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Original articles

The effect of vaginal hysterectomy with and without sacrospinous ligament fixation on the female sexual function

a retrospective study

El-Sabaa, Haitham; Tamara, Tarek; Kamel, Mostafa M.

Author Information
Evidence Based Women's Health Journal: August 2014 - Volume 4 - Issue 3 - p 155-158
doi: 10.1097/01.EBX.0000451488.57468.7e
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Abstract

Introduction

Hysterectomy is the most common practiced major operation in women. Vaginal bleeding, chronic pelvic pain, and symptomatic fibroids are the most common causes for this elective procedure 1. Removal of the uterus by the vaginal route is an alternative to abdominal hysterectomy in the parous woman, as it has no greater chance of interfering with sexual activity, and may have different merits over the abdominal procedure 2.

Vaginal vault prolapse has been defined by the International Continence Society as descent of the vaginal cuff below a point, that is, 2 cm less than the vaginal length above the plane of the hymen 2. Sacrospinous ligament fixation (SSF) was first described by Sederl in 1958 and later popularized in Europe by Ritcher and Albright, and in the USA by Radall and Nicholas 3. Women’s quality of life may be affected in case of prolapse owing to associated urinary, anorectal, and coital dysfunction 4. The best procedure for restoration of vaginal vault prolapse remains controversial, with abdominal and vaginal routes commonly utilized. A single procedure based on the surgeon’s preference is not usually optimal. Procedure selection should be tailored according to the patient’s age, comorbidities, level of physical and sexual activity, and prior surgical history. The transvaginal SSF vaginal vault suspension is one of the best procedures of choice for management of the apical defect because of its feasibility, reduced postoperative morbidity, and best short-term results 4. The aim of the current study was to compare the effect of vaginal hysterectomy (VH) with and without SSF on the patients’ sexual function.

Patients and methods

The current retrospective case–control study was conducted at Ain-Shams University Maternity Hospital, and it included the patients who underwent VH with and without SSF for uterovaginal prolapsed in the past 3 years (2010–2012). An informed consent was obtained from all women who participated in the study.

The included patients were sexually active and underwent VH with or without SSF. Any concomitant procedure with VH as posterior or anterior repair, stress urinary incontinence operations as transobturator tape, and tension-free vaginal tape might be performed. Six months had passed since the operation. Indications for VH were any degree of uterine prolapse with or without with any other gynecologic disorder as perimenopausal bleeding. Patients having any medical disorders that may affect the sexual function, such as diabetes mellitus; developing social situations that prevent them from having a healthy sexual life, such as being divorced or a widow; having any vaginal condition that interferes with a healthy sexual life, such as persistent stress urinary incontinence, as this condition may affect the orgasm and desire; having long-term complications after the operation, such as vesicovaginal fistula or de-novo stress urinary stress incontinence, were excluded from the study.

Patients’ files in the Medical Record Department were revised. All women who underwent VH with or without SSF during the past 3 years were recruited in the study. Women who fulfilled the inclusion/exclusion criteria were subjected to the study procedures and included in the analysis. The included women were divided into two groups: group I (study group) that included women who underwent VH plus SSF, and group II (control group) that included women who underwent VH without SSF.

All patients were interviewed and a detailed history was taken from them, including personal history and sexual history such as desire, pain, lubrication, and frequency.

Education pamphlet was explained in simple Arabic language by a female doctor. Then a questionnaire [female sexual function index (FSFI) scoring appendix] on sexual function was answered by the patient that was presented to her by a female doctor. The questioner investigates sexual activity with six domains investigating sexual function in relation to desire, arousal, lubrication, orgasm, satisfaction, and pain after at least 6 months of surgery 5.

Female sexual function index domain scores and full-scale score

The individual domain scores and full-scale (overall) score of the FSFI can be obtained from the computational formula outlined in Table 1. For individual domain scores, add the scores of the individual items that comprise the domain, and multiply the sum by the domain factor (Table 1). Add the six domain scores to obtain the full-scale score. It should be noted that within the individual domains, a domain score of zero indicates that the subject reported having no sexual activity during the past month. Subject scores can be entered in the right-hand column.

T1-8
Table 1:
Computational formula to assess the female sexual function index scoring

This means that each patient answered the questions subjected to the six main domains; each of them is represented by several questions. The summation multiplied by the factor gave us the score domain.

General, abdominal, vaginal, and rectal examination were conducted; patients were asked to cough or strain with the bladder full to detect stress incontinence.

Statistical methodology

Statistical analysis was performed using SPSS for Windows version 15.0 (SPSS; SPSS Inc., Chicago, Illinois, USA). Data were presented as range, mean, SD (for parametric variables), number, and proportion (for categorical variables). Difference between the two groups was analyzed using independent Student’s t-test (for parametric variables), Fisher’s exact, or χ2-test (for categorical data). Significance level was set at 0.05.

This study has been done after taking the approval of the ethical committee at maternity hospital of Ain shams university.

Results

A total of 72 women who underwent VH with or without SSF were included in the current study. The included women were divided into two groups.

Group I (study group) that included 30 women who underwent VH plus SSF, and group II (control group) that included 42 women who underwent VH without SSF. No significant difference was found between patients who underwent VH with or without SSF in terms of age, parity, BMI (Table 2), and time passed since operation (Table 3).

T2-8
Table 2:
Comparison between patients who underwent vaginal hysterectomy with or without sacrospinous ligament fixation regarding age, parity, and BMI
T3-8
Table 3:
Comparison between patients who underwent vaginal hysterectomy with or without sacrospinous ligament fixation regarding the time passed since operation

Desire, arousal, lubrication, orgasm, satisfaction, pain, and total scores were significantly higher in patients without SSF than in patients with SSF (Table 4).

T4-8
Table 4:
Comparison between patients who underwent vaginal hysterectomy with or without sacrospinous ligament fixation regarding desire, arousal, lubrication, orgasm, satisfaction, pain, and total scores

Discussion

Female sexual dysfunctions are important health problems worldwide, and studies evaluating the prevalence of female sexual dysfunction have been authenticated in different countries with different cultures 6.

Sexual dysfunction in women is defined as any problem related to sexual desire, arousal, orgasm, and/or sexual pain that have an impact on the quality of life 7. VH is related to the improvement of sexual function, as the patient feels no concerns about getting pregnant or any symptoms as vaginal bleeding or heaviness, or stress urinary incontinence, or any other cause of the operation. In the current study, the questions stressing on six main items in sexual life were pain, arousal, satisfaction, desire, orgasm, and lubrication. With regard to dyspareunia, all the patients had a variable degree of dyspareunia ranging from mild to severe that led them to abstain from sex. However, these results are inconsistent with the findings of other investigators who stated that SSF is an efficacious operation with few intraoperative and postoperative complications. Despite alteration of the anatomic axis of the vagina in unilateral SSF, the patients were mainlysatisfied with their sexual life as authenticated by the FSFI results. The score 4.2 obviously shows that painful intercourse is not an important postoperative issue; however, the patients did not deny the presence of a degree of dyspareunia, with 6% of them experiencing de-novo dyspareunia 8.

Our results disagree with the findings of Richter and Albrich 9 who suggested that SSF does not predispose to dyspareunia, unless vaginal narrowing occurs, owing to repair of associated defects and reported 10% apareunia rate for 36 patients.

This difference in results of the current study may be owing to the fact that our patients underwent unilateral SSF that could have led to deviation in the anatomic axis of the vagina; in addition, it may be related to the culture factor in Egyptian society, and the myth of the relation between the presence of the uterus and the ability to have sex.

In the current study, regarding lubrication, the results show higher scores in the group that had VH without SSF than those with SSF; this may be owing to possible injury to the nerves that supply the coccygeus and levator ani muscles, leading to unrecognized muscle spasm or dysfunction, which, in addition to the deviation of the vaginal axis, mayaffect the sexual function of the patient, leading to narrowing of the vagina, affecting the need for lubrication 10.

The G-spot on the anterior wall is a super sensitive area for some women; the exact site differs among women. Because sensitivity of the anterior vaginal wall may be altered by the creation of scars in this area, sexual function may also be altered; however, only a few data on this issue are available 11.

With regard to satisfaction, the group that underwent VH without SSF has higher scores than those with SSF. This may be because of the unilateral SSF carried out, and may be this is the reason why the satisfaction ratein the group that underwent SSF was lower. In comparison, another study conducted by others showed that, of the patients who underwent bilateral SSF, 93% stated that satisfaction was higher, and this may be because the bilateral vault suspension is better than the unilateral SSF in our study 12.

Factors such as arousal, desire, and orgasm are affected with the degree of dyspareunia and lubrication, and therefore it is obvious that the scores were better in the patients who underwent VH without SSF.

Few surgeons suggest SSF to sexually active women, and obviously, the abdominal approach in terms of sacrocolpopexy is a better option for improvement in pelvic floor symptoms including sexual function and physiological position of the vaginal axis 12.

This suggests that SSF is a method available for elderly patients who had undergone VH, as it may affect the sexual function. That is why VH without SSF is better than VH with SSF as far as sexual function is concerned, as it relieves the symptoms with minimal scarring and narrowing of the vagina and no deviation to the axis.

Overall, this study showed that VH only for prolapse had a positive effect on sexual activity. Limitations of the current study included the retrospective nature and the lack of preoperative assessment of the sexual life of the patient before concluding which is better; comparison between unilateral SSF and bilateral fixation must be made.

Conclusion

VH with SSF was considered as an option in an elderly patient who was not sexually active, as it lowers the rate of vault prolapse; however, in younger patients, VH alone has a better effect as it does not interfere with the normal vaginal axis.

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

References

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Keywords:

female sexual function; sacrospinous ligament fixation; vaginal hysterectomy

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