Postpartum sexual function; the importance of the levator ani muscle.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle function plays an important role in female sexual functioning. Smaller genital hiatal dimensions have been associated with sexual dysfunction, mainly dyspareunia. On the other hand, trauma of the levator ani muscle sustained during childbirth is associated with increased genital hiatus, which potentially can affect sexual functioning by causing vaginal laxity. This study aims to determine the association between levator hiatal dimensions and female sexual dysfunction after first vaginal delivery. METHODS: This is a secondary analysis of a prospective observational study. Two hundred four women who had a first, spontaneous vaginal delivery at term between 2012 and 2015 were recruited at a minimum of 6 months postpartum. Thirteen pregnant women were excluded. We analyzed the association of total PISQ-12 score, as well as individual sexual complaints (desire, arousal, orgasm and dyspareunia), with levator hiatal dimensions at rest, with maximum Valsalva and during pelvic floor muscle contraction as measured by 4D transperineal ultrasound. Statistical analysis was performed using linear regression analysis and Mann-Whitney U test. RESULTS: One hundred ninety-one women were evaluated at a median of 11 months postpartum. There was no significant association between total PISQ-12 score and levator hiatal dimensions. Looking at individual sexual complaints, women with dyspareunia had significantly smaller levator hiatal area and anterior-posterior diameter on maximum Valsalva. By using multivariate logistic regression analysis however we found dyspareunia was not independently associated with levator hiatal dimensions. CONCLUSIONS: After first vaginal delivery sexual dysfunction is not associated with levator hiatal dimensions as measured by 4D transperineal ultrasound.

Outcome of repair of obstetric anal sphincter injuries after three years.

OBJECTIVE: To prospectively assess change in bowel symptoms and quality of life (QoL) approximately 3 years after primary repair of obstetric anal sphincter injuries (OASIS). METHODS: Between July 2002 and December 2007 women who attended the perineal clinic at Croydon University Hospital, UK, 9 weeks following primary repair of OASIS were asked to complete the Manchester Health Questionnaire and a questionnaire to obtain a St Mark incontinence score. All women had endoanal scans at this visit. In June 2008 all women were asked to complete the questionnaires again. RESULTS: Of 344 patients who responded to the questionnaires and were included in the analysis, long-term symptoms of fecal urgency, flatus incontinence, and fecal incontinence occurred in 62 (18.0%), 52 (15.1%), and 36 (10.5%), respectively. Overall, there was a significant improvement in fecal urgency (P<0.001) and flatus incontinence (P<0.001) from 9 weeks to 3 years. Of 31 women with fecal incontinence symptoms at early follow-up, 28 were asymptomatic at 3 years. However, 33 women developed de novo symptoms. The only predictors of fecal incontinence at 3 years were fecal urgency at 9 weeks (OR 4.65; 95% CI, 1.38-15.70) and a higher St Mark score (OR 1.40; 95% CI, 1.09-1.80). CONCLUSION: Following primary repair of OASIS, the majority of symptoms and QoL significantly improve, unless there is a persistent anal sphincter defect. This highlights the importance of adequate repair.

Sexual experiences of male partners before and after female pelvic floor surgery: a qualitative study.

INTRODUCTION AND HYPOTHESIS: To obtain a precise idea of the partner's thoughts and experiences with regard to the effect of female pelvic floor disorders and surgery on his sexual life. METHODS: Qualitative semi-structured interviews were conducted in 8 partners of women undergoing pelvic floor surgery prior to, and in 6 partners at a median of 18 weeks after surgery. The data gathered were systematically analysed using data matrices. RESULTS: Although most men evaluated their sex life prior to surgery in a positive way, one or more changes in the sexual life of our participants as a result of the female pelvic floor disorder were common. This was a result of changes in the man's physical sensations and behaviour during sex (direct changes), and changes in the female partner's sexual behaviour and reduced body confidence (indirect changes). The cure of the pelvic floor disorder and changes in vaginal tightness following surgery caused direct improvements in the man's physical sensations, as well as indirect improvements in his sexual experience as a result of positive changes in the woman's sexual behaviour and body confidence. CONCLUSIONS: As only a small group of men participated in this study, the results should be interpreted with caution. The information gathered in our study can provide guidance to clinicians on possible aspects to explore with their patients prior to and after pelvic floor surgery, and can form the basis of disease-specific male sexual function questionnaires that can be used in quantitative studies on this topic.

Pelvic floor dysfunction: women's sexual concerns unraveled.

INTRODUCTION: Sexual function of women suffering from pelvic organ prolapse (POP) and/or urinary incontinence (UI) is adversely affected. However, our current understanding of the exact relationship between female sexual dysfunction and POP and/or UI is incomplete. A qualitative study can improve our understanding by describing what women themselves perceive as the real problem. AIM: To gain a more in-depth understanding of the impact of POP and/or UI on the different categories of female sexual dysfunction by way of a qualitative study. METHODS: Qualitative semistructured interviews were conducted in 37 women scheduled for pelvic floor surgery, and one was excluded from analysis due to incomplete recordings. MAIN OUTCOME MEASURES: The impact of POP and/or UI on female sexual function. RESULTS: Only 17% of women were completely positive about their sex life. Both POP and UI had a negative effect on body image. Women with POP had a negative image of their vagina, which caused them to be insecure about their partner's sexual experience, while women with UI were embarrassed about their incontinence and pad use, and feared smelling of urine. Worries about the presence of POP during sexual activity, discomfort from POP, and reduced genital sensations were the most important reasons for decreased desire, arousal, and difficulty reaching an orgasm in women with POP. Fear of incontinence during intercourse affected desire, arousal, and orgasm and could be a cause for dyspareunia in women with UI. Desire was divided into two main elements: "drive" and "motivation." Although "drive," i.e., spontaneous sexual interest, was not commonly affected by POP and/or UI, a decrease in "motivation" or the willingness to engage in sexual activity was the most common sexual dysfunction mentioned. CONCLUSIONS: Body image plays a key role in the sexual functioning of women with POP and/or UI with the biggest impact on women's "motivation."

Sexual problems in the gynecology clinic: are we making a mountain out of a molehill?

INTRODUCTION AND HYPOTHESIS: This study aims to assess the prevalence of sexual problems in general gynecology and urogynecology clinics using a simple screening tool and to compare the prevalence between patients presenting with gynecology or urogynecology complaints. METHODS: Patients attending (uro)gynecology clinics completed three screening questions for sexual problems to be assessed. A fourth question was later introduced to address sexual problems which bother them. Student's t-test, chi-square test, and logistic regression were used. RESULTS: Of 1,194 women, 37% had a sexual complaint. Seventeen percent volunteered this information as part of their main complaint, while the remaining only admitted it on questioning. The last 290 questionnaires included the question on "bother." Of these, 37% had a sexual complaint and only 45% found them bothersome. Multivariate analysis showed that urogynecology complaints were significantly associated with sexual complaints. CONCLUSIONS: As most women only volunteer symptoms when asked directly, clinicians should be vigilant in identifying sexual problems but always establish the question of bother to avoid over-diagnosis.

Predicting anal sphincter defects: the value of clinical examination and manometry.

INTRODUCTION AND HYPOTHESIS: The aims of this study were, firstly, to determine the diagnostic accuracy of an anal incontinence score, clinical examination and anal manometry in identifying anal sphincter defects and, secondly, to establish manometric cut-off values associated with sphincter defects. METHODS: One hundred fifty-nine women were evaluated by clinical examination, anal manometry and endoanal ultrasound (EAU). Accuracy measures were calculated, using EAU as the gold standard. RESULTS: Perineal body length (p = 0.84) and pelvic floor muscle strength (p = 0.10) were not associated with anal sphincter defects. Anal inspection was associated with anal sphincter defects (p < 0.001), although its sensitivity was low at 26%. The sensitivity of digital rectal examination was 67% and the specificity 55%. Cut-off values of manometric findings were set to maximise sensitivity at 30 mm anal length, 54 mm Hg maximum resting pressure, 95 mm Hg maximum squeeze pressure and 53 mm Hg squeeze increment. CONCLUSIONS: Clinical assessment has a poor sensitivity for detecting anal sphincter defects. The proposed manometric cut-off values can be used to either reassure or identify women who may need further assessment by EAU.

St. Mark's incontinence score for assessment of anal incontinence following obstetric anal sphincter injuries (OASIS).

The aim of this study was to assess the correlation between St. Mark's incontinence score (SMIS) for anal incontinence and impact on quality of life (QoL), following primary repair of obstetric anal sphincter injuries (OASIS). Three hundred sixty-eight women who sustained OASIS completed a Manchester Health Questionnaire (MHQ) and the clinician calculated a SMIS. Spearman's correlation coefficients were calculated, and Mann-Whitney U test was used to compare different severity subgroups. Mean follow-up was 10 weeks and mean age was 30 years. Mean SMIS was 1.35. All MHQ QoL domains showed statistically significant positive correlation with SMIS. When comparing SMIS subgroups (0-4, 5-8, >8), mean QoL domain scores were higher with increasing SMIS. This shows that the objective assessment of severity of anal incontinence, using the SMIS, correlates to its impact on QoL in a relatively young population with low severity of symptoms and can, therefore, be used in women who sustain OASIS.

Female sexual dysfunction: are urogynecologists ready for it?

The aim of this study was to assess the practice of members of the British Society of Urogynaecology (BSUG) with respect to female sexual dysfunction (FSD) and compare it to members of the American Urogynecologic Society (AUGS). A web-based anonymous electronic questionnaire was sent to all (n = 150) BSUG members. Frequencies of responses and chi-square test for association with demographics were calculated. One hundred questionnaires were returned of which 95 were sufficiently filled. Fifty percent regularly screened for FSD at clinic visits and 49.5% after surgery, compared to 77% and 76% of AUGS members, respectively. The most important barrier was lack of time. Only 2% said FSD was not an important problem. Seventy-six percent found training for FSD unsatisfactory. FSD is not part of normal practice for half of BSUG members. There is, therefore, a need for better implementation of education and training at both undergraduate and postgraduate levels.