The relationship between pelvic organ prolapse, genital body image, and sexual health

Associated factors of vaginal laxity and female sexual function: a cross-sectional study

BACKGROUND

Female sexual dysfunction (FSD), including vaginal laxity (VL), can lead to a decrease in quality of life and affect partner relationships.

AIM

We aimed to investigate the associated factors of VL and FSD and their relationship with other pelvic floor disorders in a female population.

METHODS

This cross-sectional study was conducted at Chelsea and Westminster Hospital from July to December 2022. All women referred to clinical care at the urogynecology clinic were included. Participants were assessed according to sociodemographic and clinical aspects, the Pelvic Organ Prolapse Quantification system, sexual function, VL, sexual attitudes, sexual distress, sexual quality of life, vaginal symptoms, and pelvic floor disorders. Unadjusted and adjusted associated factors of VL and FSD were analyzed.

OUTCOMES

The primary outcome was the identification of the associated factors of VL and FSD in a female population, and secondary outcomes included the association between VL and pelvic organ prolapse (POP) with the questionnaire scores.

RESULTS

Among participants (N = 300), vaginal delivery, multiparity, perineal laceration, menopause, and gel hormone were significantly more frequent in those reporting VL (all P < .05). When compared with nulliparity, primiparity and multiparity increased the odds of VL by approximately 4 and 12 times, respectively (unadjusted odds ratio [OR], 4.26 [95% CI, 2.05-8.85]; OR, 12.77 [95% CI, 6.53-24.96]). Menopause and perineal laceration increased the odds of VL by 4 and 6 times (unadjusted OR, 4.65 [95% CI, 2.73-7.93]; OR, 6.13 [95% CI, 3.58-10.49]). In multivariate analysis, menopause, primiparity, multiparity, and POP remained associated with VL.

CLINICAL IMPLICATIONS

Parity, as an obstetric factor, and menopause and staging of POP, as clinical factors, were associated with VL.

STRENGTHS AND LIMITATIONS

The investigation of associated factors for VL will contribute to the understanding of its pathophysiology. The study design makes it impossible to carry out causal inference.

CONCLUSION

Menopause, primiparity, multiparity, and POP were highly associated with VL complaints in multivariate analysis.

Associations Between Negative Body Image and Sexual Health Practices in Emerging Adults from Malaysia

Past findings on the association between negative body image and sexual health behaviors have been mixed and mostly derived from Western samples. The aim of the current study was to examine associations between indices of negative body image and sexual health practices that reduce the risk of disease transmission in emerging adults, and whether these associations are moderated by gender. Using an online survey, a convenience sample of 584 Malaysian adults aged 18-30 years (230 men, 354 women) completed measures of satisfaction with overall appearance, body size dissatisfaction, weight satisfaction, height satisfaction, and genital image evaluation. They also reported if they ever had partnered sex, condomless sex, and been screened for human immunodeficiency virus (HIV), as well as their lifetime number of penetrative sex partners. Hierarchical logistic and ordinal regression analyses indicated that more positive genital image evaluation, but not the other body image indices, was significantly associated with having had partnered sex and fewer lifetime penetrative sex partners. None of the body image indices were significantly associated with condomless sex. All associations were consistent across men and women. For HIV testing, a significant interaction between genital image evaluation and gender emerged. However, this was reduced to non-significance after controlling for the number of penetrative sex partners. Overall, our findings underline the importance of promoting improved genital image in interventions aimed at increasing positive sexual health behaviors.

A Qualitative Exploration of the Perceptions of Women Living with Pelvic Floor Disorders and Factors Related to Quality of Life

Background: Pelvic floor dysfunction encompasses conditions like urinary and fecal incontinence, pelvic organ prolapse, and pelvic pain, significantly affecting women's quality of life. Despite its prevalence, few studies have adopted a qualitative approach to understanding women's perceptions and emotions regarding these issues. This study aims to delve into how women with pelvic floor disorders perceive their condition and its impact on their daily lives. Methods: We analyzed qualitative data from interviews with 160 women suffering from pelvic floor dysfunctions. Using inductive qualitative content analysis, we systematically examined the data to identify variations, differences, and similarities. Results: The analysis revealed four primary themes in the women's narratives: "Physical Impacts", "Emotional and Psychological Impacts", "Social and Relational Impacts", and "Sexual Health Impacts", along with 12 subthemes. The findings predominantly highlight how pelvic floor dysfunctions detrimentally affect women's quality of life and emotional well-being, instilling fear and insecurity in daily activities, compounded by sleep disturbances and sexual dysfunction. Conclusions: Women living with pelvic floor dysfunction face multifaceted challenges that adversely affect various aspects of their lives, diminishing their overall quality of life. This includes notable impacts on sleep, physical, and sexual activities. However, not all affected women report these issues, often due to fear of stigma, choosing instead to conceal their struggles in an effort to maintain an appearance of normalcy.

Does the Surgical Margin Affect Sexual Function Following Linear Labiaplasty Technique?

BACKGROUND

How much labial tissue should be left after labiaplasty is a controversial issue.

OBJECTIVES

The objective was to investigate the effect of residual labial tissue following labiaplasty operations on sexual function.

METHODS

A total of 150 females who underwent labiaplasty between 2019 and 2021 and their partners were included in the study. In this retrospective study, linear labiaplasty technique was applied according to the patient's request. Patients were either below 1 cm or above 1 cm according to the remaining labial width at follow-up. The remaining labial tissues were classified according to the Motakef classification. Patients with a labial width above 1 cm were included in Group 1, and patients with a labial width below 1 cm were included in Group 2. Sexual function, sexual experience, body image, and erectile function of their partners were compared preoperatively and 2 years postoperatively with appropriate questionnaires.

RESULTS

Sexual function, sexual experience, and body image of females improved in all patients. However, the improvement was more apparent with with remaining labial tissue of greater than 1 cm. The increase in the survey results of the partners was found to be similar.

CONCLUSIONS

The sexual function of the patients was better when the width of the labium was longer than 1 cm. This may be due to better protection of the neurovascular structures. This favorable effect was also seen in the subjective evaluation of the partners.

LEVEL OF EVIDENCE: 3

Effect of knack technique on vaginal laxity in multiparous women: A randomized controlled trial

BACKGROUND

Vaginal laxity defined according to the International Urogynecological Association/International Continence society is excessive vaginal looseness; it is one of the most common symptoms of pelvic floor dysfunction, which refers to medical/functional disorders that can have a significant impact on a woman's sexual self-esteem and sexual life.

AIM

This study aimed to determine the impact of the Knack Technique on Pelvic floor muscle (PFM) and sexual function in women with vaginal laxity.

METHODS

Thirty females complaining of vaginal laxity were randomly chosen from the outpatient clinic at Deraya University. Their ages varied from 35 to 45 years, their body mass index was 25-30 kg/m2, and a number of parities ≤ three normal vaginal deliveries and at least two years from the last delivery complaining about vaginal laxity, water entrapment, and loss of friction during sexual intercourse. They were randomized into two equal groups at random (A, B). Group A (15 females) received (PSTES) and group B (15 females) received (PSTES) and Knack Technique. Both the groups received three sessions per week for 2 months.

EVALUATION

The outcome measures were evaluated through pre- and post-interventions by using ultrasonography imaging to assess PFM function, Sexual Satisfaction Index, and Vaginal Laxity Questionnaires (VLQ) to assess sexual function.

RESULTS

Analysis indicated a significant improvement in vaginal laxity in the two groups. Comparison between groups pre- and posttreatment showed that there was no statistically significant difference between the groups B and A in SSI and VLQ, while there were significant differences between the groups A and B in PFM force.

CONCLUSION

Combining Parasacral transcutaneous electrical stimulation (PSTES) and Knack Technique is more effective than PSTES alone in reducing vaginal laxity as well as improving PFM and sexual function in women with vaginal laxity.

Associations between Genital Self-Image and Individuals' Own and Perceived Partner Sexual Satisfaction

Negative genital self-image is linked with lower sexual satisfaction, but no research has examined its association with perceptions of partners' sexual satisfaction. In two studies (N = 475, N = 234), we examined links between genital self-image and own and individuals' perceived partner sexual satisfaction. In the second study, we tested whether a mindfulness intervention moderated these associations. In both studies, more negative genital self-image was significantly associated with individuals' lower own and perceived partner sexual satisfaction concurrently and over a two-week period. Mindfulness intervention exposure did not moderate associations. Findings support negative genital self-image as a risk factor for sexual dissatisfaction.

Relationship Involving Sexual Function, Distress Symptoms of Pelvic Floor Dysfunction, and Female Genital Self-Image

OBJECTIVE

 To assess the relationship involving sexual function (SF), the distress symptoms caused by pelvic floor dysfunction (PFD), and female genital self-image (GSI).

MATERIALS AND METHODS

 We assessed the GSI, SF and PFD distress symptoms by the Female Genital Self-Image Scale (FGSIS), the Female Sexual Function Index (FSFI), and the Pelvic Floor Distress Inventory (PFDI-20) respectively. Data were analyzed by multiple linear regression.

RESULTS

 Among the 216 women (age: 50.92 ± 16.31 years) who participated in the study, 114 were sexually active in the previous 4 weeks. In the total sample (p < 0.001; adjusted R2 = 0.097) and among sexually active women (p = 0.010; adjusted R2 = 0.162), the distress symptoms caused by pelvic organ prolapse (POP) were related to the GSI. Among sexually active women, sexual desire also was related to the GSI (p < 0.001; adjusted R2 = 0.126).

CONCLUSION

 The findings of the present study provide additional knowledge about female GSI and suggest that SF and POP distress symptoms should be investigated together with the GSI in the clinical practice.

Pelvic organ prolapse: The lived experience

BACKGROUND

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life. This study explores the lived experience of women with POP.

METHODOLOGY

A qualitative study was undertaken. Following institutional ethical approval women from an online peer support group (n = 930 members) were recruited to participate in semi-structured interviews. Inclusion criteria stipulated women (> 18years), pre-menopausal, at least one-year post-partum, diagnosed with POP and aware of their diagnosis. Semi-structured interviews were undertaken with a clinician specialising in pelvic health. A battery of questions was designed to elicit discussion on their experience of being diagnosed with POP and its impact on daily life and relationships. Interviews were carried out via Zoom, recorded and transcribed. Thematic analysis was undertaken.

FINDINGS

Fourteen women (32-41 years), para 1-3 participated. All had at least one vaginal birth; three had vacuum, four had forceps operative births. All had Grade 1-3 POP. Interviews lasted 40-100 minutes. Three core themes with subthemes were identified; biological/physical, psychological and social. Women were particularly affected in terms of sport and exercise participation, their own perceptions of their ability as mothers and fear of their condition worsening. They described societal attitudes, reporting stigma around POP and women's pelvic health in general, expectations placed on women to put up with their symptoms and an idealised perception of new motherhood.

CONCLUSIONS

The impact of POP from a biopsychosocial perspective reflects other chronic conditions. Prevention, early education and supports for developing strong self-management approaches would be beneficial for long term management of this condition.

Development of symptomatic pelvic organ prolapse over 10 years of mid-life follow-up is affected by occupational lifting and/or pushing for parous women

OBJECTIVE

To document the risk of new-onset symptomatic pelvic organ prolapse (POP) among perimenopausal women and examine whether occupational lifting and/or pushing is a risk factor in the development of POP over a 10-year follow-up window.

STUDY DESIGN

Secondary analysis of prospective, longitudinal data from the Study of Women's Health Across the Nation (SWAN) cohort study.

MAIN OUTCOME MEASURES

We analyzed women with current employment at the start of SWAN who were followed annually during mid-life. At baseline, women self-reported the frequency of occupational lifting and pushing, which was classified as Never, Infrequent (less than half the time), or Frequent (half the time or more) occupational lifting and/or pushing. Women were asked about new-onset symptomatic POP from the second to tenth annual follow-up. Modified Poisson regression was used to quantify crude and adjusted risk ratios (RRs) and 95 % confidence intervals (CIs) for POP according to load-bearing categories. Parous women were modelled separately, as initial analyses suggested effect modification by parity status.

RESULTS

In our sample of 1590 parous women, 8.2 % reported new-onset symptomatic POP over 10 years of follow-up. Multivariable analysis revealed that Infrequent (aRR 1.51, 95 % CI 1.04-2.20) and Frequent (aRR 2.03, 95 % CI 1.29-3.17) occupational lifting and/or pushing were associated with the development of POP.

CONCLUSION

Frequent occupational lifting and/or pushing significantly increased parous women's risk of developing POP symptoms. This strengthens existing evidence that occupational exposures can be risk factors for POP. Gender-based education and prevention strategies in the workplace and in primary health care are necessary to reduce the burden of this condition for mid-life women.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Effect of radiofrequency and pelvic floor muscle training in the treatment of women with vaginal laxity: A study protocol

Background

Vaginal laxity is an underreported condition that negatively affects women’s sexual function and their relationships. Evidence-based studies are needed to better understand this complaint and to discuss its treatment options. Thus, we present a study protocol to compare the effect of radiofrequency and pelvic floor muscle training in the treatment of women with complaints of vaginal laxity.

Methods/Design

This is a prospective, parallel-group, two-arm, randomized clinical trial (Registry: RBR-2zdvfp–REBEC). Participants will be randomly assigned to one of the two groups of intervention (Radiofrequency or Pelvic Floor Muscle Training). The study will be performed in the Urogynecology outpatient clinic and in the physiotherapy outpatient clinic at the State University of Campinas–UNICAMP and will include women aged ≥ 18 years and with self-reported complaints of vaginal laxity. Participants will be assessed at baseline (pre-intervention period) and will be followed up in two periods: first follow-up (30 days after intervention) and second follow-up (six months after intervention).

Expected results

The results of this randomized clinical trial will have a positive impact on the participants’ quality of life, as well as add value to the development of treatment options for women with complaints of vaginal laxity.

Trial registration

Registry: RBR-2zdvfp–Registro Brasileiro de Ensaios Clínicos–REBEC (19/02/2020).

Pelvic Organ Prolapse Takes Up Space in the Bedroom: A Mixed Method Exploration of the Circular Sexual Response Cycle in Women With Pelvic Organ Prolapse

OBJECTIVE

Pelvic organ prolapse (POP) is a multidimensional reproductive health issue, which negatively affects women's sexual well-being. Using the circular sexual response cycle as a framework, we sought to evaluate women's sexual experiences living with POP.

METHODS

Measures of genital self-image, sexual distress, sexual satisfaction, and sexual function were administered before conducting semistructured interviews. Participants were 16 heterosexual partnered women seeking surgical and nonsurgical treatment for symptomatic POP.

RESULTS

Standardized questionnaires indicated normal genital self-image, sexual satisfaction, and sexual function; however, sexual distress scores exceeded normal cutoffs. Eight themes emerged, including reasons for having sex, willingness to initiate and sexual receptivity, contextual factors, sexual stimuli, sexual arousal, responsive desire, outcomes, and spontaneous sexual desire. In contrast to quantitative findings, themes demonstrated sexual difficulty. Women with POP mainly engage in sex out of obligation and report reduced sexual initiation and receptiveness, as well as a negative impact on genital self-image. Pelvic organ prolapse was perceived to adversely affect subjective arousal, responsive desire, and spontaneous desire, despite intact physiological arousal. Difficulty experiencing subjective arousal was profound and seemed to be limited by preoccupation with POP. Sexual satisfaction and rewards were diminished after POP, including orgasmic capacity. Rewarding motivators to engage in sex were seldom discussed and often overshadowed by experiencing guilt and obligation related to sex.

CONCLUSIONS

The circular sexual response cycle largely fit participants' experiences; however, POP inhibits subjective arousal, which prevents responsive desire for many. Patients may need better support to cope with preoccupation with POP, indicating that addressing the psychosocial symptoms of POP should be prioritized.

Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS)

Introduction

Vaginal laxity (VL) is a sensation of vaginal looseness which may develop after pregnancy and vaginal delivery and may be affected by prior pelvic surgery, menopause and aging. Pelvic organ prolapse (POP) is a disorder in which pelvic organs descend from the normal position. VL has attracted recent attention due to the advent of energy-based treatments for this symptom.

Aim

To determine the correlation between VL symptoms and physical exam findings of POP, specifically the introital measurement of genital hiatus.

Methods

This was a multi-center cross-sectional study of sexually active women over 18 years of age with a parity of one or greater. Subjects completed the Vaginal Laxity Questionnaire (VLQ), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index (FSFI), and were asked if a sexual partner had commented on laxity. Subjects underwent pelvic exam, including the pelvic organ prolapse quantification (POP-Q).

Main Outcomes Measures

Correlation between VL symptoms as measured by the VLQ and POP as measured by elements of the POP-Q.

Results

A total of 95 subjects with an average age was 54.3 ± 13.18 years were included. Sixty-three percent of patients were postmenopausal. The average VLQ score was 4.2 ± 1.35 and the average FSFI score was 23.42 out of 36. There was no significant correlation between VLQ score and POP or mid-vaginal caliber. Sensation of vaginal tightness was significantly associated with age (P=0.03) and menopausal status (P=0.04). Only 28% of partners commented on laxity and the majority commented on the vagina being tight (21%) rather than loose (7%).

Conclusion

VL was not correlated with physical exam findings quantifying POP or sexual function. This study emphasizes the need to develop a more standardized definition of VL and a better assessment tool for VL symptoms.

Polland A, Duong V, Furuya R, et al. Description of Vaginal Laxity and Prolapse and Correlation With Sexual Function (DeVeLoPS). Sex Med 2021;9:100443.

Protocol for a prospective multisite cohort study investigating hysterectomy versus uterine preservation for pelvic organ prolapse surgery: the HUPPS study

INTRODUCTION

Pelvic organ prolapse (POP) is the descent of pelvic organs into the vagina resulting in bulge symptoms and occurs in approximately 50% of women. Almost 20% of women will elect surgical correction of this condition by age 85. Removal of the uterus (hysterectomy) with concomitant vaginal vault suspension is a long-standing practice in POP surgery to address apical (uterine) prolapse. Yet, contemporary evidence on the merits of this approach relative to preservation of the uterus through suspension is needed to better inform surgical decision making by patients and their healthcare providers. The objective of this study is to evaluate POP-specific health outcomes and service utilisation of women electing uterine suspension compared with those electing hysterectomy and vaginal vault suspension for POP surgery up to 1-year postsurgery.

METHODS AND ANALYSIS

This is a prospective cohort study planning to enrol 321 adult women with stage ≥2 POP from multiple sites in Alberta, Canada. Following standardised counselling from study surgeons, participants self-select either a hysterectomy based or uterine preservation surgical group. Data are being collected through participant questionnaires, medical records and administrative data linkage at four time points spanning from the presurgical consultation to 1-year postsurgery. The primary outcome is anatomic failure to correct POP, and secondary outcomes include changes in positioning of pelvic structures, retreatment, subjective report of bulge symptoms, pelvic floor distress and impact, sexual function and health service use. Data will be analysed using inverse probability weighting of propensity scores and generalised linear models.

ETHICS AND DISSEMINATION

This study is approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB19-2134). Results will be disseminated via peer-reviewed publications, presentations at national and international conferences, and educational handouts for patients.

TRIAL REGISTRATION NUMBER

NCT04890951.

Male Genital Self-Image Scale (MGSIS): Cutoff Point, Cultural Adaptation and Validation of Measurement Properties in Brazilian Men

BACKGROUND

Concerns about genital self-image (GSI) can influence sexual function and quality of life, and instruments that assess male GSI, such as the Male Genital Self-Image Scale (MGSIS), need to be adapted and validated in different cultures.

AIMS

To culturally adapt and validate the measurement properties of MGSIS in Brazilian men, according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline, and to create a cutoff point for satisfaction with male GSI.

METHODS

We assessed the validity of content through a committee of experts and cognitive interviews. The internal consistency and test-retest reliability were assessed using Cronbach's α and Intraclass Correlation Coefficient (ICC). We also calculate measurement errors using the Bland and Altman graph. The structural validity was investigated through exploratory and confirmatory factor analysis. The hypothesis test for construct validity was assessed using Spearman correlation from MGSIS with the International Index of Erectile Function (IIEF), Body Appreciation Scale (BAS-2) and Rosenberg Self-Esteem Scale (RSES). To create a cutoff point for satisfaction with the GSI, the item response theory and the classic test theory were used.

OUTCOMES

Male's (i) GSI, (ii) sexual function, (iii) body appreciation, and (iv) self-esteem were assessed.

RESULTS

In this study, 518 men with a mean age of 33.90 (±13.83) years participated. The Brazilian version of MGSIS demonstrated good content validity and a single factor that explained 64.57% of the variance. Cronbach's α and ICC values were 0.905 and 0.806, respectively. By assessing measurement errors, we found no systematic bias in the sample. MGSIS showed a moderate to weak correlation with IIEF, BAS-2 and RSES. A cut-off point of 23 in the MGSIS total score was found to rate satisfaction with the GSI.

CLINICAL TRANSLATION

MGSIS is a valid and reliable measurement instrument for measuring male GSI in Brazil.

STRENGTHS AND LIMITATIONS

This study evaluated the measurement properties of MGSIS according to COSMIN, which is a powerful and useful guideline for measurement properties. However, due to the lack of a gold standard for measuring the GSI, we have not assessed the criterion validity.

CONCLUSION

MGSIS is valid, reliable and can be useful to assess the GSI and classify the satisfaction with the GSI of Brazilian men. de Arruda GT, da Silva EV, Braz MM. Male Genital Self-Image Scale (MGSIS): Cutoff Point, Cultural Adaptation and Validation of Measurement Properties in Brazilian Men. J Sex Med 2021;18:1759-1767.

Methods for the defining mechanisms of anterior vaginal wall descent (DEMAND) study

INTRODUCTION AND HYPOTHESIS

The protocol and analysis methods for the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study are presented. DEMAND was designed to identify mechanisms and contributors of prolapse recurrence after two transvaginal apical suspension procedures for uterovaginal prolapse.

METHODS

DEMAND is a supplementary cohort study of a clinical trial in which women with uterovaginal prolapse randomized to (1) vaginal hysterectomy with uterosacral ligament suspension or (2) vaginal mesh hysteropexy underwent pelvic magnetic resonance imaging (MRI) at 30-42 months post-surgery. Standardized protocols have been developed to systematize MRI examinations across multiple sites and to improve reliability of MRI measurements. Anatomical failure, based on MRI, is defined as prolapse beyond the hymen. Anatomic measures from co-registered rest, maximal strain, and post-strain rest (recovery) sequences are obtained from the "true mid-sagittal" plane defined by a 3D pelvic coordinate system. The primary outcome is the mechanism of failure (apical descent versus anterior vaginal wall elongation). Secondary outcomes include displacement of the vaginal apex and perineal body and elongation of the anterior wall, posterior wall, perimeter, and introitus of the vagina between (1) rest and strain and (2) rest and recovery.

RESULTS

Recruitment and MRI trials of 94 participants were completed by May 2018.

CONCLUSIONS

Methods papers which detail studies designed to evaluate anatomic outcomes of prolapse surgeries are few. We describe a systematic, standardized approach to define and quantitatively assess mechanisms of anatomic failure following prolapse repair. This study will provide a better understanding of how apical prolapse repairs fail anatomically.

Investigating the birth-related caudal maternal pelvic floor muscle injury: The consequences of low cycle fatigue damage

BACKGROUND

One of the major causes of pelvic organ prolapse is pelvic muscle injury sustained during a vaginal delivery. The most common site of this injury is where the pubovisceral muscle takes origin from the pubic bone. We hypothesized that it is possible for low-cycle material fatigue to occur at the origin of the pubovisceral muscle under the large repetitive loads associated with pushing during the second stage of a difficult labor.

PURPOSE

The main goal was to test if the origin of the pubovisceral muscle accumulates material damage under sub-maximal cyclic tensile loading and identify any microscopic evidence of such damage.

METHODS

Twenty origins of the ishiococcygeous muscle (homologous to the pubovisceral muscle in women) were dissected from female sheep pelvises. Four specimens were stretched to failure to characterize the failure properties of the specimens. Thirteen specimens were then subjected to relaxation and subsequent fatigue tests, while three specimens remained as untested controls. Histology was performed to check for microscopic damage accumulation.

RESULTS

The fatigue stress-time curves showed continuous stress softening, a sign of material damage accumulation. Histology confirmed the presence of accumulated microdamage in the form of kinked muscle fibers and muscle fiber disruption in the areas with higher deformation, namely in the muscle near the musculotendinous junction.

CONCLUSIONS

The origin of ovine ishiococcygeous muscle can accumulate damage under sub-maximal repetitive loading. The damage appears in the muscle near the musculotendinous junction and was sufficient to negatively affect the macroscopic mechanical properties of the specimens.

Safety and efficacy of ischial spine fascia and sacrospinous ligament fixation for symptomatic stage 2 and 3 apical prolapse

OBJECTIVE

To compare safety, efficacy, and impact on quality of life (QoL) between ischial spine fascia fixation (ISFF) and sacrospinous ligament fixation (SSLF) for stage 2-3 pelvic organ prolapse (POP).

METHOD

A prospective cohort study among women with POP attending a national referral university hospital in Beijing, China, between May 2007 and May 2015. Women underwent either ISFF or SSLF. Primary end point was objective success rates at 3 months after surgery. Exploratory outcomes included perioperative parameters, complications, subjective satisfaction rates and QoL at 1 year.

RESULTS

There was no difference in baseline characteristics between the groups (all P>0.05). After ISFF and SSLF, the objective success rate at 3 months was 100% and 98.1% (P>0.99), the recurrence rate at 1 year was 5.3% and 8.3% (P=0.266), and the subjective satisfaction rate at 1 year was 97.8% and 97.9%, respectively. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 scores improved significantly after ISFF. De novo urinary incontinence occurred for 5.3% and 6.3% of women, respectively, and de novo dyspareunia for approximately 14% of women in both groups.

CONCLUSION

ISFF was found to be a safe and effective alternative to SSLF for women with symptomatic stage 2 and 3 POP.

Is voluntary pelvic floor muscles contraction important for sexual function in women with pelvic floor disorders?

AIMS

To investigate relationships between pelvic floor muscles (PFM) and sexual function (SF) in sexually active (SA) and not-SA (NSA) women with pelvic floor disorders (PFD).

METHODS

In 350 women with PFD: 173 (49.4%) SA, 177 (50.6%) NSA, Pelvic Organ Prolapse (POP)-Quantification, PFM tone, and strength were evaluated. Transperineal ultrasound (TPS) measured genital hiatus (GH) diameter, bladder neck (BN) movement. Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), and Female Sexual Function Index (FSFI) were used. SA women were dichotomized according to muscle strength (weak/strong) and tone (normal/hypoactive).

RESULTS

FSFI scores reflected sexual dysfunction in 63.5% SA women. 32.2% partnered NSA stated PFD the reason for sexual inactivity. NSA women had higher POP stages and hypoactive PFM rates compared to SA: 72 (40.7%) vs 52 (30.1%), P = .04. TPS GH diameter did not differ between SA and NSA at rest, contraction, and did not correlate with SF. BN length was longer in SA at rest (15.0 ± 7.0 vs 13.1 ± 9.4, P = .03) and contraction (19.7 ± 7.0 vs 16.7 ± 10.2, P = .006); 30 (8.6%) subjects depressed BN during contraction. GH change at contraction correlated with Oxford Grading Scale (r_ps  = 0.41; P < .001), and was smaller in women with nonfunctioning vs normal/underactive PFM (P < .001). Women with hypoactive PFM had lower SF in PISQ-IR Global quality and FSFI Desire domains vs normal tone. BN length at rest, contraction, and total mobility correlated with several PISQ-IR and FSFI domains.

CONCLUSIONS

In SA women with PFD, lower rates of hypoactive PFM tone were found. The ability to contract PFM did not influence SF. Greater mobility of BN correlated with lower SF.

Sexual Function and Socio-Sexual Difficulties in Women with Polycystic Ovary Syndrome (PCOS)

Introduction PCOS is the most common endocrine syndrome in women of the reproductive age that has manifold effects on the life of affected women. Little scientific attention has been devoted to these womenʼs sexual lives.

Aim To investigate sexual quality of life in women with PCOS.

Methods The sample size was n = 44. Measures employed were: An extended list of sexual dysfunctions and perceived distress based on DSM-IV-TR, Female Sexual Function Index (FSFI), German Questionnaire on Feelings of Inadequacy in Social and Sexual Situations (FUSS), Rosenberg Self-Esteem Scale (RSE), Brief Symptom Inventory (BSI) subscale depression. The relationships of these components were examined including further variables (body mass index, degree of hirsutism using the Ferriman-Gallwey Score, wish for a child). An open question about what participants see as the source of their sexual problems was presented.

Results Only moderate impairment in sexual function was detected, but feelings of inadequacy in social and sexual situations were markedly elevated and positively correlated with the degree of hirsutism. Depression showed to be a major problem.

Conclusion Patients with PCOS should be screened for socio-sexual difficulties and emotional problems. Specialized psychological and sexological counselling can complement patient care.

The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment

INTRODUCTION

Many conditions of pelvic and sexual dysfunction can be addressed successfully through pelvic floor physical therapy (PFPT) through various manual therapy techniques, neuromuscular reeducation, and behavioral modifications. The field of pelvic rehabilitation, including sexual health, continues to advance to modify these techniques according to a biopsychosocial model.

AIM

To provide an update on peer-reviewed literature on the role of PFPT in the evaluation and treatment of pelvic and sexual dysfunctions in men and women owing to the overactive and the underactive pelvic floor.

METHODS

A literature review to provide an update on the advances of a neuromusculoskeletal approach to PFPT evaluation and treatment.

MAIN OUTCOME MEASURE

The use and advancement of PFPT methods can help in successfully treating pelvic and sexual disorders.

RESULTS

PFPT for pelvic muscle overactivity and underactivity has been proven to be a successful option for pelvic and sexual dysfunction. Understanding the role of the organs, nerves, fascia, and musculoskeletal system in the abdomino-pelvic and lumbo-sacro-hip region and how pelvic floor physical therapists can effectively evaluate and treat pelvic and sexual health. It is important for the treating practitioner to know when to refer to PFPT.

CONCLUSION

Neuromusculoskeletal causes of pelvic floor disorders affect a substantial proportion of men, women, and children and PFPT is a successful and non-invasive option. Pelvic floor examination by healthcare practitioners is essential in identifying when to refer to PFPT. Use of a biopsychosocial model is important for the overall well-being of each patient. Further research is needed. Stein A, Sauder SK, Reale J. The role of physical therapy in sexual health in men and women: Evaluation and treatment. Sex Med Rev 2019;7:46-56.

Recovering sexual satisfaction after prolapse surgery: a secondary analysis of surgical recovery

INTRODUCTION AND HYPOTHESIS

We compared pre- and postoperative sexual function scores in sexually active women undergoing pelvic organ prolapse (POP) surgery.

METHODS

Planned secondary analysis of women enrolled in the Restricted Convalescence: Outcomes Following Urogynecologic Procedures study, a randomized trial of postoperative activity after POP surgery. All participants could return to sexual activity at 6 weeks. Participants completed the Pelvic Floor Distress Inventory (PFDI), the Patient-Reported Outcomes Measurement Information System (PROMIS) profile, and the Golombok Rust Inventory of Sexual Satisfaction (GRISS) questionnaires at baseline and 3 months. GRISS is a validated 28-item survey for heterosexual couples that contains seven subscales to assess sexual function. Higher scores represent worse sexual function.

RESULTS

Thirty-seven sexually active women were assessed. Mean age ±  standard deviation (SD) was 56 ± 11, most of whom (92%) were Caucasian; 78% had undergone minimally invasive sacrocolpopexy, and the remainder had native tissue vaginal repairs. GRISS scores improved 3 months after surgery [4.5 ± 2.6 to 3.6 ± 2.2, p < 0.001; mean decrease of 0.9, 95% confidence interval (CI) 0.36-1.36]. PFDI scores improved from 122 ± 53 at baseline to 28 ± 31 at 3 months (p < 0.001). Higher GRISS scores were correlated with higher PFDI scores (Spearman's rho = 0.35, p = 0.03) at baseline and 3 months (Spearman's rho = 0.31, p = 0.03). Several GRISS subscales improved after surgery: partner avoidance (p = 0.01), vaginismus (p = 0.02), noncommunication (p = 0.01), dissatisfaction (p = 0.03), and anorgasmia (p = 0.001). However, sexual infrequency (p = 0.08) and nonsensuality (p = 0.4) did not change. Fifty-one percent had sexual dysfunction before surgery, which decreased to 32% after surgery (p = 0.04).

CONCLUSION

Sexual function and satisfaction are significantly improved 3 months following POP surgery. Improved sexual function is correlated with improved pelvic floor symptoms.

A Scoping Study of Psychosocial Factors in Women Diagnosed With and/or Treated for Pelvic Organ Prolapse

OBJECTIVE

Pelvic organ prolapse (POP) is prevalent and can impact women's physical and psychosocial health. To develop interventions that support this population, an understanding of the state of research on psychosocial factors related to POP is essential. We conducted a scoping study focused on the psychosocial experience of women with POP. The purpose of this review was to (1) inventory and describe the current state of knowledge of the psychosocial experience of women with POP, (2) identify gaps in knowledge, and (3) identify targets for future research.

METHOD

Electronic databases PsycINFO, PubMed, EMBASE, and CINAHL were searched through November 1, 2017.

RESULTS

Of 524 titles reviewed, 103 articles met all inclusion criteria. Articles were grouped by the disease period (ie, prediagnosis, diagnosis/preintervention, intervention, follow-up, and mixed) and psychosocial factors. Most articles (n = 73) focused on women undergoing intervention. Articles focusing on the preintervention period was the next largest category (n = 14). Follow-up after intervention (n = 8) and samples of mixed disease periods (n = 7) were less common. One article focused on women before diagnosis. Articles focused on quality of life (QOL; n = 79), sexual function (n = 51), satisfaction (n = 16), body image (n = 13), psychological distress (n = 4), and knowledge (n = 3).

CONCLUSIONS

Research on the psychosocial experience of POP has largely focused on changes in QOL and sexual function. Future research should target emotional experience of women with POP; relationships among QOL, psychological distress, body image, and sexual function; and psychosocial factors related to treatment outcomes.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Body Image, Regret, and Satisfaction 24 Weeks After Colpocleisis: A Multicenter Study

OBJECTIVE

To evaluate the impact of colpocleisis on body image, regret, satisfaction, and pelvic floor symptoms 24 weeks after surgery.

METHODS

This was a prospective multicenter study conducted through the Society of Gynecologic Surgeons' Fellows' Pelvic Research Network with 7 sites across the United States. Women undergoing colpocleisis were enrolled. Outcomes assessed at 24 weeks included body image, regret, satisfaction, and pelvic floor symptoms. The Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory, the modified Body Image Scale, the Decision Regret Scale, and the Satisfaction with Decision Scale were administered. A sample size of 88 subjects was calculated for a significant change in the Body Image Scale.

RESULTS

Ninety subjects were enrolled. Two did not undergo surgery, and 7 were deceased at the time of 24-week follow-up. Significant improvements in all pelvic floor symptoms were noted 6 weeks postoperatively, and 24-week data showed sustained improvement. In addition, mean and total body image scores showed lasting significant improvement when compared with preoperative scores (P < 0.001 and P < 0.001, respectively). Finally, patients continued to be satisfied with their decision to undergo surgery (mean [SD] 4.6, [0.6]) and had a very low level of regret regarding this decision (mean [SD], 1.5 [0.7]).

CONCLUSIONS

Colpocleisis is a highly effective surgical treatment option for pelvic organ prolapse with improvements in both pelvic floor symptoms and body image. Furthermore, high satisfaction and low regret seen 24 weeks after surgery provide reassurance that colpocleisis is an excellent option for appropriate patients.

Body after baby: a pilot survey of genital body image and sexual esteem following vaginal birth

OBJECTIVE

The aim of this study was to determine acceptability of the Vaginal Changes Sexual and Body Esteem (VSBE) scale for women post childbirth and explore the association between childbirth events and sexual/body esteem.

DESIGN

This is a cross-sectional study within the Evaluating Maternal Recovery from Labor and Delivery study.

SETTING

This study was conducted in a community setting.

POPULATION

The study was conducted in women post first vaginal birth with birth events that posed risk factors for levator ani muscle tears.

METHODS

Survey, magnetic resonance images of levator ani, and physical examination were the data collected 8 months postpartum. Birth variables were collected by hospital chart review. Descriptive analysis of VSBE response rates and distribution of responses was conducted. An exploratory analysis of the potential association of demographic, birth, clinical, and magnetic resonance image characteristics with VSBE scores was conducted.

MAIN OUTCOME MEASURES

The outcome measure used in this study is VSBE scale.

RESULTS

The majority of participants (97%) completed the scale, with responses to most questions skewed toward positive sexual/body esteem, with the exception of sexual enjoyment, where 38% indicated some interference due to genital changes. The scale showed high internal consistency (alpha =0.93). In the exploratory analysis of potential characteristics associated with VSBE, women with episiotomies had lower sexual/body esteem compared to those who did not (median VSBE scores 35 vs 42.5, P=0.01). Anal sphincter tear was not associated with sexual/body esteem (P=0.78). Additional study is indicated to further explore observed trends toward the association of severe levator ani tear, maternal age at childbirth, and forceps with VSBE scores.

CONCLUSION

The VSBE is suitable for use to assess sexual/body esteem in women post childbirth. Most women in this sample did not indicate negative genital body image/sexual esteem. However, some indicated that the changes post birth negatively affected their sexual/body esteem, particularly those who had episiotomies.

The impact of genital self-image on sexual function in women with pelvic floor disorders

OBJECTIVE

There is conflicting evidence regarding the impact of urinary incontinence and pelvic organ prolapse on overall sexual function. However, psychological variables thought to be associated with sexual function, have not been fully explored. We assessed the sexual functioning of women with pelvic floor disorders while measuring for psychological factors such as distress and genital self-image.

STUDY DESIGN

In a cross-sectional study, 155 women in an urogynecology outpatient clinic of a tertiary health center completed a demographic questionnaire, the Brief Symptom Index-18 (BSI-18), Pelvic Floor Distress Inventory-20 (PFDI-20), Genital Self-Image Scale-20 (GSIS-20) and the Female Sexual Function Index (FSFI).

RESULTS

Linear regression showed that when controlling for age and depression, GSIS significantly predicted FSFI total score (Beta=0.38, p<0.001) and the Desire subscale (Beta=0.55, p<0.001). Due to the low response rate in the GSIS and FSFI questionnaires, a preliminary analysis was conducted to characterize the responders. On univariate logistic regression, response to the GSIS was negatively correlated with age (OR=0.94, p=0.02) and being in a relationship (OR=2.3, p=0.016), yet the effect of being in a relationship was diminished in a multivariate model that included age.

CONCLUSION

The main variable associated with overall sexual function in women with pelvic floor disorders was low genital self-image. This variable is more important than self-reported symptoms, type of specific disorder or other demographic variables. Older women tended not to complete the scales concerning more intimate matters. We suggest that urogynecologists should inquire about genital self-image as well as sexual function in this population.

Genital Self-Image and Considerations of Elective Genital Surgery

The present study explores how genital self-image may be related to considerations of surgically altering one's genitals and documents the wanted genital changes among young adults. Evidence of a nontrivial proportion of respondents (98 of 1,110) had seriously considered elective genital surgery. Regression models indicate that, for both men and women, identifying as heterosexual and reporting lower composite genital self-image scores results in higher odds of considering genital surgery. Additionally for men, feeling unsatisfied with penis size increased the odds. Clinical and educational efforts to normalize and celebrate genital variation may influence considerations for genital modification in young adults.

Female Cosmetic Genital Surgery: Delivering What Women Want

Female cosmetic genital surgery (FCGS) is the latest and fastest growing sub-specialty in the broad specialty of gynecology. It encompasses procedures designed to change aesthetic and/or functional aspects of women's genitalia. In case of FCGS, there is difficulty in separating purely aesthetic concerns from medical concerns, because there is much overlap. The initial controversies over FCGS have almost settled down in the light of the mounting scientific evidence suggesting that a number of procedures that currently exist are safe, effective, and capable of treating to a considerable extent the suite of conditions associated with course-of-life vulvo-vaginal changes. Also, the rapidly expanding demands that have arisen for FCGS procedures from women across the globe have made it imperative for the reconstructive pelvic surgeons to master the cosmetic genital procedures so as to deliver the women what they want, in the most scientific manner. The issue of asking for and provisioning of FCGS is essentially a matter of individual patient and physician decision-making.

Evaluation of Body Image and Sexual Satisfaction in Women Undergoing Female Genital Plastic/Cosmetic Surgery

BACKGROUND

Little prospective data exists regarding the procedures constituting female genital plastic/cosmetic surgery (FGPS).

OBJECTIVES

To evaluate whether the procedures of labiaplasty and vaginoperineoplasty improve genital self image, and evaluate effects on sexual satisfaction.

METHODS

Prospective cohort case-controlled study of 120 subjects evaluated at baseline, 6, 12, and 24 months postoperative, paired with a demographically similar control group. Interventions include labiaplasty, clitoral hood reduction, and/or aesthetic vaginal tightening, defined as perineoplasty + "vaginoplasty" (aka "vaginal rejuvenation."). Outcome measures include body image, genital self-image, sexual satisfaction, and body esteem.

RESULTS

As a group, study patients tested at baseline showing body dissatisfaction, negative genital self-image, and poorer indices of sexual satisfaction. Preoperative body image of study patients were in a range considered to be mild to moderately dysmorphic, but matched controls at one and two years; genital self-image scores at entry were considerably lower than controls, but by 2-year follow-up had surpassed control value at entry. Similarly, sexual satisfaction values, significantly lower at entry, equaled at one, and surpassed control values, at 2 years. Postoperatively, at all points in time, these differences in body image and genital self-image disappeared, and sexual satisfaction markedly improved. Overall body esteem did not differ between study and control groups, with the exception of the genital esteem quotient, which improved after surgery.

CONCLUSIONS

Women requesting and completing FGPS, when tested by validated instruments, at entry report sexual dissatisfaction and negative genital self-image. When tested at several points in time after surgery up to two years, these findings were no longer present. When performed by an experienced surgeon, FGPS appears to provide sexual and genital self-image improvement.

LEVEL OF EVIDENCE

2 Therapeutic.

Finite element model focused on stress distribution in the levator ani muscle during vaginal delivery

Introduction and hypothesis

During vaginal delivery, the levator ani muscle (LAM) undergoes severe deformation. This stress can lead to stretch-related LAM injuries. The objective of this study was to develop a sophisticated MRI-based model to simulate changes in the LAM during vaginal delivery.

Methods

A 3D finite element model of the female pelvic floor and fetal head was developed. The model geometry was based on MRI data from a nulliparous woman and 1-day-old neonate. Material parameters were estimated using uniaxial test data from the literature and by least-square minimization method. The boundary conditions reflected all anatomical constraints and supports. A simulation of vaginal delivery with regard to the cardinal movements of labor was then performed.

Results

The mean stress values in the iliococcygeus portion of the LAM during fetal head extension were 4.91–7.93 MPa. The highest stress values were induced in the pubovisceral and puborectal LAM portions (mean 27.46 MPa) at the outset of fetal head extension. The last LAM subdivision engaged in the changes in stress was the posteromedial section of the puborectal muscle. The mean stress values were 16.89 MPa at the end of fetal head extension. The LAM was elongated by nearly 2.5 times from its initial resting position.

Conclusions

The cardinal movements of labor significantly affect the subsequent heterogeneous stress distribution in the LAM. The absolute stress values were highest in portions of the muscle that arise from the pubic bone. These areas are at the highest risk for muscle injuries with long-term complications.

The Impact of Sacrospinous Hysteropexy and Vaginal Hysterectomy With Suspension of the Uterosacral Ligaments on Sexual Function in Women With Uterine Prolapse: A Secondary Analysis of a Randomized Comparative Study

INTRODUCTION

Studies on pelvic organ prolapse (POP) surgery show conflicting evidence regarding the impact of uterus preservation and hysterectomy on sexual function and no large randomized trials with long-term follow-up have been published on this topic.

AIMS

The aim of this secondary analysis was to evaluate and compare sexual function after sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse.

METHODS

This is a secondary analysis of the SAVE U trial data, a multicenter trial in 4 nonuniversity hospitals in the Netherlands comparing sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments in primary surgery of uterine prolapse stage II or higher. Primary outcome of the original study was recurrent prolapse stage II or higher of the uterus or vaginal vault (apical compartment) evaluated by POP-Q examination in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months follow-up. Secondary outcomes were overall anatomical recurrences, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning. Data from patients who had completed the POP/urinary incontinence sexual questionnaire (PISQ-12) at baseline and 24 months after surgery were used in the present trial. Total, subscale, and individual question analyses were performed. The SAVE U trial is registered in the Dutch trial registry, number NTR1866.

MAIN OUTCOME MEASURES

Differences and changes in sexual function 24 months after surgery, measured by the PISQ-12 questionnaire.

RESULTS

Between November 2009 and March 2012, 208 women were randomized between sacrospinous hysteropexy (n = 103) and vaginal hysterectomy with suspension of the uterosacral ligaments (n = 105). Of these, 99 women completed questionnaires at baseline and after 24 months follow-up and were included in the present study. During a follow-up period of 24 months, no significant differences in total PISQ-12 scores were observed between the groups. After both interventions the item "avoidance of intercourse due to prolapse" significantly improved, as did the physical subscale of the PISQ-12 questionnaire.

CONCLUSION

There was no statistically significant difference in overall sexual functioning (total PISQ-12 scores) between uterus-preserving sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments after a follow-up period of 24 months.

Body image in the Pelvic Organ Prolapse Questionnaire: development and validation

OBJECTIVE

The purpose of this study was to develop and validate a prolapse-specific body image questionnaire.

STUDY DESIGN

Prolapse-specific body image themes that were identified in our previous work served as a framework for the development of a question pool. After review for face and content validity and reading level, the question pool was reduced to 21 items that represent predominant themes and that form the initial Body Image in Pelvic Organ Prolapse (BIPOP) questionnaire. Women with symptomatic prolapse of Pelvic Organ Prolapse Quantification (POPQ) of more than stage II were enrolled from 2 academic urogynecology practices; they completed questionnaires on pelvic floor symptoms and distress, general body image, depression, self-esteem, and the BIPOP questionnaire, and they underwent the POPQ. We field-tested the BIPOP questionnaire with approximately 200 participants; 10 women completed cognitive interviews, and 100 women repeated the BIPOP questionnaire to assess test-retest reliability.

RESULTS

Two hundred eleven participants were enrolled, and 201 women had complete data. Participants had mean age of 60.2 ± 10.5 years, were predominantly white (98%), were partnered (80%), and had median POPQ stage III. Cognitive interviews confirmed comprehension and clarity of questions and acceptability of length and subject matter. Exploratory factor analysis was performed in an iterative process until a parsimonious, 10-item scale with 2 subscales was identified (subscale 1 represented general attractiveness; subscale 2 represented partner-related prolapse reactions). Cronbach's α score for the subscales were 0.90 (partner) and 0.92 (attractiveness). Correlations between related questionnaires and BIPOP subscales were strong and directionally appropriate. Test-retest correlations on both total and subscale measurements were high.

CONCLUSION

We developed and validated a prolapse-specific body image measurement that has face and content validity, high internal consistency, strong correlation with general prolapse and body image measures, and strong test-retest reliability.

The management of pelvic organ prolapse in England: a 4-year analysis of hospital episode statistics (HES) data

The aim of this study was to establish the number and trend of surgical procedures and pessary management of pelvic organ prolapse in England, using Hospital Episode Statistics (HES) data. An online search ( www.hesonline.nhs.uk ) was carried out. The number of various surgical procedures, as well as pessary insertions and removals for pelvic organ prolapse was obtained. Data were available for the 4-year period March 2002 to June 2005. Over 20,000 procedures performed and 600 pessaries inserted annually. The total number of patients having treatment for pelvic organ prolapse as well as the number of patients having surgery and pessary in English hospitals increased by < 10% over the previous year in 2 of the 4 years included and decreased by < 1% in one. Anterior vaginal wall repair was the commonest performed procedure for pelvic organ prolapse and sacrocolpopexy appears to be the most frequent procedure for post-hysterectomy vaginal vault prolapse. There was no change in trends between surgery and pessary over the studied 4-year interval (p < 0.05). The lack of specific codes precluded providing more detailed information. The availability of data sooner and for longer periods as well as the use of more specific codes are needed to provide more useful information.

Long-term follow-up after colpocleisis: regret, bowel, and bladder function

INTRODUCTION AND HYPOTHESIS

Colpocleisis is not a popular option amongst surgeons, possibly due to concern about long-term regret. This study assessed a cohort of women who underwent colpocleisis 2-5 years previously to determine the regret rate, the effect on quality of life (QOL) and bladder and bowel function.

METHODS

This was a longitudinal study of patients who underwent colpocleisis at least 2 years previously. Participants were asked to complete the Prolapse QOL (P-QOL), International Consultation on Incontinence-Urinary Incontinence (ICIQ-UI Short Form) and Colorectal Anal Distress Inventory questionnaires (CRADI). Two additional questions were asked: (1) Do you regret having vaginal closure surgery for prolapse? (never, sometimes, often, all the time), and (2) Would you recommend this surgery to a relative or friend who is not sexually active? (yes, no.)

RESULTS

Thirty-four women were identified. Six had died by the time of follow-up, and five declined to answer the questionnaires because of ill health. Twenty-three women responded (67 %). Mean age was 78.68 years. One woman regretted having had the surgery, as the colpocleisis had failed. Twenty-one women (91.3 %) would recommend this surgery; one would not (4.3 %), and another was not sure (4.5 %). Low P-QOL [8 (0-37) ± 9.41), ICIQ-UI (7 (0-17) ± 5.44) and CRADI (10; 0-28 ± 8.13] scores suggest a positive impact on QOL, bladder and bowel function.

CONCLUSION

In this cohort, colpocleisis produced a good outcome with low regret rate (4.3 %), good QOL and minimal effect on bladder and bowel function at 2-5 years.

Body image, regret, and satisfaction following colpocleisis

OBJECTIVE

Colpocleisis is a definitive surgical treatment for prolapse resulting in vaginal obliteration. We sought to evaluate body image, regret, satisfaction, and pelvic floor symptoms following this procedure.

STUDY DESIGN

This was a prospective multicenter study through the Fellows' Pelvic Research Network. All women electing colpocleisis for management of pelvic organ prolapse were screened for enrollment. The Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory, and the modified Body Image Scale (BIS) were completed preoperatively and 6 weeks following surgery. Additionally, the Decision Regret Scale and the Satisfaction with Decision Scale were administered at the 6-week postoperative visit. A sample size of 88 subjects was calculated to evaluate change in the BIS score.

RESULTS

In all, 87 patients were analyzed. Mean age was 79 years (SD 5.8) with a mean body mass index of 27 (SD 5.3). The majority (89.3%) was Caucasian. Six weeks after surgery, significant improvements were noted in all parameters. Mean BIS scores decreased from 4.8 to 1.2 (P < .001), signifying improved body image. Indeed, the overall number of subjects with BIS scores in the normal range doubled after surgery. Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire scores decreased significantly (P < .001 and P < .001), suggesting a positive impact on bladder, bowel, and prolapse symptoms. Finally, low levels of regret (mean score 1.35) and concurrent high satisfaction (mean score 4.73) were documented.

CONCLUSION

Colpocleisis improves body image and pelvic floor symptoms while giving patients a definitive surgical option that results in low regret and high satisfaction.

Cross-cultural adaptation of the Female Genital Self-Image Scale (FGSIS) in Iranian female college students

The aim of the present study was to investigate the psychometric properties of a translated and culturally adapted Iranian version of the Female Genital Self-Image Scale (FGSIS-I) in a sample of college women. Further, the relationship between women's self-image, body appreciation, sexual functioning, and gynecological exam behavior was explored. A sample of 1,877 female students from five different universities across Qazvin and Tehran completed the Female Sexual Function Index (FSFI), the Body Appreciation Scale (BAS), the Rosenberg Self-Esteem Scale (RSES), the FGSIS-I, and a gynecological exam behavior questionnaire. Good to excellent internal consistency reliability, test-retest reliability, and convergent and construct validity were found. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) both provided a two-factor structure for the FGSIS-I. The validity of the FGSIS-I in predicting gynecological exam behavior of college women was tested using structural equation modeling (SEM). The final model accounted for 33% of the variance in gynecological exam behavior (p < 0.01). In conclusion, the FGSIS-I was found to be a highly valid and reliable instrument to assess female genital self-image in Iranian women.

Laxity of the vaginal introitus after childbirth: nonsurgical outpatient procedure for vaginal tissue restoration and improved sexual satisfaction using low-energy radiofrequency thermal therapy

INTRODUCTION

Vaginal childbirth may result in vaginal introital laxity, altered genital sensation during sexual intercourse, and reduced sexual satisfaction. We report the long-term effectiveness of a single nonsurgical procedure with radiofrequency (RF) energy for laxity at the vaginal introitus.

MATERIALS AND METHODS

Prospective single-arm study of 30 premenopausal women (21-52 year) with one 30-minute office procedure using RF applied to the vaginal introitus; 12-month outcome assessments included the linguistic validated Japanese versions of the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) and the Vaginal Laxity and Sexual Satisfaction Questionnaires.

RESULTS

Sexual function improved significantly throughout 6 months (30 subjects); mean FSFI total score was 22.4±6.7 before treatment and then improved to mean 26.0±5.8 at month 6 (P=0.002), inclusive of improved scores in five of six FSFI domains except desire (P<0.001 -<0.01). In the 22 of 30 subjects remaining evaluable at 12 months, the mean was 26.0±5.2 (P=0.08). Distress related to sexual activity decreased significantly; baseline FSDS-R mean score of 15.8±11.7 improved to 9.8±8.0 at one month and was sustained throughout 12 months (P<0.001 - 0.002). Subjects reported decreased vaginal laxity within the first month after the procedure (P<0.001); responses peaked, and effectiveness was sustained through 12 months (P<0.001).

CONCLUSIONS

A single nonsurgical office-based RF procedure for vaginal introital laxity achieved significant and sustainable 12-month effectiveness with respect to improved integrity at the vaginal introitus and improved sexual satisfaction. Treatment was well-tolerated with no adverse events.