., Apel, L. A., and Scott, S. Sexual Function After
Sacrospinous Ligament Fixation for Vaginal Vault Prolapse. J.Reprod.Med. 1996;41(5):355-8.
29. Haase, P. and Skibsted, L. Inuence of Operations for Stress Incontinence and/or Genital
Descensus on Sexual Life. Acta Obstet.Gynecol.Scand. 1988;67(7):659-61.
30. Lukban, J. C. Suburethral Sling Using the Transobturator Approach: a Quality-of-Life
Analysis. Am.J.Obstet.Gynecol. 2005;193(6):2138-43.
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89
31. Elzevier, H. W., Venema, P. L., and Nijeholt, A. A. Sexual Function After Tension-Free
Vaginal Tape (TVT) for Stress Incontinence: Results of a Mailed Questionnaire. Int.
Urogynecol.J.Pelvic.Floor.Dysfunct. 2004;15(5):313-8.
32. Ghezzi, F., Serati, M., Cromi, A., Uccella, S., Triacca, P., and Bolis, P. Impact of Tension-Free
Vaginal Tape on Sexual Function: Results of a Prospective Study. Int.Urogynecol.J.Pelvic.
Floor.Dysfunct. 6-23-2005.
90
Chapter 6
APPENDIX
QUESTIONNAIRES
1 Date of Birth
2 Operation date
3 Do you have menstruation
n Yes, regular (every 4 weeks)
n Yes, but not regular
n No, since a few months not anymore
n No, since more than 1 year not anymore
4 Did you have other abdominal or vaginal operation before the
incontinence operation n yes n no
4a If yes, please write down the kind of operation you have.
The next questions refer to the situation one year before operation
5 Were you last year sexually active? n yes n no
If you answered this question with no please answer next questions.
If you answered yes, you can go to answer 10
6 This question refers to the reason why you were not sexually active before operation.
Was this the result of:
n Not having a partner
n Partner related problems as, for example, illness, impotence, age
n Patient related problems as, for example illness, age
n A combination of these factors
6a If you would you like to give an explanation, you can write it underneath.
91
Female sexual function in urological practice
The reason for not being sexually active anymore was due to the next problems?
7 Incontinence during sexual intercourse n yes n no
8 Pain during sexual intercourse n yes n no
9 Lost of libido n yes n no
The next questions refer to sexual activity before the operation
10 Frequency of sexual activity with penetration
n More than 2 times a week
n 1–2 times a week
n 1–3 times a month
n less than once a month
11 Sexual activity with penetration is?
n Enjoyable
n Neither enjoyable nor painful
n Painful
12 Was there a question of incontinence, loss of urine during sexual intercourse?
n No
n Yes, but rarely
n Yes, occasionally
n Yes, frequently
n Yes, always
The next questions refer to the situation after the operation
13 Were you sexually active after operation? n yes n no
If you answered this question with no please answer next question.
If you answered yes, you can go to question 18
92
Chapter 6
This questions refers to the reason why you werent sexually active after
operation
14 Was this the result of?
n Not having a partner
n Partner-related problems, for example illness, impotence, age
n Patient-related problems, for example illness, age
n A combination of these factors
14a If you would you like to give an explanation, you can write it underneath
The reason for not being sexually active anymore was due to the next problems?
15 Incontinence during sexual intercourse
n yes n no
16 Pain during sexual intercourse
n yes n no
17 Lost of libido n yes n no
The next questions refer to sexual activity after the operation
18 Frequency of sexual activity with penetration
n More than 2 times a week
n 1–2 times a week
n 1–3 times a month
n less than once a month
19 Sexual activity with penetration is?
n Enjoyable
n Neither enjoyable nor painful
n Painful
20 Was there a question of incontinence, loss of urine during sexual intercourse?
n No
n Yes, but rarely
n Yes, occasionally
n Yes, frequently
n Yes, always
93
Female sexual function in urological practice
21 How would you describe having sexual intercourse after the operation?
n Better than before the operation
n Worse than before the operation
n No dierence between before or after the operation
If you answered the question with better please answer the next
question.
22 Is sexual intercourse better because of the reduction of
urine loss during sexual intercourse n yes n no
22a If there is another reason plaese write it underneath
If you answered the question with worse please answer the next
question.
23 Please give some comment why sexual intercourse is worsened
Sexual neuroanatomical questions
24 My lubrication during sexual activity is less since the operation n yes n no
25 The sensibility of my clitoris is less since the operation n yes n no
26 The tumescence (swelling) of my clitoris is decreased by the operation n yes n no
27 Do you experience pain because of vaginal
narrowing due to the operation n yes n no
28 Since the operation I don’t like to have sex anymore, is that true n yes n no
94
Chapter 6
Male questionnaire
The next questions refer to sexual activity before the operation
1 Did you experience pain during sexual
intercourse due to vaginal narrowing n yes n no
2 There is question of narrowing but this is not painful n yes n no
3 Pain because of dryness n yes n no
4 Vaginal dryness without pain n yes n no
The next questions refer to sexual activity after the operation
5 Did you experience pain during sexual
intercourse due to vaginal narrowing n yes n no
6 There is question of narrowing but this is not painful n yes n no
7 Pain because of dryness n yes n no
8 Vaginal dryness without pain n yes n no
9 Are there other problems after the operation:
10 Do you feel the tape during sexual intercouse n yes n no
11 If yes, is it painfull n yes n no
12 How would you describe having sexual intercourse after the operation?
n Better than before the operation
n Worse than before the operation
n No dierence between before or after the operation
12a If you want to give som comment on it please write it underneath
95
Female sexual function in urological practice
96
97
CHAPTER 7
Female Sexual Function and Activity
Following Cystectomy and Continent
Urinary Tract Diversion for Benign
Indications: A Clinical Pilot Study
and Review of Literature
Based on:
Elzevier HW, Nieuwkamer BB, Pelger RCM, Lycklama à Nijeholt AAB Female
Sexual Function and Activity Following Cystectomy and Continent Urinary Tract
Diversion for Benign Indications: A Clinical Pilot Study and Review of Literature.
J Sex Med 2007;4:406–416
98
Chapter 7
INTRODUCTION
In 1950 Bricker introduced the ureteroileal urostomy, which has become the
standard for urinary diversion during the last 55 years (1). Several studies have
indicated that, as a consequence of noncontinent diversions for faeces or
urine, patients restrict social and sexual activities (2-4). Techniques aiming for
continence after radical cystectomy (RC) for bladder cancer, e.g. continent
cutaneous urinary diversion and orthotopic bladder substitution have become
well-accepted alternatives to ileal conduit diversion in selected patients. The
advantages of a competent reservoir are a non-protruding “dry” stoma, intact
peristomal skin, absence of odor and no need for a collecting appliance.
Indications for cystectomy are mainly cancer, such as muscle invasive bladder
cancer and bladder inltrating malignancies or, in a minority, benign diseases
leading to progressive bladder dysfunction.
In women, RC and hysterectomy (5) may cause sexual dysfunction because the
neurovascular bundles, located lateral to the vaginal wall, are usually excised or
damaged by removal of the bladder, urethra and anterior vaginal wall. The pelvic
plexus, also called the “inferior hypogastric plexus”, consisting of aerent and
eerent sympathetic and predominantly parasympathetic autonomic nerves and
some sensory pudendal nerve branches, is supplying the network of pathways
innervating the rectum, uterus, vagina, vestibular bulbs, clitoris, bladder and
urethra. Centrally these nerves are derived from the sacral nerves (mainly
parasympathetic) connected to the superior hypogastric plexus and hypogastric
nerves (mainly sympathetic).
Theoretically, disruption of the pelvic plexus could lead to impaired vascular
function during sexual arousal and possibly a disordered orgasm. The pelvic plexus
supplies the blood vessels of the internal genitals and is involved in the neural
control of vasocongestion and, consequently, the lubrication-swelling response.
The innervation of the vaginal wall originates predominantly from the pelvic
plexus.
In addition, signicant devascularization of the clitoris often occurs with removal
of the distal urethra, aecting subsequently sexual arousal and desire. The
sensation of the external genitalia is not related to the pelvic plexus: pudendal
nerve branches are the somatosensory pathways for the vulva and clitoris.
Most of the literature on cystectomy and sexual function is cancer and male-
related. Female sexual function in relation to cystectomy for benign (non-
oncological) indications is rarely investigated (6-9). In the group of bladder
dysfunction patients, for example, interstitial cystitis, preoperative sexual
dysfunction may exist as a result of the disease. As mentioned, the cystectomy
itself may inuence sexual function as well (10). A simple cystectomy performed
for a benign indication could result in less neurovascular complications in
Female sexual function in urological practice
99
comparison to a RC (11).
Moreover, postoperatively female sexuality is not only inuenced by the surgical
technique as such, but also by other factors, such as impaired body image,
concomitant disease, hormonal inuences like menopause (12) and partnership.
Although it is dicult to separate all items, which could inuence sexual function
after cystectomy, it is important for the purpose of informed consent, to know
how patients with a continent diversion function sexually following cystectomy
for benign indications.
The aims of the present study on female sexual function was to describe the
impact of cystectomy and continent urinary diversion for benign indications
and to review literature investigating changes in women’s sexual function after
cystectomy.
MATERIALS AND METHODS
Between 1985 and 2004, cystectomy including bladder substitution was performed
in 27 female patients for a benign indication. In the early years a Kock pouch was
used (13;14), as a heterotopic diversion, later on an Indiana pouch (15). The Mainz
pouch technique (16) was used for orthotopic reconstruction or, depending on
surgeon’s preference, an ileal neobladder technique as described by Hautmann (17).
Patients were selected out of a database. All patients available for evaluation
were informed by telephone about the aim of the study. Following consensus a
questionnaire was sent .
Because of the retrospective nature of the questions about sexual function
we could not use the Female Sexual Function Index (FSFI) (18) to evaluate
sexual function before operation. Instead we asked patients if they had sexual
problems before operation and if the problems were pain, incontinence or libido
related. Furthermore, we asked if the patient was informed about the potential
consequences of the operation on her sexual function.
Postoperative sexual function was evaluated, in case of sexual inactivity, by
questions relating to the reason of sexual inactivity and FSFI. In sexually active
women, sexual function was assessed using the FSFI, and questions on overall
sexual appreciation following operation. (Appendix A)
Review has been performed by a search on pubmed with the key words:
cystectomy, bladder, sexuality, quality of life, female, female sexual function,
female sexual dysfunction, urinary diversion, ileal conduit, nerve-sparing.
100
Chapter 7
RESULTS
Of the total of 27 female patients, 2 had died and 2 were lost to follow-up. All
remaining 23 patients agreed to participate in the study. 21 Of the 23 patients
actually responded (91%) by returning the questionnaires and were available for
analysis. The mean age, at operation date, was 47.3 yr (range 25-66 yr) with a mean
follow-up of 11.9 years (range 3.08-20.33 yr) after the operation.
Preoperative data
Preoperative data are summarized in Table 1. Out of the 21 patients, 10 (48%) had
sexual complaints before operation. Most common complaints were incontinence
during intercourse (70%), pain (60%), and loss of libido (50%). Preoperatively,
four out of 21 patients (19%) were sexual inactive. Of these inactive patients, two
had sexual complaints, one had no partner and one patient was inactive because
of partner related problems.
In 70% of women sexual function was not discussed by the treating physician
prior to operation, one patient could not remember if she was asked about her
sexuality. The potential consequences on sexual function were discussed only in
38% of patients.
The indications for cystectomy and continent diversion are listed in Table 2.
Table 1 Preoperative: Sexual function and counseling data (n=21, mean age 47 year, range 25-66years)
Yes No
Asked about sexual function
Informed about consequences
operation on sexual function
Sexual problems before operation
Sexually active
Sexual problems before operation
due to (n=10):
Incontinence during sexual intercourse
Pain during sexual intercourse
Loss of libido
* One patient did not answer the question because she did
not remember.
6 (30%)
8 (38%)
10 (48%)
17 (81%)
7 (70%)
6 (60%)
5 (50%)
14 (70%)*
13 (62%)
11 (52%)
4 (19%)
3 (30%)
4 (40%)
5 (50%)
Female sexual function in urological practice
101
Tabel 2 Preoperative: bladder disease (n=21)
n %
Sexually active
postoperatively
(n)
Interstitial cystitis
Eosinofilic cystitis
Chronic infection bladder
Sensory-urge complaints
Neurogenic bladder
15
1
2
1
2
21
71.4
4.8
9.5
4.8
9.5
100
12
-
2
-
2
16
Operative data
The kind of cystectomy, with or without preservation anterior vaginal wall,
and diversions are listed in Table 3. A small part of the anterior vaginal wall was
resected in 3 women (14%), two of them received an Indiana pouch and one a
Kock pouch. The remaining patients underwent a simple cystectomy.
Tabel 3 Operative: technique of cystectomy and urinary diversion (n=21)
Operation n %
Preservation
anterior vaginal
wall (n)
Sexually active
postoperative
(n)
Kock pouch
Indiana pouch
Mainz pouch
Hautmann
6
8
3
4
21
28.6
38.1
14.3
19.0
100
5
6
3
4
18
5
4
3
4
16
102
Chapter 7
Postoperative data
Sexual activity:
Fourteen out of the 17 preoperatively sexually active patients are still sexually
active postoperatively (82%). Nine out of these 14 active patients still are active
at the present time. Two out of the four preoperative sexual inactive patients
became sexual active again, one because of reduction of incontinence and one
patient without a partner preoperatively started a relation. The mean age of the
16 postoperatively sexual active patients at the date of operation was 45.7 years
(range 25-65yr) with a mean follow-up of 12.8 years (range 3.08-20.08yr).
Sexual inactivity:
The reasons for sexual inactivity are shown in Table 4. The mean age of the ve
direct postoperatively sexually inactive patients at the date of operation was 52.7
years (range 46-66yr) with a mean follow-up of 9.2 years (range 4.3-20.3years).
Sexual inactivity developed in an extra ve patients during follow-up (mean age
at the date of operation 46 years (range 25-65years), mean follow up of 14.9 (range
8.08-20.08) years).
The most frequently reported reasons of sexual inactivity are patient-related
(30%) or combinations of patient- and partner-related issues (40%). The most
common complaints reported by sexually inactive women are: pain during
intercourse (50%), libido loss (40%) and impaired body image (30%). Two
patients reported vaginal narrowing, although an anterior vaginal wall resection
was not performed. The majority of sexually inactive patients, 7 out of 10
(70%), had already sexual complaints before operation. The other three patients
(30%) without sexual problems before operation reported having pain during
intercourse and loss of libido. Two of them complained about impaired body
image and one about vaginal narrowing making penetration impossible.
Female sexual function in urological practice
103
Table 4 Postoperative: reasons for sexual inactivity (n=10, mean age 52.7 year range 46-66years)
Postop
n = 5
Acquired
n = 5*
Total
n=10
Overall reason:
No partner
Partner-related issues
Patient-related issues
Both
Specified reason:**
Incontinence during sexual intercourse
Pain during sexual intercourse
Loss of libido
Impaired body image
My partner doesn’t want have sex with me anymore
Vaginal narrowing so penetration is impossible
* Sexually active postoperatively but not sexually
active at present time
** A patient can indicate one or more reasons
1
0
2
2
0
2
3
2
1
0
1
1
1
2
1
3
1
1
1
2
2 (20%)
1 (10%)
3 (30%)
4 (40%)
1 (10%)
5 (50%)
4 (40%)
3 (30%)
2 (20%)
2 (20%)
Perception of change in sexual function:
The overall sexual appreciation after operation is listed in Table 5. The majority of
the women (62.5%) described improved or unchanged intercourse after operation.
Of the improved patients, four had incontinence during sexual intercourse
before operation, two of them had had loss of libido and two had pain. Only two
patients had no sexual problems before operation. Six patients had a declined
sexual function after the operation, three became sexually inactive and three are
still sexually active. These three constitute 27% of the sexually active patients
at the present time, none of them having sexual complaints preoperatively.
Out of these three, one experienced penetration problems because of vaginal
narrowing. Anterior vaginal wall resection was not performed in six patients with
postoperatively declined sexual function.
104
Chapter 7
Table 5 Postoperative: overall sexual appreciation in sexually active women (n=16, mean age 45.7year, range
25-65years)
Overall, how would
you describe intercourse
postoperatively
Vaginal narrowing
postoperatively
Better than prior to surgery
No different than prior to surgery
Worse than prior to surgery
Penetration impossible
Penetration possible but difficult
Penetration possible without
problem
6
4
6
1
5
10
37.50%
25.00%
37.50%
6.25%
31.25%
62.50%
Sexual function at present:
Eleven out of the total of 16 sexually active patients immediately postoperatively,
are still sexually active. The mean age of the 11 patients (52%) who still are
sexually active at the present time is 57.7 years (range 42-70yr), with a mean
follow-up of 11.86 years (range 3.08-20.08yr). Table 6 shows the present FSFI
scores of the 11 sexually active patients. The domains of desire, arousal,
lubrication, orgasm and pain, scores are above average. The domain of satisfaction
shows results below average. Table 7 shows the present FSFI scores of the sexually
inactive patients. All domains are below average.
Female sexual function in urological practice
105
Tabel 6 Postoperative: domain characteristics sexually active patients at present time (n=11, mean age 57.7 year,
range 42-70 years)
Domain
Question No.
Item
Score
range
score
by item
score by
domain
Desire:
1
2
Arousal:
3
4
5
6
Lubrication:
7
8
9
10
Orgasm:
11
12
13
Satisfaction:
14
15
16
Pain:
17
18
19
FSFI Full scale
score
Frequency
Level
Frequency
Level
Confidence
Satisfaction
Frequency
Difficulty
Maintenance frequency
Maintenance difficulty
Frequency
Difficulty
Satisfaction
Closeness with partner
Sexual relationship
Overall sex life
During vaginal penetration
Following vaginal penetration
Level
1-5
1-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
1-5
1-5
0-5
0-5
0-5
2.0-36.0
3.7
3.7
4.3
4.1
3.9
3.1
3.3
3.7
2.4
3.9
3.0
4.3
2.4
2.0
2.2
2.5
3.8
3.9
3.9
4.44
4.62
3.99
3.88
2.68
4.64
24.25
106
Chapter 7
Tabel 7 Postoperative: domain characteristics sexually inactive patients at present time (n=10*, mean age 61.5
year, range 46-75 years)
Domain
Question No.
Item Score
range
score
by item
score by
domain
Desire:
1
2
Arousal:
3
4
5
6
Lubrication:
7
8
9
10
Orgasm:
11
12
13
Satisfaction:
14
15
16
Pain:
17
18
19
FSFI Full scale
score
Frequency
Level
Frequency
Level
Confidence
Satisfaction
Frequency
Difficulty
Maintenance frequency
Maintenance difficulty
Frequency
Difficulty
Satisfaction
Closeness with partner
Sexual relationship
Overall sex life
During vaginal penetration
Following vaginal penetration
Level
1-5
1-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
0-5
1-5
1-5
0-5
0-5
0-5
2.0-36.0
1.3
1.5
0.9
0.4
0.8
0.6
0.4
0.1
0.1
0.1
0.6
0.3
0.1
0.0
3.0
3.0
0.0
0.0
0.0
1.68
0.75
0.24
0.40
2.4**
0.0
5.47
* Nine out of the 10 sexually inactive patients were willing to complete the FSFI.
** Only three patients answered question 15 and 16.
Female sexual function in urological practice
107
DISCUSSION
According to Albarran, Pawlick rst performed a cystectomy in a woman more
than a century ago including diversion of the ureters into the vagina (19). The
patient was almost continent and survived for 16 years. However, others were
unable to reproduce this result and a multitude of dierent techniques was
developed subsequently to reconstruct the lower urinary tract in women.
Recently there has been a marked increase in interest in continent urinary
diversions. Porter (20) published a systematic review and critical analysis of the
literature on the health related quality of life (HRQOL) after radical cystectomy
(RC) and urinary diversions for bladder cancer. He stated that the current body of
published literature is insucient to conclude that one form of urinary diversion
is superior to another based on HRQOL outcomes.
In relation to cystectomy and urinary diversion, few reports on sexual function
have been published as part of quality of life studies. Most of them are related to
cystectomy because of malignancy and are male sexual function related. Only few
studies refer to female sexual function separately (21-29). (Table 8)
Recently, surgeons have acknowledged the impact of pelvic surgery on female
sexual function by attempting to preserve the vagina and its neurovascular
innervation during removal of the bladder (30-33).
A good option in benign indications is simple cystectomy as described by
Neulander (34). Simple cystectomy consist of removal of the bladder without
the adjacent structures, including adnex, urethra and part of vagina. This type of
procedure was performed in 86% of our patients.
Zippe demonstrated that female sexual dysfunction is a prevalent problem,
with 52% of preoperatively sexually active women becoming dysfunctional after
RC for transitional cell carcinoma of the bladder (35). The baseline and follow-
up data were obtained from 27 sexual active female patients who underwent
RC. He suggested some surgical modications may be appropriate in sexually
active women: (a) in selected diversions routine preservation of the distal
urethra in order to preserve the clitoral neurovasculature; (b) preservation of
the anterior vaginal wall (as much as possible) to maintain vaginal lubrication
and neurovascular innervations; and (c) tubular reconstruction of the vagina
(versus posterior ap rotation) to preserve vaginal depth and maintain pain-free
intercourse.
108
Chapter 7
Table 8 Studies on female sexual function after cystectomy and urinary diversion
Author Study design N Bladder disease
Maligne (M)
Benigne (B)
Diversion
procedure
Age at
operation
Results on postoperative sexual function
Schover (1985) 19 Prospective
Interview
9 M 9 Ileal conduit 59 (44-77) 2/9 inactive, 6/9 unchanged, 1/9 decreased
Nordström (1992)6 Prospective
Interview
26 M 11
B 15
Ileal conduit
Ileal conduit
58 (43-67)
46 (20-64)
5/6 decreased, 1/6 unchanged, 5 unchanged inactive
2/10 decreased, 1/10 unchanged, 7/10 increased, 5
unchanged inactive
Bjerre (1997) 7 Retrospective
Interview
33 M 13
B 4
M 8
B 8
Ileal conduit
Kock pouch
64 (29-76)
40 (19-66)
3/17 coital freq. unchanged, more often,
14/17 decrease/cessation (29% dysparaeunia or
vaginal dryness, 36% decrease in desire, 36% feel
less atractive)
7/16 coital freq. unchanged, more often,
9/16 decrease/cessation (33% dysparaeunia or vaginal
dryness, 33% decrease in desire, 22% feel less
atractive)
Sullivan (1998) 20 Retrospective
Questionnaire
8 Unknown Hetrotopic Unknown 4/8 adversely affected sex life
Henningsohn (2002) 21 Cohort
Questionnaire
9 M Kock
neobladder
Unknown 6/9 sexual desire < 1/mo, 6/8 no intercourse,
1/2 lubrication problems (2 patients sexually active)
Zippe (2003) 22 Prospective
Questionnaire
27 M 10
M 7
M 10
Studer
Indiana
Ileal conduit
55
58
66
No difference between the three groups.
14/27 decreased satisfaction, 13/27 successful vaginal
intercourse, 12/27orgasm problems, 11/27decrease
Lubrication, 10/27 Decreased sexual desire,
6/27dyspareunia
Protogerou (2004)23 Cohort
Interview
18 M 13
M 5
Ileal conduit
S-pouch
neobladder
Unknown Vaginal dysfunction: 6/13 not at all, 5/13 Sometimes,
1/13 Often, 1/13 very often
Vaginal dysfunction: 3/5 not at all, 1/5 Sometimes,
1/5 Often
Volkmer (2004) 8,9 Retrospective
Questionnaire
29 M 21
B 8
Hautmann 61 17/29 preoperative. sexual active,
6/17 became inactive, 1/12 became active
In 12/29 active patients FSFI unchanged after
cystectomy
M= Maligne, B= Benigne
Female sexual function in urological practice
109
Table 8 Studies on female sexual function after cystectomy and urinary diversion
Author Study design N Bladder disease
Maligne (M)
Benigne (B)
Diversion
procedure
Age at
operation
Results on postoperative sexual function
Schover (1985) 19 Prospective
Interview
9 M 9 Ileal conduit 59 (44-77) 2/9 inactive, 6/9 unchanged, 1/9 decreased
Nordström (1992)6 Prospective
Interview
26 M 11
B 15
Ileal conduit
Ileal conduit
58 (43-67)
46 (20-64)
5/6 decreased, 1/6 unchanged, 5 unchanged inactive
2/10 decreased, 1/10 unchanged, 7/10 increased, 5
unchanged inactive
Bjerre (1997) 7 Retrospective
Interview
33 M 13
B 4
M 8
B 8
Ileal conduit
Kock pouch
64 (29-76)
40 (19-66)
3/17 coital freq. unchanged, more often,
14/17 decrease/cessation (29% dysparaeunia or
vaginal dryness, 36% decrease in desire, 36% feel
less atractive)
7/16 coital freq. unchanged, more often,
9/16 decrease/cessation (33% dysparaeunia or vaginal
dryness, 33% decrease in desire, 22% feel less
atractive)
Sullivan (1998) 20 Retrospective
Questionnaire
8 Unknown Hetrotopic Unknown 4/8 adversely affected sex life
Henningsohn (2002) 21 Cohort
Questionnaire
9 M Kock
neobladder
Unknown 6/9 sexual desire < 1/mo, 6/8 no intercourse,
1/2 lubrication problems (2 patients sexually active)
Zippe (2003) 22 Prospective
Questionnaire
27 M 10
M 7
M 10
Studer
Indiana
Ileal conduit
55
58
66
No difference between the three groups.
14/27 decreased satisfaction, 13/27 successful vaginal
intercourse, 12/27orgasm problems, 11/27decrease
Lubrication, 10/27 Decreased sexual desire,
6/27dyspareunia
Protogerou (2004)23 Cohort
Interview
18 M 13
M 5
Ileal conduit
S-pouch
neobladder
Unknown Vaginal dysfunction: 6/13 not at all, 5/13 Sometimes,
1/13 Often, 1/13 very often
Vaginal dysfunction: 3/5 not at all, 1/5 Sometimes,
1/5 Often
Volkmer (2004) 8,9 Retrospective
Questionnaire
29 M 21
B 8
Hautmann 61 17/29 preoperative. sexual active,
6/17 became inactive, 1/12 became active
In 12/29 active patients FSFI unchanged after
cystectomy
M= Maligne, B= Benigne
110
Chapter 7
It is of interest that the only patient in our study with anterior vaginal wall
resection who still is sexual active had no vaginal narrowing problems. On the
other hand, 6 patients (29%) that underwent a simple cystectomy had vaginal
narrowing postoperatively making penetration impossible in one and dicult in 5.
3 Out of them became sexual inactive during follow-up. In a recent study Volkmer
concluded that resection of the upper part of the anterior vaginal wall did not
aect lubrication, vaginal sensibility or the ability to perform sexual intercourse
(36). With regard to the urinary diversion Zippe concluded that the type of
continent diversion did not aect sexual function (37). Bjerre et al found a higher
frequency of dyspareunia among patients with a continent reservoir compared to
an ileal conduit (38).
Women that undergo radical cystectomy are a considerable older group.
Completely dierent populations are patients that need a cystectomy because of
bladder function problems like interstitial cystitis or severe incontinence. First,
these patients are usually younger and secondly, in contrast to bladder cancer, a
long history of severe daily bladder complaints has already impacted on sexual
function. In our study 48% had sexual problems before operation, in 3out of 10
patients improvement was seen after operation, sexual function was worsened in1
and unchanged in 6 patients. Improvement in 2 of the 3 patients was related to
regaining continence.
Interstitial cystitis has a devastating impact on sexuality, leading to decreased
interest in sexual interactions in most women and to painful sensations during
intercourse in 60% to 90% of patients (39;40). Some interstitial cystitis patients
have a progressive course with rapid development of a small contracted bladders
and intractable symptoms. Major surgery should be reserved for this desperate
group of patients with severe unremitting symptoms not controlled by other
measures. Sexual dysfunction, like vulvar pain disorders, is common in this
population and it seems plausible that the positive impact of cystectomy and
continent deviation on sexual function is primarily attributable to relief of this
distressing condition.
In our study 15 patients with IC, with a mean age at operation date of 45,9 years
(range 25-66yr) and mean follow-up of 14,9 years (range 5,7-20,3yr) after the
operation, underwent a cystectomy with a continent diversion. 6 Of them (40%)
had sexual diculties preoperatively with complaints as incontinence (100%),
dyspareunia (100%) and loss of libido (67%). Shortly after operation 12 are sexual
active (80%), at the present time 8 patients still are active (53%). Inactivity in 7 IC
patients (47%), including the patients who became inactive later on, was related
to dyspareunia (29%), urine leakage during intercourse (10%), loss of libido (57%),
feeling of unattractiveness due to surgery (43%), less interest of the partner (29%)
or vaginal narrowing (43%).
In our study 4 (19%) of the patients have body image complaints; 3 of them, all IC
Female sexual function in urological practice
111
patients, indicated this as one of the main reasons of sexual inactivity. The impact
on body image was described before by Sullivan, who observed an adverse aect
on sex life in 4 of 8 women stating that these problems were cosmetic (41).
Interesting are the postoperative FSFI scores of sexual active patients at the
present time. The domains desire, arousal, lubrication, orgasm and pain scores are
above average.
The domain of satisfaction shows results below average. This domain consists
of questions on closeness with partner, sexual relationship and overall sex life.
Adequate communication is a prerequisite for solving this problem. Maybe sexual
counseling, with partner, is a good option to help to increase patients’ satisfaction
after cystectomy. Van Driel nicely described some practical guidelines (42). It is of
note that none of the patients in our study wanted to participate in a follow-up
study on sexual counseling after cystectomy.
It is of importance that the lubrication and orgasm scores are above average
in sexual active patients, which could suggest an intact clitoral function. It is
important to mention that in women may also induced by erotic stimulation of
nongenital sites. The clitoris and vagina are the most usual sites of stimulation, but
stimulation of the periurethral glans, breast/nipple or mons, mental-imagenary/
fantasy or hypnosis have been reported to induce orgasm as well (43-47). So
orgasm and lubrication are not synonymous with intact clitoral function. To know
if clitoral function is still intact an objective investigation, like MRI, is needed to
demonstrate the clitoral function after operation (48).
Postoperatively female sexuality is not only inuenced by the surgical technique as
such, but also by other factors like menopause (49).
We are not informed about the hormonal situation pre and postoperatively. In
our study out of all 21 patients, 18 patients (86%) are not menstruating at the
present time, 2 patients (10%) have a regular menstrual cycle and 1 patient (4%)
has stopped menstruating since a few months. 9 Of the 11 sexually active patients
at the present are not menstruating, 1 is menstruating normal and 1 patient has
stopped menstruating since a few months. The mean age of these sexually active
patients is 57,7 years (range 42-70 years).
Of the patients with non-preserved sexual function, 5 are directly related to the
operation. Another 5 patients became sexually inactive during follow-up. Of these,
2 were partner related (partner deceased and ED) and 3 patients had complaints
summarized in table 4. All 3 patients are not menstruating at the present time.
The postoperative interval to the start of sexual inactivity is unknown. We only
know the reason of inactivity of these 3 patients: pain in all patients, lost of libido
in 1 and body image complaints in 2. This kind of complaints can be also related
to hormonal status, age (50), sexual relationship and not exclusively related to
operation.
112
Chapter 7
The present paper is a novel report on an area only described by few authors and
in those cases mainly in relation to cystectomy for malignancy. Although the study
is awed by its retrospective design and a long interval between the procedure
and the questionnaire, overall the results of 62,5% improved or unchanged
intercourse are reassuring in relation to available literature on female sexual
function after cystectomy (table 8).
It is dicult to separate the dierent items that may inuence the outcome of
sexual function, the most relevant being the bladder disease related preoperative
problems, the cystectomy procedure as such and the type of urinary diversion.
Many questions need to be addressed in relation to urologic surgery such as
cystectomy and prospective multicenter studies are needed using validated global
sexual function questionnaires like FSFI and sexual distress scale like Female
Sexual Distress Scale (51;52). Also both neurovascular related anatomical studies
as well as more specied questionnaires are needed. Furthermore, the role of
postoperative sexual counseling needs more attention.
Female sexual function in urological practice
113
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31. Horenblas, S., Meinhardt, W., Ijzerman, W., and Moonen, L. F. Sexuality Preserving
Cystectomy and Neobladder: Initial Results. J.Urol. 2001;166(3):837-40.
32. Schoenberg, M., Hortopan, S., Schlossberg, L., and Marshall, F. F. Anatomical Anterior
Exenteration With Urethral and Vaginal Preservation: Illustrated Surgical Method. J.Urol.
1999;161(2):569-72.
33. Venn, S. N. and Mundy, A. R. ‘Nerve-Sparing’ Cystectomy in Women. Int.
Urogynecol.J.Pelvic.Floor.Dysfunct. 2000;11(4):237-40.
115
Female sexual function in urological practice
34. Neulander, E. Z., Rivera, I., Eisenbrown, N., and Wajsman, Z. Simple Cystectomy in Patients
Requiring Urinary Diversion. J.Urol. 2000;164(4):1169-72.
35. Zippe, C. D., Raina, R., Shah, A. D., Massanyi, E. Z., Agarwal, A., Ulchaker, J., Jones, S., and
Klein, E. Female Sexual Dysfunction After Radical Cystectomy: a New Outcome Measure.
Urology 2004;63(6):1153-7.
36. Volkmer, B. G., Gschwend, J. E., Herkommer, K., Simon, J., Kufer, R., and Hautmann, R.
E. Cystectomy and Orthotopic Ileal Neobladder: the Impact on Female Sexuality. J.Urol.
2004;172(6 Pt 1):2353-7.
37. Zippe, C. D., Raina, R., Shah, A. D., Massanyi, E. Z., Agarwal, A., Ulchaker, J., Jones, S., and
Klein, E. Female Sexual Dysfunction After Radical Cystectomy: a New Outcome Measure.
Urology 2004;63(6):1153-7.
38. Bjerre, B. D., Johansen, C., and Steven, K. A Questionnaire Study of Sexological Problems
Following Urinary Diversion in the Female Patient. Scand.J.Urol.Nephrol. 1997;31(2):155-60.
39. McCormick, N. B. Psychological aspects of interstitial cystitis. Sant, G. R. Interstitial
Cystitis. Philadeldelphia, PA: Lippincott-Raven Publisher; 1997. p.193.
40. Webster, D. Survey on sexual problems in IC. 8, 4. 1993. Ref Type: Generic
41. Sullivan, L. D., Chow, V. D., Ko, D. S., Wright, J. E., and McLoughlin, M. G. An Evaluation of
Quality of Life in Patients With Continent Urinary Diversions After Cystectomy. Br.J.Urol.
1998;81(5):699-704.
42. van Driel, M. F., Weymar Schultz, W. C., van de Wiel, H. B., Hahn, D. E., and Mensink, H.
J. Female Sexual Functioning After Radical Surgical Treatment of Rectal and Bladder Cancer.
Eur.J.Surg.Oncol. 1993;19(2):183-7.
43. Levin, R. J. The Mechanisms of Human Female Arousal. Ann Rev Sex Res 1992;3:1-48.
44. Levin, R. J. Sexual desire and the deconstruction and reconstruction of the human female
sexual response model of Masters & Johnson. In: Everaerd W, Laan E, Both S, eds. Sexual
Appetite, Desire and Motivation: Energetics of the Sexual System. In. Amsterdam: Royal
Netherlands Avademy of Arts and Sciences; 2001. pp.63-93.
45. Masters, W. M.; Johnson, V. Sexual Respons. Boston, MA:Little Brown: 1966.
46. Meston, C. M., Hull, E., Levin, R. J., and Sipski, M. Disorders of Orgasm in Women. J Sex
Med. 2004;1(1):66-8.
47. Whipple, B., Ogden, G., and Komisaruk, B. R. Physiological Correlates of Imagery-Induced
Orgasm in Women. Arch.Sex Behav. 1992;21(2):121-33.
48. Maravilla, K. R., Cao, Y., Heiman, J. R., Yang, C., Garland, P. A., Peterson, B. T., and Carter,
W. O. Noncontrast Dynamic Magnetic Resonance Imaging for Quantitative Assessment of
Female Sexual Arousal. J Urol. 2005;173(1):162-6.
49. Dennerstein, L. and Hayes, R. D. Confronting the Challenges: Epidemiological Study of
Female Sexual Dysfunction and the Menopause. J Sex Med. 2005;2 Suppl 3:118-32.
50. Hayes, R. and Dennerstein, L. The Impact of Aging on Sexual Function and Sexual
Dysfunction in Women: a Review of Population-Based Studies. J Sex Med. 2005;2(3):317-30.
116
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51. Althof, S. E., Dean, J., Derogatis, L. R., Rosen, R. C., and Sisson, M. Current Perspectives on
the Clinical Assessment and Diagnosis of Female Sexual Dysfunction and Clinical Studies of
Potential Therapies: a Statement of Concern. J Sex Med. 2005;2 Suppl 3:146-53.
52. Derogatis, L. R., Rosen, R., Leiblum, S., Burnett, A., and Heiman, J. The Female Sexual
Distress Scale (FSDS): Initial Validation of a Standardized Scale for Assessment of Sexually
Related Personal Distress in Women. J Sex Marital Ther. 2002;28(4):317-30.
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Female sexual function in urological practice
APPENDIX
QUESTIONNAIRES
1 Date of Birth
2 Do you have menstruation
n Yes, regular (every 4 weeks)
n Yes, but not regular
n No, since a few months not anymore
n No, since more than 1 year not anymore
3 Did they ask you about your sexual function n yes n no
4 Did they preoperative informed you about the
consequence on sexual function n yes n no
5 Did you have any sexual problems before operation n yes n no
If Yes, was this because of:
6 Incontinence during sexual intercourse n yes n no
7 Pain during sexual intercourse n yes n no
8 Libido loss n yes n no
A. The next questions refer to the situation after the operation.
9 Were you sexually active after operation? n yes n no
Did you answer this question with no please answer next question.
Did you answer yes, go to section B.
10 This question refers to the reason, why you weren’t sexual active after operation
Was this the result of?
n Not having a partner
n Partner related problems as, for example, illness, impotence, age
n Patient related problems as, for example illness, age
n A combination of these factors
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Chapter 7
Would you like to give an explanation, you can write it underneath.
The reason for not being sexual active anymore was due to the next problems?
11 Incontinence during sexual intercourse n yes n no
12 Pain during sexual intercourse n yes n no
13 Libido loss n yes n no
14 I don’t want to have sex because since the operation
I am not attractive anymore n yes n no
15 My partner don’t want to have sex with me anymore n yes n no
16 Since the operation my vagina is narrowed
so penetration is impossible. Is this true? n yes n no
If you would like to give an explanation, you can write it underneath.
B. If you are sexual active we ask you to ll in the following questions
and the two sexual questionnaires.
17. How would you describe having sexual intercourse after the operation?
n Better than before the operation
n Worse than before the operation
n No dierence between before or after the operation
If you like to give an explanation why it is better ore worse, you can write
underneath.
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Female sexual function in urological practice
18. Is because of the operation the vagina narrowed so penetration is impossible?
n It is impossible
n It is possible but dicult
n Is penetration without problem possible
Next FSFI
120
121
CHAPTER 8
Sexual function after partial
cystectomy and urothelial stripping
in a 32-year-old woman with radiation
cystitis
Based on:
Elzevier HW, Gaarenstroom KN, Lycklama à Nijeholt AAB. Sexual function
after partial cystectomy and urothelial stripping in a 32-year-old women with
radiation cystitis. Int Urogynaecol J, 2005; 16:412-4.
122
Chapter 8
INTRODUCTION
It is generally known that radiotherapy can cause severe bladder problems.
Sometimes cystectomy is the only possible solution. Preserving sexual function
during this procedure in women is likely to be forgotten. The urological literature
contains little information on female sexual function after radical cystectomy, in
contrast to the increasing data on the sexual dysfunction of men after cystectomy.
Radical cystectomy and hysterectomy (1) in women may cause sexual dysfunction
because the neurovascular bundles located lateral to the vaginal wall are usually
excised or damaged by removal of the bladder, urethra, and anterior vaginal
wall. This pelvic plexus, also called the inferior hypogastric plexus, including
aerent and eerent sympathetic and mainly parasympathetic autonomic nerves
as well as some sensory pudendal nerve branches is the network of pathways
supplying the rectum, uterus, vagina, vestibular bulbs, clitoris, bladder, and
urethra. More cranial these nerves are connected to the superior hypogastric
plexus and hypogastric nerves (mainly sympathetic) and the sacral nerves (mainly
parasympathetic).
Theoretically, disruption of the pelvic plexus could lead to altered vascular
function during sexual arousal and possibly disordered orgasm. The pelvic plexus
supplies the blood vessels of the internal genitals and is involved in the neural
control of vasocongestion and, consequently, the lubrication-swelling response.
The innervation of the vaginal wall originates mostly from the pelvic plexus. In
addition, signicant devascularization of the clitoris often occurs with removal of
the distal urethra, aecting subsequent sexual arousal and desire. The sensation of
the external genitalia is not related to the pelvic plexus: pudendal nerve branches
are the somatosensory pathway for the vulva. This case describes a partial
cystectomy, indicated in a patient with a crippled bladder after radiotherapy.
Hence, there was no need for radical cystectomy. Normally, a simple cystectomy is
done in our clinic in benign cases. In this case, after radiotherapy it was dicult
to perform a simple cystectomy without damaging the neurovascular bundle.
Thus, we introduced this novel approach of partial cystectomy and stripping o
the remaining urothelium to preserve sexual function, which can be helpful in a
selected group of patients.
CASE REPORT
A 32-year-old woman presented in November 2002 with gross hematuria, urgency,
urge incontinence, frequency, and lower abdominal pain at the Department
of Urology. In December 2000 she had been treated for cervical cancer stage
IB1 (2). Pelvic lymphadenectomy was performed with postoperative radiation
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Female sexual function in urological practice
therapy because of lymph node metastases. The uterus remained in situ. Before
treatment she had a normal sex life. Because of ileus, related to radiation enteritis,
she underwent ileocecal resection in October 2001. Cystoscopy showed severe
radiation cystitis with ulcers. Transurethral bladder biopsy indicated radiation
cystitis and no evidence of recurrent disease.
The symptoms, consisting of pain, urgency, frequency, and incontinence, increased
despite conservative treatment with tolterodine, oral and intravesical oxybutynin,
and pain medication (morphine). Hematuria was not a major problem. Repeated
cystoscopies revealed progression of the ulcers. She also developed pain in the
kidney region. Ultrasonography indicated hydronephrosis of both kidneys,
necessitating percutaneous nephrostomies.
Because of the increasing crippling of the bladder, including pain, we advised
a cystectomy and urinary diversion. Because of the previous bowel operation
a continent reservoir was not regarded as a good option, and therefore an ileal
conduit was selected.
Another important issue in this young woman was her wish to retain sexual
functions, e.g., sexual arousal and orgasm, to the best possible extent because she
was still sexually active. Her clitoral function was normal. However, penetration
was dicult because she had dyspareunia, related to some narrowing of the vagina
due to radiation therapy.
Because of her wish to remain as sexually active as possible after the operation,
we decided to do a partial cystectomy to spare the neurovascular bundle. After
resection of the dome of the bladder, the rest of the urothelium was stripped out
of the remaining bladder. The stripped bladder was covered with omentum to
promote the healing process. Subsequently, an ileal conduit was constructed and
dilatation of the vagina was performed. Pelvic pain subsided and then disappeared
after the operation. Postoperatively, the patient used a vibrator for vaginal self-
dilatation.
Three months after the operation her clitoral and other sexual functions were
intact, including normal sexual arousal and orgasm. This indicated an intact
neurovascular bundle. The patient still has penetration problems, because of the
preexistent vaginal narrowing, but this is no longer relevant in her sex life.
DISCUSSION
Approximately 1.5–2.5% of patients with a history of pelvic radiation become
a bladder cripple and require urinary diversion with or without cystectomy (3).
Hematuria, pain, urgency, frequency, and incontinence refractory to conservative
therapy make operations like these mandatory. Because of the morbidity of
the bladder problems, sexual function is likely to be forgotten. A few reports
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Chapter 8
on sexual function were part of quality of life studies. Most of them conceived
cystectomies for oncological indications and were related to male sexual function.
Only a few reports were related to female sexual function (4-7). Zippe at al.
demonstrated that impairing female sexual function is a prevalent problem, with
52% of preoperatively sexually active women becoming dysfunctional after radical
cystectomy . They suggested that some surgical modications may be appropriate
in sexually active women: (a) routine preservation of the distal urethra in selected
cases in an eort to preserve the clitoral neurovasculature, (b) preservation of
the anterior vaginal wall (as much as possible) to maintain vaginal lubrication
and neurovascular innervation, and (c) tubular reconstruction of the vagina
(versus posterior ap rotation) to preserve vaginal depth and maintain pain-free
intercourse.
How to perform a nerve-sparing radical cystectomy was nicely reviewed by
Venn et al. (8). Preservation of sexual function in males and females undergoing
cystectomy without compromising oncological results was described incidentally
(9). Only three women were included in these data with little information on
sexual function.
It is more dicult to nd information in the literature on benign cases like ours.
Cystectomy after radiotherapy almost always damages the neurovascular bundle.
Furthermore, the vagina is likely to be opened and subsequently to be narrowed.
Such a procedure results in a nonpenetrable vagina without clitoral function.
Supravesical diversion without cystectomy is an option, although morbidity
from the crippled bladder remaining in situ is high (28–67%), so that serious
consideration should be given to primary cystectomy performed simultaneously
with the supravesical diversion. Particularly patients with chronically infected
bladders, obstructed bladders, and interstitial cystitis are at risk (10;11).
Simple cystectomy described by Neulander et al. (12) implies removal of the
bladder without the adjacent structures, including adnexa, urethra, and part of
the vagina. Also with this operation technique the neurovascular bundle is likely
to be damaged in patients who had previous radiotherapy.
In our opinion, the procedure described in this report is a good, novel alternative
in women who are candidates for cystectomy because of a crippled bladder and
want to retain sexual function.
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Female sexual function in urological practice
REFERENCES
1. Maas, CP., DeRuiter, MC., Kenter, GG., and Trimbos, JB. The Inferior Hypogastric Plexus in
Gynecologic Surgery. J Gynecol Tech 1999;5:55-62.
2. Creasman, W. T. New Gynecologic Cancer Staging. Gynecol.Oncol. 1995;58(2):157-8.
3. Levenback, C., Eifel, P. J., Burke, T. W., Morris, M., and Gershenson, D. M. Hemorrhagic
Cystitis Following Radiotherapy for Stage Ib Cancer of the Cervix. Gynecol.Oncol.
1994;55(2):206-10.
4. Bjerre, B. D., Johansen, C., and Steven, K. A Questionnaire Study of Sexological Problems
Following Urinary Diversion in the Female Patient. Scand.J.Urol.Nephrol. 1997;31(2):155-60.
5. Nordstrom, G. M. and Nyman, C. R. Male and Female Sexual Function and Activity
Following Ileal Conduit Urinary Diversion. Br.J.Urol. 1992;70(1):33-9.
6. Schover, L. R. and von Eschenbach, A. C. Sexual Function and Female Radical Cystectomy: a
Case Series. J.Urol. 1985;134(3):465-8.
7. Zippe, C. D., Raina, R., Shah, A. D., Massanyi, E. Z., Agarwal, A., Ulchaker, J., Jones, S., and
Klein, E. Female Sexual Dysfunction After Radical Cystectomy: a New Outcome Measure.
Urology 2004;63(6):1153-7.
8. Venn, S. N. and Mundy, A. R. ‘Nerve-Sparing’ Cystectomy in Women. Int.Urogynecol.J.Pelvic.
Floor.Dysfunct. 2000;11(4):237-40.
9. Horenblas, S., Meinhardt, W., Ijzerman, W., and Moonen, L. F. Sexuality Preserving
Cystectomy and Neobladder: Initial Results. J.Urol. 2001;166(3):837-40.
10. Adeyoju, A. B., Thornhill, J., Lynch, T., Grainger, R., McDermott, T., and Butler, M. R.
The Fate of the Defunctioned Bladder Following Supravesical Urinary Diversion. Br.J.Urol.
1996;78(1):80-3.
11. Eigner, E. B. and Freiha, F. S. The Fate of the Remaining Bladder Following Supravesical
Diversion. J.Urol. 1990;144(1):31-3.
12. Neulander, E. Z., Rivera, I., Eisenbrown, N., and Wajsman, Z. Simple Cystectomy in Patients
Requiring Urinary Diversion. J.Urol. 2000;164(4):1169-72.
126
127
CHAPTER 9
Summery and future perspectives
128
Chapter 9
CHAPTER 1
In this chapter we give a short overview of the relation between urology and
female sexual function. Dierent aspects are discussed, like anatomy, urological
complaints, pelvic and vaginal surgery and sexual abuse. The question “Why
should the urologist play a role in managing female sexual dysfunction?” is asked.
In order to answer this question the outline of this thesis is described.
CHAPTER 2
Introduction
Recent studies have demonstrated a relationship between urogynecological
complaints and female sexual dysfunction; evaluation of female sexual function in
an urological outpatient clinic has not been undertaken before.
Aim
The aim of this study was to assess the prevalence of female sexual complaints in
an outpatient urological clinic related to a variety of urological complaints.
Methods
We evaluated 326 female patients during the rst visit at an outpatient
urological university clinic using a general questionnaire, urological complaints
questionnaire and two sexual questionnaires: Female Sexual Function Index
(FSFI) for evaluating sexual function and the subscales; non-communication and
female dissatisfaction of the Golombok Rust Inventory of Sexual Satisfaction
(GRISS) as bother scales.
Results
A total of 326 patients were included in the study, 119 (36.5%) were sexually
inactive and 207 (63.5%) patients were sexually active. The major reasons for
sexual inactivity were related to not having a partner, and to partner- and patient
related health issues. The total FSFI score of the sexually active patients was
28.3 (3.9-36) and of these, 41.4% had a FSFI score below 26.55, which could be
indicative of sexual complaints. Female patients with urological complaints such
as lower abdominal pain and lower urinary tract symptoms (LUTS) were more
likely to have sexual complaints. In the FSFI score below 26.55 group the patients
reported more diculties to discuss sexual issues with their partner, were more
dissatised and experienced sexual contact as less enjoyable.
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Female sexual function in urological practice
Conclusion
In urological practice female sexual complaints are common. We therefore
recommend integrating female sexual function questionnaires in standard
urological care.
CHAPTER 3
Introduction
The relationship between sexual abuse and urinary tract symptoms, sexual abuse
and gastrointestinal symptoms, or sexual abuse and sexual dysfunction have been
described before. A correlation between all these symptoms and sexual abuse has
not yet been reported.
Aims
The rst aim of this study was to document the prevalence rates of reported
sexual abuse in a large sample of female patients with complaints of the pelvic
oor. The second aim was to evaluate the frequency of complaints in the dierent
domains of the pelvic oor, such as complaints of micturition, defecation and
sexual function in female patients reporting sexual abuse and comparing these
data with female patients without a history of sexual abuse.
Methods
Female patients with pelvic oor complaints were evaluated in a tertiary referral
center. History taking was assessed by a pelvic-oor clinician. The number of
domains with complaints of patients with a history of sexual abuse was compared
to the number of domains with complaints of patients without sexual abuse.
Results
Twenty-three percent (42/185) of the patients reported a history of sexual abuse.
Female patients with a history of sexual abuse had signicantly more complaints
in three domains of the pelvic oor (35/42) compared to non-abused (69/143) (83%
vs. 48%, p<0.001).
Conclusions
Twenty-three percent of the female patients in a pelvic oor center evaluated by
a pelvic- oor clinician reported a history of sexual abuse. This is comparable to
the percentage of sexual abuse observed in the population at large. In our sample,
patients with multiple pelvic oor complaints (micturition, defecation and sexual
function) related to pelvic oor dysfunction were more likely to have a history of
sexual abuse than patients with isolated complaints.
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Chapter 9
CHAPTER 4
Introduction
Sexual abuse and sexual functioning are topics that health professionals nd
dicult to discuss. Women who present with pelvic oor complaints often
experience sexual diculties; therefore, questions regarding sexual function
should be a routine part of screening. Furthermore, pelvic oor complaints are
correlated with sexual abuse and asking about abuse should be a routine part of
screening as well. Considering the fact that many practitioners have diculty
enquiring about abuse, we have suggested that a questionnaire may be helpful
in improving the recognition and management of patients who have a history of
sexual abuse. The aim of the study was to assess the accuracy in the eciency of
detecting sexual abuse of a self-administered questionnaire
Methods
Report of sexual abuse in a self-administered pelvic oor questionnaire before
visiting our outpatient pelvic oor department was evaluated with the Pelvic
Floor Leiden Inventories (PelFIs) administered by a pelvic oor clinician in a later
stage.
The percentage of sexual abuse detected by a taken questionnaire administered
by a pelvic oor clinician not mentioned in a previous self-administered
questionnaire was taken as main outcome measure.
Results
Sexual abuse was reported in 20 patients with pelvic oor dysfunction during
administration of the PelFIs and were also evaluated on our pelvic oor
department. Six of them (30%) did not mention in the self-administered
questionnaire their history of sexual abuse.
Conclusion
A self-administered questionnaire for pelvic oor complaints does contribute
substantially in detecting sexual abuse and can be helpful in daily practice
CHAPTER 5
In a retrospective study we evaluated sexual function after tension-free vaginal
tape (TVT) placement for urinary stress incontinence based on responses to
a mailed questionnaire at least 3 months after the operation, to a maximum of
1 year. From 1999 to 2002, a sexual function questionnaire was mailed to 128
women (and their partners) who had undergone a TVT procedure for genuine
131
Female sexual function in urological practice
urinary stress incontinence, without pelvic organ prolapse or detrusor instability.
The questionnaire was returned by 96 women (75%), 69 (72%) of whom reported
being sexually active. Mean frequency of intercourse did not change. Overall,
26% described improved intercourse compared to before the operation. Only one
patient described worsening of intercourse after the TVT operation because of
an increase in her incontinence. Overall, in this study the technique of tension-
free vaginal tape as such seems to have no negative impact on sexual function.
However, because of its successful outcome on incontinence, it has a positive
overall eect on sexual function. The possible causes of postoperative partner
discomfort require further investigation.
CHAPTER 6
Introduction
Transobturator suburethral tape (TOT) and tension free vaginal tape obturator
(TVT-O) procedures are relative new incontinence treatment procedures. Studies
on inuence on sexual function as a result of these procedures are limited. The
aim of the study was to investigate the inuence of TOT or TVT-O for the
surgical treatment of stress urinary incontinence (SUI) on female sexual function.
Methods
We evaluated 77 sexual active patients after TVT-O (n=34, mean age 53.2 years)
and TOT (OB-TAPE, Porges) (n=44, mean age 52.0 years) placement for SUI
based on responses to a mailed questionnaire 3 months after operation.
Dierence in postoperative sexual complaints related to the TVT-O (inside-out)
and TOT (outside-in) procedure was taken as main outcome measure.
Results
Postoperative TOT and TVT-O
There was almost no dierence in frequency of sexual intercourse and an
improvement of the continence during intercourse: continence was reported in 33
patients (42.3%) before and 67 patients (78.4%) after operation. The appreciation
of sexual intercourse was improved in 15 patients (19.2%) and worsened in 8
patients (10.3%).
Postoperative TVT-O vs TOT
No dierence was seen in lost of lubrication, clitoral tumescence reduction and
clitoral sensibility reduction between both procedures. Pain because of vaginal
narrowing was seen signicantly more in the TOT procedure group.
Conclusion
Overall, in this study the technique of TOT gave rise to more sexual dysfunction
132
Chapter 9
than TVT-O. However, because of the successful outcome on incontinence,
both procedures had overall a positive eect on sexual function. The cause of
signicant more pain during intercourse as a result of vaginal narrowing in the
TOT procedure requires further investigation. Like other studies this study
demonstrated that incontinence surgery can have a positive and negative outcome
on sexual function. It is important to include this issue in the informed consent.
CHAPTER 7
Introduction
There are limited data on female sexual function after cystectomy for benign
indications.
To evaluate postoperative sexual items following cystectomy and continent
urinary diversion for benign indications (e.g. severe incontinence, interstitial
cystitis) in female patients. Furthermore, to review the studies investigating
changes in women’s sexual function after cystectomy were the aims of this study.
Methods
In a retrospective study 21 out of 23 patients (91%) that underwent a cystectomy
for a benign indication completed a questionnaire. These women had a median
age at the date of operation of 47.3 yr (range 25-66yr) and mean follow-up of
11.9 yr. Questions on preoperative and postoperative sexuality, postoperative
sexual activity, sexual appreciation and the Female Sexual Function Index (FSFI)
in patients at present were evaluated. Electronic databases were searched for
published studies investigating female sexual function after cystectomy.
Results
Sexual complaints before operation were present in 48% of the patients. The
most common complaints reported were incontinence during intercourse,
pain and loss of libido. Seventeen out of 21 patients (81%) were sexual active
preoperatively, 14 were still active postoperatively, and two preoperative inactive
patients became active. Sexual inactivity postoperative is mainly due to patient-
related or combination of patient- and partner-related issues (70%), such as
pain during intercourse, loss of libido and impaired body image. In the sexual
active group, the majority (62.5%) showed improved or unchanged intercourse
postoperatively. In the FSFI in 11 sexual active patients at present (52%), domains
of desire, arousal, lubrication, orgasm and pain scored above average. The domain
of satisfaction scored below average.
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Female sexual function in urological practice
Conclusions
Despite extensive surgery, female sexuality may remain unchanged or even
improve, following cystectomy and continent diversion for benign indication.
Sexual inactivity postoperatively needs more attention in respect to sexual
counseling. Overall the results are reassuring.
CHAPTER 8
We report a case of a 32-year-old woman who underwent a partial cystectomy
to preserve sexual function. After radiotherapy for stage IB1 cervical cancer,
cystectomy was indicated because of severe radiation cystitis. During this
procedure we resected the upper part of the bladder followed by stripping o
urothelium of the remaining bladder to spare the neurovascular bundle. Follow-up
after 3 months indicated intact sexual function including orgasm. In our opinion
the cystectomy procedure described in this case report is a good, novel option
in women who are candidates for cystectomy because of a crippled bladder, after
radiotherapy, and want to retain sexual function.
FUTURE PERSPECTIVES
Female sexual (dys)function is a relative new topic in urological practice. This
thesis illustrates the importancy of this issue. The most important nal question is
“How can we incorporate female sexual function in urological practice”.
More research has to be done in order to incorporate female sexual function
as one of the outcome measurements in relation to uro-gynecological practice
and operations, as was the case with erectile function in relation to radical
prostatectomy. We state that the impact of an operation in the small pelvis on
sexual function needs to be part of informed consent.
In order to achieve this goal in general, sexology should be an integrated part of
clinical urological practice.
We realize that discussing sexuality is not only dicult for patients but also for
physicians. However, this should not refrain patients and physicians to address
these issues. Sexual patient care, as part of quality of life, should be independent
of the interest of an individual doctor on the subject of sexual function. We need
to create opportunities, to incorporate sexual function in clinical care
At the end I ask again: “Why should the urologist play a role in managing female
sexual dysfunction?” Hopefully this thesis has illustrated that female sexual
function is an important part of urological practice.
134
135
CHAPTER 10
Samenvatting en
toekomstperspectieven
136
Chapter 10
Seksuele disfunctie bij de vrouw is een frequent voorkomend probleem dat diverse
oorzaken kan hebben. Uit analyse van de data van National Health and Social
Life Survey blijkt dat 43% van de Amerikaanse vrouwen lijdt aan een seksuele
functiestoornis.
De vraag is gesteld waarom de uroloog zich moet interesseren in vrouwelijke
seksuele functieproblematiek in zijn urologische praktijk.
In hoofdstuk 1 worden enkele facetten besproken. Allereerst de nauwe relatie
tussen de “urologische” anatomie en seksuele functie. Vervolgens de invloed
van urologische klachten op het seksueel functioneren evenals de invloed van
chirurgisch ingrijpen. Als laatste wordt het onderwerp van seksueel misbruik
besproken.
In 2004 werd de Pelvic Floor & Sexuality Research Group Leiden opgericht
die als doel heeft seksuologisch en bekkenbodemonderzoek te genereren en te
faciliteren. Om dit onderzoek te steunen hebben Pzer en Stichting Amsterdam 98
“unrestricted grants” geschonken.
Recente studies hebben een relatie aangetoond tussen urogynaecologische klachten
en seksueel disfunctioneren bij vrouwen. Een evaluatie van seksueel functioneren in
de urologische praktijk, gerelateerd aan urologische klachten, is nog niet verricht.
In hoofdstuk 2 wordt de prevalentiestudie beschreven welke werd verricht op de
Polikliniek Urologie. Het doel van de studie was de seksuele functie te evalueren bij
vrouwen op de polikliniek urologie in relatie tot verschillende urologische klachten.
Alle nieuwe vrouwelijke patiënten die zich meldden bij de polikliniek urologie
werd gevraagd een vragenlijst in te vullen. Deze vragenlijst bevat een algemeen
niet-medisch deel, de medische voorgeschiedenis, de urologische klacht en een
seksuologische vragenlijst: de Female Sexual Function Index (FSFI, zie Appendix)
en de Golombok Rust Inventory of Sexual Satisfaction (GRISS). Uiteindelijk
werden 326 vrouwen geïncludeerd in de studie. Van de 326 patiënten waren 119
(36,5%) seksueel inactief en 207 (63,5%) seksueel actief. De belangrijkste reden
van inactiviteit was geen partner en vervolgens ziekte van de patiënte en/of haar
partner. De totale FSFI-score van de seksueel actieve patiënten was 28,3 (3,9-36),
bij 41.4% was sprake van een FSFI-score lager dan 26,55 (lage FSFI-score groep)
wat kan passen bij seksuele klachten. Patiënten met urologische klachten als pijn
in de onderbuik en LUTS (urgency en frequency) scoorden gemiddeld ruim onder
de FSFI-score van 26,55. In de lage FSFI-score groep melden patienten dat ze het
moeilijker vinden om partner te zeggen wat ze prettig en niet prettig vinden in
de seksuele relatie. Daarnaast zijn ze ontevredener over hun seksuele relatie en
genieten er minder van.
We kunnen concluderen dat seksuele problemen frequent voorkomen bij vrouwen
met urologische klachten. Daarom adviseren wij om standaard seksuologische
vragenlijsten te gebruiken in de urologische praktijk.
Female sexual function in urological practice
137
In de periode van patiëntinclusie in de prevalentiestudie werden bij evaluatie van
patiënten met bekkenbodemklachten opvallend veel patiënten gezien met een
voorgeschiedenis van seksueel misbruik. Hoofdstuk 3 beschrijft onderzoek naar
de prevalentie van seksueel misbruik op een bekkenbodemcentrum. Daarnaast
werd onderzocht of er verschil was in de prevalentie van seksueel misbruik in
de voorgeschiedenis, bij klachten in 1 of meerdere bekkenbodemdomeinen
(mictie, defecatie en seksuele klachten). Daartoe werden patiënten met
bekkenbodemklachten door een bekkenfysiotherapeut met behulp van een
gevalideerde bekkenbodemvragenlijst, de Pelvic Floor Inventories Leiden (PelFIs),
geëvalueerd. De frequentie van voorkomen van klachten in de verschillende
domeinen van de bekkenbodem werden vergeleken in de groep van vrouwen met en
respectievelijk zonder seksueel misbruik.
Van de 185 patiënten gaven 42 (23%) patiënten aan een voorgeschiedenis te hebben
van seksueel misbruik. Klachten in alle 3 domeinen werd signicant meer gezien in
de groep van patiënten met een voorgeschiedenis van seksueel misbruik (35/42 in de
seksueel misbruik groep en 69/143 in de niet seksueel misbruik groep, 83% versus
48%, p<0.001).
We kunnen concluderen dat een voorgeschiedenis van seksueel misbruik in 23% van
de patiënten werd gezien die werden geëvalueerd door een bekkenfysiotherapeut
op een bekkenbodemcentrum. Patiënten met klachten in alle drie domeinen van
de bekkenbodem, betreende mictie, defecatie en seksuele klachten, blijken een
grotere kans te hebben op een voorgeschiedenis van seksueel misbruik.
Seksueel misbruik en seksualiteit in het algemeen vinden artsen moeilijk om te
bespreken. Vrouwen die zich melden met klachten op het gebied van mictie en/
of defecatie hebben vaak ook op seksueel gebied problemen, daarom zou de
seksuologische anamnese een standaardonderdeel van de analyse moeten zijn
bij deze patiënten. Zorgvuldig vragen naar seksueel misbruik zou, ook met het
oog op invasieve urologische diagnostiek en behandeling, een vaste routine
moeten zijn, aangezien bij patiënten met een zodanige voorgeschiedenis frequent
bekkenbodemklachten voorkomen. Omdat artsen het vaak moeilijk vinden naar
seksueel misbruik te vragen, is de gedachte geopperd dat een vragenlijst mogelijk
zou kunnen helpen bij het detecteren van seksueel misbruik.
Hoofdstuk 4 beschrijft de uitkomst van een studie waarbij werd nagegaan in welke
mate seksueel misbruik aangetoond kan worden met behulp van een opgestuurde
vragenlijst voordat de patiënte zich op onze polikliniek meldde.
De uitkomst van deze vragenlijst werd vergeleken met de PelFIs, een
vragenlijst die later, na verwijzing vanuit het Bekkenbodemcentrum, door een
bekkenfysiotherapeut werd afgenomen. Het percentage seksueel misbruik dat niet
werd aangegeven in de eerste vragenlijst werd als uitkomstmaat genomen om de
waarde van de opgestuurde vragenlijst te bepalen.
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Seksueel misbruik werd genoemd door 20 patiënten met bekkenbodemklachten die
werden geëvalueerd middels de PelFIs. Deze patiënten waren ook al geëvalueerd
op ons Bekkenbodemcentrum. Het bleek dat 6 van deze 20 patiënten (30%) in
de opgestuurde vragenlijst niet aangegeven hadden dat zij vroeger seksueel zijn
misbruikt.
Derhalve kunnen we concluderen dat een zelf in te vullen bekkenbodemvragenlijst
voordat een patiënt de polikliniek bezoekt, waardevol is bij het detecteren van
seksueel misbruik in de dagelijkse praktijk.
Incontinentieklachten hebben een impact op het seksuele functioneren van de
vrouw. Hoofdstuk 5 beschrijft een retrospectieve multicenter studie waarin
de seksuele functie wordt geëvalueerd na een Tension-free Vaginal Tape (TVT)
incontinentie-operatie middels een opgestuurde vragenlijst, minimaal 3 maanden
en maximaal 1 jaar na de operatie. Van 1999 tot 2002 is een seksuologische
vragenlijst opgestuurd naar 128 vrouwen en partners die een TVT- operatie hebben
ondergaan voor stressincontinentie zonder, dat sprake was van prolapsklachten en
detrusorinstabiliteit. De vragenlijst werd door 96 vrouwen (75%) teruggestuurd,
69 (72%) hiervan waren seksueel actief. De gemiddelde coïtusfrequentie na de
operatie veranderde niet. In totaal meldde 26% een verbetering van seksuele
functie. Slechts één patiënte gaf een verslechtering aan, vanwege toename van
incontinentieklachten als gevolg van de operatie. In deze studie werd vrijwel
geen negatieve impact gezien van de TVT-procedure op de seksuele functie. Dit
was vooral te danken aan de positieve uitkomst wat betreft de continentie: de
vermindering van urineverlies tijdens het vrijen resulteerde in een verbetering
van de seksuele functie. De seks wordt immers beter gewaardeerd als urineverlies
tijdens het vrijen is verminderd of verdwenen. De postoperatieve klachten die in
deze studie door de partner werden gemeld, moeten verder worden onderzocht.
Aansluitend op de TVT-studie wordt in hoofdstuk 6 een seksuologische
vervolgstudie beschreven naar twee relatief nieuwe stress incontinentieoperaties: de
Tension-free Vaginal Tape Obturator (TVT-O) en TransObturator suburethral Tape
(TOT) . Het doel van de studie was de invloed van deze operaties op de seksuele
functie te onderzoeken. Hiertoe werden 77 seksueel actieve patiënten middels een
vragenlijst geëvalueerd 3 maanden nadat een TVT-O (n=34, gemiddelde leeftijd 53,2
jr.) of TOT (n=44, gemiddelde leeftijd 52,0 jr.) was uitgevoerd.
In de gehele groep (n=77) werd postoperatief vrijwel geen verschil in coïtale
frequentie gezien. Wel werd een verbetering van continentie tijdens het vrijen
beschreven: voor de operatie waren 33 patiënten (42,3%) continent en na de
operatie 67 patiënten (78,4%). Een verbetering van seksuele functie werd
beschreven door 15 patiënten (19,2%) en een verslechtering door 8 patiënten
(10,3%).
Female sexual function in urological practice
139
Postoperatief TVT-O versus TOT: geen verschil werd in verminderde lubricatie,
reductie van de clitorale tumescentie en clitorale sensibiliteit tussen beide
procedures. Pijn als gevolg van vaginale vernauwing was signicant meer aanwezig
na de TOT-procedure.
Algemeen kan men stellen dat in deze studie de TOT-techniek meer seksuele
disfunctie geeft dan de TVT-O. Door de positieve invloed op de incontinentie
hebben beide procedures echter in het algemeen een positieve invloed op de
seksuele functie, vooral door vermindering van incontinentie tijdens het vrijen.
De oorzaak van het signicant meer voorkomen van vaginale vernauwing na de
TOT-procedure moet verder worden onderzocht. Zoals in hoofdstuk 5 beschreven,
wordt wederom aangetoond dat incontinentiechirurgie zowel een positieve als een
negatieve invloed kan hebben op het seksueel functioneren. Dit dient besproken te
worden voor de operatie.
Er is weinig bekend over de seksuele functie bij vrouwen na een cystectomie voor
benigne indicatie. In hoofdstuk 7 wordt een studie beschreven die als doel had de
seksuele functie te evalueren na cystectomie vanwege onbehandelbare incontinentie
of interstitiële cystitis. Daarnaast werd de literatuur gereviewed betreende
seksuele functie en cystectomie.
In een retrospectieve studie vulden 21 van de 23 patiënten (91%) die een cystectomie
ondergingen voor een benigne indicatie, de vragenlijst in. Deze vrouwen hadden een
gemiddelde leeftijd tijdens de operatie van 47,3 jaar (range 25-66 jaar), de gemiddelde
follow-up was 11,9 jaar. Aan de hand van een vragenlijst werd de seksualiteit pre- en
postoperatief de seksuele activiteit postoperatief, de kwaliteit van de seks en de
huidige FSFI-score geëvalueerd.
Seksuele problemen waren pre-operatief aanwezig bij 48% van de patiënten. Meest
voorkomende problemen waren incontinentie tijdens coïtus, pijn of minder zin in
vrijen. Van de 21 patiënten waren er 17 (81%) pre-operatief seksueel actief. Veertien
bleven postoperatief seksueel actief en 2 patiënten die pre-operatief inactief waren,
werden postoperatie seksueel actief. Postoperatieve seksuele inactiviteit werd vooral
veroorzaakt door patiënte danwel patiënte en partner gerelateerde problemen, zoals
pijn tijdens de seks, afwezige libido en gestoord zelfbeeld (body image). Een groot
deel (62,5%) van de pre-operatief seksueel actieve groep gaf aan dat de seksualiteit
postoperatief onveranderd of verbeterd was. In de FSFI van de nog heden 11
seksueel actieve patiënten (52%) scoren de domeinen zin in vrijen, opwinding,
lubricatie, orgasme en pijn boven gemiddeld. Alleen het domein satisfactie
(bevrediging) scoort onder het gemiddelde.
Ondanks uitgebreid chirurgisch ingrijpen, als cystectomie met urinedeviatie, kan de
vrouwelijke seksuele functie ongewijzigd blijven of zelfs verbeteren. Aan seksuele
inactiviteit na de operatie moet middels counseling meer aandacht worden besteed.
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In hoofdstuk 8 wordt een casus beschreven van een 32-jarige vrouw waarbij
met een aangepaste techniek een partiële cystectomie werd uitgevoerd ten einde
seksuele functie te behouden. Na bestraling in verband met gemetastaseerd
cervixcarcinoom ontwikkelde zij een ernstige radiatiecystitis. Conservatieve
therapie had geen baat en uiteindelijk was een cystectomie noodzakelijk, in
combinatie met een urinedeviatie (stoma). Aangezien patiënte nog seksueel actief
was, werd een partiële cystectomie verricht. Bij deze procedure werd het dak van
de blaas gereserceerd. Vervolgens werd de bodem ontdaan van het blaasslijmvlies
(urotheel). Bij deze procedure werd de neurovasculaire bundel gespaard. Naar onze
mening is de beschreven procedure een mogelijkheid die men kan toepassen om
seksuele functie te behouden in een geselecteerde patiëntenpopulatie.
TOEKOMSTPERSPECTIEVEN
Vrouwelijke seksualiteit is een relatief nieuw aandachtsgebied in de urologische
praktijk. Dit proefschrift laat het belang van dit onderwerp zien. De belangrijkste
vraag aan het eind is hoe we vrouwelijke seksuologie kunnen incorporeren in de
dagelijkse urologische praktijk.
Er is meer onderzoek noodzakelijk alvorens het seksueel functioneren als een van
de uitkomstmaatstaven na uro-gynecologische operaties gesteld kan worden, zoals
erectiele disfunctie dit al jaren is na een radicale prostatectomie.
Uiteindelijk zal seksuele functie dan een onderdeel zijn van informed consent bij de
vrouwelijke patiënt.
In algemene zin dient de seksuologische problematiek gerelateerd aan verschillende
ziektebeelden, als onderdeel van quality of life in de klinische danwel poliklinische
setting, meer aan bod te komen.
We weten dat het bespreekbaar maken van seksualiteit moeilijk is voor patiënten
maar ook voor artsen. Daarom is er een structuur (werkmethode) nodig, waarbij de
vrouwelijke seksualiteit als onderdeel van quality of life van de patiënt besproken
wordt, die onafhankelijk is van de interesse van de arts ten opzichte van het
onderwerp seksualiteit. Dit impliceert dat seksuologische hulpverlening meer
geïncorporeerd moet worden in de klinische en poliklinische setting.
Aan het eind stel ik wederom de vraag: “Waarom moet de uroloog zich interesseren
in vrouwelijke seksuele functieproblematiek in zijn urologische praktijk?” Ik hoop
dat met dit proefschrift een eerste antwoord is gegeven en dat aangetoond is dat
vrouwelijke seksualiteit een belangrijk onderdeel is van de urologische praktijk.
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APPENDIX
FEMALE SEXUAL FUNCTION INDEX
Deze vragen gaan over uw seksuele gevoelens en seksuele reacties gedurende de
afgelopen 4 weken. Beantwoord deze vragen alstublieft zo eerlijk en duidelijk
mogelijk. Uw antwoorden zullen strikt vertrouwelijk behandeld worden.
Bij het beantwoorden van de vragen zijn de volgende denities van toepassing:
Seksuele activiteit: dit kan zijn strelen, voorspel, masturbatie en vaginale
geslachtsgemeenschap.
Geslachtsgemeenschap: hiermee wordt vaginale penetratie bedoeld (het
binnengaan van de penis in de vagina).
Seksuele stimulatie: hieronder worden onder meer situaties verstaan als voorspel
met een partner, zelfbevrediging (masturbatie), of fantaseren over seks.
Per vraag slecht één rondje aankruisen s.v.p
Seksuele verlangens: hieronder wordt verstaan zin hebben in seks, in willen gaan
op het seksuele initiatief van een partner, en denken aan of fantaseren over het
hebben van seks.
1 Hoe vaak had u de afgelopen 4 weken seksuele verlangens?
1 Bijna altijd of altijd
2 Meestal (meer dan de helft van de tijd)
3 Af en toe (ongeveer de helft van de tijd)
4 Een paar keer (minder dan de helft van de tijd)
Bijna nooit of nooit
2 Hoe sterk vond u dat uw seksuele verlangens de afgelopen 4 weken waren?
1 Zeer sterk
2 Sterk
3 Middelmatig
4 Zwak
5 Zeer zwak of niet aanwezig
Seksuele opwinding: hieronder wordt verstaan zowel de lichamelijke als geestelijke
gevoelens van seksuele opwinding. Dit kunnen gevoelens zijn van warmte of
tintelingen in de geslachtsdelen, vochtig (“nat”) zijn, of het samentrekken van
spieren.
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3 Hoe vaak voelde u zich de afgelopen 4 weken seksueel opgewonden (“geil”) tijdens seksuele
activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
4 Hoe sterk vond u dat uw seksuele opwinding (het “geil” zijn) was de afgelopen 4 weken
tijdens seksuele activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Zeer sterk
3 Sterk
4 Middelmatig
5 Zwak
6 Zeer zwak of niet aanwezig
5 Hoe zeker was u er de afgelopen 4 weken van dat u seksueel opgewonden zou worden
tijdens seksuele activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Heel zeker
3 Zeker
4 Middelmatig
5 Onzeker
6 Heel onzeker
6 Hoe vaak was u de afgelopen 4 weken tevreden over uw seksuele opwinding tijdens
seksuele activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
7 Hoe vaak werd u de afgelopen 4 weken vochtig (“nat”) tijdens seksuele activiteit of
geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
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Female sexual function in urological practice
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
8 Hoe moeilijk was het de afgelopen 4 weken om vochtig (“nat”) te worden tijdens seksuele
activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Heel erg moeilijk of onmogelijk
3 Erg moeilijk
4 Moeilijk
5 Een beetje moeilijk
6 Niet moeilijk
9 Hoe vaak bleef u de afgelopen 4 weken vochtig (“nat”) totdat de seksuele activiteit of
geslachtsgemeenschap voltooid was?
1 Geen seksuele activiteit
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
10 Hoe moeilijk was het de afgelopen 4 weken om vochtig (“nat”) te blijven totdat de
seksuele activiteit of geslachtsgemeenschap voltooid was?
1 Geen seksuele activiteit
2 Heel erg moeilijk of onmogelijk
3 Erg moeilijk
4 Moeilijk
5 Een beetje moeilijk
6 Niet moeilijk
11 Hoe vaak heeft u de afgelopen 4 weken een orgasme (klaarkomen) gehad bij seksuele
stimulatie of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
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12 Hoe moeilijk was het de afgelopen 4 weken voor u om een orgasme (klaarkomen) te
krijgen bij seksuele stimulatie of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Bijzonder moeilijk of onmogelijk
3 Zeer moeilijk
4 Moeilijk
5 Enigszins moeilijk
6 Niet moeilijk
13 Hoe tevreden was u de afgelopen 4 weken over uw vermogen een orgasme te krijgen
tijdens seksuele activiteit of geslachtsgemeenschap?
1 Geen seksuele activiteit
2 Zeer tevreden
3 Redelijk tevreden
4 Ongeveer even tevreden als ontevreden
5 Tamelijk ontevreden
6 Zeer ontevreden
14 Hoe tevreden was u de afgelopen 4 weken over de sterkte van de emotionele band tussen
u en uw partner tijdens seksuele activiteit?
1 Geen seksuele activiteit
2 Zeer tevreden
3 Redelijk tevreden
4 Ongeveer even tevreden als ontevreden
5 Tamelijk ontevreden
6 Zeer ontevreden
15 Hoe tevreden was u de afgelopen 4 weken over uw seksuele relatie met uw partner?
1 Zeer tevreden
2 Redelijk tevreden
3 Ongeveer even tevreden als ontevreden
4 Tamelijk ontevreden
5 Zeer ontevreden
16 Hoe tevreden was u de afgelopen 4 weken met uw seksleven in het algemeen?
1 Zeer tevreden
2 Redelijk tevreden
3 Ongeveer even tevreden als ontevreden
4 Tamelijk ontevreden
5 Zeer ontevreden
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Female sexual function in urological practice
Vaginale penetratie: hiermee wordt bedoeld het binnengaan van de penis in de
vagina.
17 Hoe vaak had u de afgelopen 4 weken een ongemakkelijk gevoel of pijn tijdens vaginale
penetratie?
1 Niet geprobeerd om geslachtsgemeenschap te hebben
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
18 Hoe vaak had u de afgelopen 4 weken een ongemakkelijk gevoel of pijn nadat de vaginale
penetratie voltooid was?
1 Niet geprobeerd om geslachtsgemeenschap te hebben
2 Bijna altijd of altijd
3 Meestal (meer dan de helft van de tijd)
4 Af en toe (ongeveer de helft van de tijd)
5 Een paar keer (minder dan de helft van de tijd)
6 Bijna nooit of nooit
19 Hoe sterk zou u het ongemakkelijke gevoel of de mate van pijn noemen die u de afgelopen
4 weken ervoer tijdens of na aoop van de vaginale penetratie?
1 Niet geprobeerd om geslachtsgemeenschap te hebben
2 Zeer sterk
3 Sterk
4 Middelmatig
5 Zwak
6 Zeer zwak of niet aanwezig
Developed by Bayer AC, Zonagen, Inc. and Target Health Inc.
Copyright ©2000 All Rights Reserved.
Translated by E.Laan and L.Beekman; Copyright ©2001 All Rights Reserved.
146
147
CURRICULUM VITAE
The author of this thesis was born in Zwolle, the Netherlands, on April 1, 1964.
He attended the Rijksscholengemeenschap de Schothorst Amersfoort, The
Netherlands (1976-1984). After MAVO-3, MAVO-4 and HAVO-5, he obtained his
VWO diploma in 1984. From 1984 to 1992 he studied medicine at the University
of Amsterdam.
After receiving his medical degree (artsendiploma) in December 1993, he worked
from 1994 till 1996 as a resident (AGNIO) at the surgical department of the
Boven IJ Hospital and urological department of VU University Medical Center.
He conducted his formal training in urology at St Antonius Hospital, Nieuwegein
(1996-1998, dr T. J. Bast and dr P.M. Go, surgeons), at the Leyenburg Hospital,
The Hague (1998-1999 and 2001-2002, dr P.L Venema, urologist) and at the Leiden
University Medical Center (1999-2001, Prof. J. Zwartendijk, urologist). After
nishing his residency he joined the sta at the Department of Urology of Leiden
University Medical Center.
In 2001 he started his education and training as sexologist, resulting in registration
as sexologist in 2007. In 2003 he started his research on female sexual function in
urological practice. The results of the studies are presented in this thesis.
Henk is married to Petra Luberti and they have one son, Quinten.
148
149
PUBLICATIONS
Elzevier HW, Venema PL, Kropman RF, Kazzaz BA. Lymphoepithelioma-like
carcinoma of the kidney. J Urol 2002; 167: 2127-8
Elzevier HW, Venema PL, Lycklama à Nijeholt AAB. Sexual function after
tension-free vaginal tape (TVT) for stress incontinence: results of a mailed
questionnaire. Int Urogynecol J 2004; 15: 313-318
Elzevier HW, Gaarenstroom KN, Lycklama à Nijeholt AAB. Sexual function after
partial cystectomy and urothelial stripping in a 32 year old women with radiation
cystitis. Int Urogynecol J 2005; 16:412-4
Elzevier HW. Re:Cystectomy and orthotopic ileal neobladder: the impact on
female sexuality. J Urol 2005; 174(3):1154; author reply
Elzevier HW, Bevers RFM, Wasser MNJM, Pelger RCM.Testis calcication of
the Tunica Albuginea. Eur Radiol 2006; 16:240-1
Voorham-van der Zalm PJ, Pelger RCM, Stiggelbout AM, Elzevier HW, Lycklama
à Nijeholt AAB. Eects of magnetic stimulation in the treatment of pelvic oor
dysfunction. BJU 2006; 97:1035-8
Voorham-der Zalm PJ, Pelger RC, van Heeswijk-Faase IC, Elzevier HW,
Ouwerkerk TJ, Verhoef J, Nijeholt GA. Placement of probes in electrostimulation
and biofeedback training in pelvic oor dysfunction. Acta Obstet Gynecol Scand.
2006;85:850-5
Elzevier HW, Nieuwkamer BB, Pelger RCM, Lycklama à Nijeholt AAB. Female
Sexual Function and Activity Following Cystectomy and continent urinary tract
diversion for benign indications: A clinical Pilot study and review of literature
J Sex Med 2007;4:406–416
Elzevier HW, Voorham-van der Zalm PJ, Pelger RCM. How reliable is a self
administered questionnaire in detecting sexual abuse: a retrospective study
in patients with pelvic oor complaints and a review of literature. J Sex Med
2007;4:956-963
Voorham – van der Zalm PJ, Elzevier HW, Lycklama à Nijeholt AAB, Pelger
RCM. Simultaneous Sacral and Tibial Transcutaneous Electrical Nerve
Stimulation: Urodynamic Evaluation. Current Urology 2007;1:77-80
150
van Driel MF, Beck JJ, Elzevier HW, van der Hoeven JH, Nijman JM. The
treatment of sleep-related painful erections. J Sex Med 2008;5:909-18.
Elzevier HW, Putter H. Pelger RCM, Delaere KPJ, Venema PL, August A.B.
Lycklama à Nijeholt AAB.Female sexual function after surgery for stress urinary
incontinence: Transobturator Suburethral Tape (TOT) versus Tension-free Vaginal
Tape Obturator (TVT-O). J Sex Med 2008;5:400-406
Voorham – van der Zalm PJ, Lycklama à Nijeholt AAB, Putter H, Elzevier HW,
Pelger RCM. Diagnostic Investigation of the Pelvic Floor: a helpful tool in the
approach in patientes with complaints of micturition, defecation and/or sexual
dysfunction. J Sex Med 2008;5:864-71
Beck JJ, Elzevier HW, Pelger RCM, Putter H, Voorham – van der Zalm PJ.
Multiple pelvic oor complaints are correlated with sexual abuse history. J Sex
Med 2008 Accepted
Wijels SAM, Elzevier HW, Lycklama a Nijeholt AAB. Transurethral mesh
resection after urethral erosion of TVT tape: report of 3 cases and review of
literature Urogynecol J 2008 Accepted
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