Evaluation of Sexual Function Outcomes in Women …

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL XXIV

Evaluation of Sexual Function Outcomes in Women Undergoing Vaginal

Rejuvenation/Vaginoplasty Procedures for Symptoms of Vaginal Laxity/Decreased Vaginal Sensation Utilizing Validated Sexual Function

Questionnaire (PISQ-12)

ROBERT D. MOORE, DO, FPMRS, FACOG, FACS DIRECTOR, ADVANCED PELVIC SURGERY

CO-DIRECTOR, INTERNATIONAL UROGYNECOLOGY ASSOCIATES ATLANTA, GEORGIA, AND BEVERLY HILLS, CALIFORNIA

JOHN R. MIKLOS, MD, FPMRS, FACOG, FACS DIRECTOR,

INTERNATIONAL UROGYNECOLOGY ASSOCIATES ATLANTA, GEORGIA, AND BEVERLY HILLS, CALIFORNIA

ORAWEE CHINTHAKANAN, MD, MPH, RTCOG FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY

FELLOW INTERNATIONAL UROGYNECOLOGY ASSOCIATES ATLANTA, GEORGIA, AND BEVERLY HILLS, CALIFORNIA

ABSTRACT

Sexual function outcomes were analyzed in a group of women (n = 78) presenting for vaginal rejuvenation/vaginoplasty procedure for a chief complaint of vaginal laxity and decreased sensation with intercourse. Outcomes were analyzed utilizing the validated Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before and at least 6 months after repair with vaginal rejuvenation/vaginoplasty procedure (VR). Mean age was 43.6 ? 7.9 (range 25?62), and 19 patients (24.3%) were found to have prolapse at time of initial exam and underwent vaginal vault suspension in addition to VR. Compared preoperatively and postoperatively, the overall sexual function (Total PISQ-12) statistically improved (30.3 ? 6.6 vs. 38.2 ? 5.2, P < 0.001). All individual scores statistically improved except in 3 categories in which there was no change (Q1-desire, Q5-pain, and Q11- partner premature ejaculation). Overall sexual satisfaction improved as well as subcategories of increased sexual excitement during intercourse and

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Evaluation of Sexual Function Outcomes in Women Undergoing Vaginal Rejuvenation/Vaginoplasty Procedures for Symptoms of Vaginal Laxity/Decreased Vaginal Sensation Utilizing Validated Sexual Function Questionnaire (PISQ-12) MOORE/MIKLOS/CHINTHAKANAN

overall increase in intensity of orgasms. Pain with intercourse subscores were found to be no different from

preoperatively to postoperatively. Previous studies have shown that sexual function improves with repair of

prolapse; however, this is the first study to show improved function using a validated questionnaire in

patients undergoing VR for laxity.

INTRODUCTION Vaginal rejuvenation has evolved as one the latest trends in female vaginal surgery, and there continues to be controversy over whether it benefits patients,1 as well as what the term actually means. Vaginal rejuvenation, also known as vaginoplasty or colpoperineoplasty, focuses primarily on reconstruction and restoration of the anatomy of the vagina and tightening of the caliber of the vaginal canal and introitus to its pre-childbirth state. The surgery is typically completed to repair damage that has occurred with childbirth and/or aging in women who present with a sense of vaginal laxity that they feel is affecting their sexual function (Fig. 1).2 The expectations of women who undergo vaginal rejuvenation procedures are to correct a feeling of loose or wide vagina, to improve sexual function, to increase sensation with intercourse, to increase sexual desirability, and to improve self-confidence3,4 with regard to their sexuality. Recent studies show that rejuvenation or repair/tightening of the caliber of the vagina prior to the development of prolapse may improve female sexual function.4,5 However, there is only one article6 that met level II-3 in evidence-based medicine3 and none to date in the literature that have utilized a validated sexual function questionnaire to evaluate sexu-

al function outcomes following the surgery.

The primary objective of the study was to evaluate the sexual function outcomes by validated PISQ-12 compared between preoperative and postoperative values in a group of women presenting for vaginal rejuvenation surgery. This is the first study of vaginal rejuvenation that has utilized a validated questionnaire as a tool to measure outcomes.

MATEMRATIEARLIAAL ANNDD MMEETHTOHDSODS Study Patients

Over a two-year period at Atlanta Urogynecology Associates, Atlanta, Georgia, a total of 78 patients underwent vaginal rejuvenation surgery for a chief complaint of vaginal laxity causing decreased vaginal sensation, which they felt was affecting their sexual function. If present, other pelvic floor support defects were repaired simultaneously. Inclusion criteria included: chief complaint of vaginal laxity/looseness causing sexual dysfunction and desiring vaginal rejuvenation surgery, age more than 18, and clinically confirmed vaginal laxity on exam. Exclusion criteria included: history of primary anorgasmia, severe psychologic disorders, clinically significant dyspareunia, vaginissmus, severe pelvic pain, or spinal lesions. All patients were

interviewed preoperatively by the treating physician to rule out patients who had sexual dysfunction that could interfere with the indication, expectations, and results of surgery. Patients who revealed personality disorders or classic sexual dysfunctions in themselves or their partners were excluded. Additionally, the patient had to confirm that she was undergoing the procedure for herself and her own symptoms and not undergoing the procedure for a partner. After signing an informed consent form for surgery, 60 subjects completed both a preoperative and postoperative PISQ-12 questionnaire. Surgical Procedures

All patients had posterior colpoperineoraphy/vaginoplasty to repair the vaginal caliber and introitus to its prechildbirth anatomic state (Figs. 2 & 3). Any clinically significant pelvic floor defects such as uterine prolapse or cystocele were repaired simultaneously prior to the posterior compartment and introitus/perineal body being addressed for the "rejuvenation" portion of the procedure, i.e., repairing/restoring/ tightening the caliber of the vagina. We utilize a standard posterior colpoperineorhaphy with modifications for the procedure. It should be noted, however, that this is not just a standard posterior repair procedure that is utilized for a rectocele. If a rectocele is present, this is repaired in a site-specific manner

Figure 1. Damaged perineal body, relaxed introitus, and vaginal canal. ? Miklos/Moore

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL XXIV

repairing any defects in the rectovaginal

fascia and ensuring the fascia is attached

out laterally to the posterior arcus on

the levators. Following this, the caliber

of the vaginal canal is addressed with a

midline plication of the fascia in one or

more layers until the proper caliber is

achieved. Care is taken not to create any

banding of the levators, nor a complete

levator plication. The introitus and per-

ineal body are then addressed in a mul-

tiple layer closure, first restoring the

superficial transverse perineal muscles

and then building up the perineal body

until it is perpendicular with the repair

of the posterior floor.

a

b

Postoperative Care Routine postoperative care was

given to patients who underwent the procedure. Surgery was performed under spinal or general anesthesia. Vaginal packing was left in for a short period of time and removed prior to the patient being discharged home. Routine instructions for vaginal surgery were given to the patients, such as no heavy lifting or vigorous exercise for 4 weeks and nothing in vagina nor sexual intercourse for 6 weeks postoperatively. Patients returned for follow-up at 4 to 6 weeks and 6 months after the surgery. Study Design and Procedures

This was a retrospective study assessing short-term sexual health as measured by the PISQ-12 following surgical intervention. All patients completed the PISQ-12 questionnaire taken preoperatively and at minimum 6 months postoperatively. Institutional Review Board and Ethics Committee approval for the protocol was obtained and patients provided written informed consent before any procedures.

c

d

Figure 2. Perineal body repair: before and after surgical illustration (a, b), picture (c, d). ? Miklos/Moore

ed using a two-sided test with a 0.05 significance level. The percentages of categorical variables were compared between the two groups with a Chisquare test or Fisher's exact test.

RESULTS RESULTS Of 78 women who were eligible for the study, 18 subjects who had not completed either preoperative or postoperative PISQ-12 questionnaires were excluded from the analysis. The mean

age was 43.6 ? 7.9 years. The average number of vaginal birth and parity were 2.4 ? 1.3 and 2.5 ? 1.2, respectively. The average vaginal deliveries were 2.4 ? 1.3. The previous cesarean section was 10.3%. Forty-two women (53.8%) had previous plastic surgery. There were breast augmentation or reduction (39.7%), abdominoplasty or liposuction (23.1%), facial plastic surgery (i.e., rhinoplasty, eyelid surgery, 10.3%), and labioplasty (1.3%). All women underwent vaginal rejuvenation of the vaginal canal with posterior colpoperineoplasty/vaginoplasty. Of these, 32 women

Study Endpoints The primary sexual function end-

point was the change from baseline (preoperative visit) to end-of-treatment (postoperative visit) in the mean PISQ12 score. The postoperative questionnaire was to be administered at a minimum of 6 months postoperatively.

Statistical Analysis Statistical analyses were performed

using SAS? version 9.2. The primary analysis assessed changes from baseline to postoperative PISQ-12 score using paired t-test or Wilcoxon signed-rank test. The statistical analysis was evaluat-

a

b

Figure 3. Three-dimensional illustration of before (a) and after (b) vaginal rejuvenation. ? Miklos/Moore

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Evaluation of Sexual Function Outcomes in Women Undergoing Vaginal Rejuvenation/Vaginoplasty Procedures for Symptoms of Vaginal Laxity/Decreased

Vaginal Sensation Utilizing Validated Sexual Function Questionnaire (PISQ-12)

MOORE/MIKLOS/CHINTHAKANAN

Table I Demographic data (n = 78)

evaluated this concept and found that 83.6% of women presenting for prolapse surgery list "improved sexual

Demographics

n (%)

function" as part of their goal for surgery.8 This clearly indicates that

Age*

43.6 (7.9)

when asked, women with prolapse are

Parity*

2.5 (1.2)

stating the prolapse has affected their sexual function, and they would like it

Vaginal birth*

2.4 (1.3)

to be improved with their repair. In

Previous cesarean section

8 (10.3)

their study they did find a significant improvement in sexual function after

Previous plastic surgery

42 (53.8)

the prolapse repair was completed. Azar et al. utilized the Female Sexual

- Breast augmentation/reduction - Abdominoplasty/liposuction - Labioplasty

31 (39.7) 18 (23.1)

1 (1.3)

Function Index (FSFI), another validated questionnaire, to evaluate women before and after surgery for prolapse and also found that sexual function was

- Facial plastic surgery (e.g., rhinoplasty, eyelid surgery, etc.)

8 (10.3)

improved postoperatively after repair of the prolapse. Domain scores of desire,

Concurrent procedures

arousal, lubrication, orgasm, and satisfaction were all increased significantly.9

- Anterior repair

32 (41.0)

Rogers et al. confirmed this as well

- Posterior repair - Laparoscopic assisted vaginal hysterectomy - Laparoscopic paravaginal repair

70 (89.7) 15 (19.2) 31 (39.7)

with a group of 102 women undergoing prolapse repair. The patients were evaluated preoperatively and postoperatively with the PISQ and were found to

- Laparoscopic vault suspension

19 (24.4)

have significantly improved sexual func-

*mean (S.D.)

tion scores postoperatively.10 Stoutjesdijk et al. also published on a series of

women undergoing vaginal reconstruc-

(41.0%) had concurrent anterior repair, women were less likely to report always tive surgery and its effect on sexual 15 (19.2%) laparoscopic-assisted vagi- and usually having negative emotional function. They found a significant

nal hysterectomy, 31 (39.7%) laparo- reactions such as fear, disgust, shame, or improvement in dyspareunia after scopic paravaginal repair, and 19 guilt after they underwent VR (preop- surgery as well as improvement in the (24.4%) vault suspension procedure erative 31.7% vs. 5.1%, p < 0.001, frequency and satisfaction with inter-

(Table I).

PISQ-9). In terms of orgasm (PISQ- course, concluding that vaginal recon-

Sixty of the 78 subjects completed 12), 34.5% of women reported more structive surgery for pelvic organ

both preoperative and postoperative and much more intense orgasms post- prolapse has a positive effect on the sex-

PISQ-12 questionnaires. For the prima- operatively, which significantly ual well being of the afflicted woman.11

ry outcome (Table II), the overall sexual increased by 29.4% compared with

Kuhn et al. from the University of

function (total PISQ score) improved prior VR (p < 0.001). Pain with inter- Bern in Switzerland evaluated both

significantly after vaginal rejuvenation course subscores were found to be no male and female sexual function before

(preoperative 30.3 ? 6.6 vs. postopera- different from preoperatively to postop- and after prolapse repair. They evaluat-

tive 38.2 ? 5.2, p < 0.001). All indi- eratively.

ed 70 women and 60 men with the FSFI

vidual scores statistically improved except in 3 categories in which there was no change (Q1-sexual desire, Q5-

DISCUSSIODISNCUSSION

for the females and the Brief Male Sexual Inventory (BMSI) for men. FSFI scores improved significantly overall

pain during intercourse, and Q11-partner having issue with premature ejaculation). The individual question

and in the domains of desire, arousal, lubrication, pain, and overall satisfacIt is well documented in the litera- tion. In men, interest, sexual drive, and

detail is shown in Table III. Overall sex- ture that pelvic organ prolapse (POP) overall satisfaction improved significantual satisfaction improved as well as sub- affects sexual function and that, when ly.12 This, again, is more data that concategories of increased sexual repaired, sexual function improves as firms repair of prolapse, albeit a more

excitement during intercourse, confirmed by validated sexual-function severe form of vaginal relaxation but decreased negative emotional reactions, questionnaires. Wehbe et al. at Drexel certainly relaxation, seems to improve and overall increase in intensity of University recently published a review sexual function.

orgasms. According to PISQ-3, women of the medical literature and concluded

We feel that the posterior vaginal

who reported always and usually feeling that "sexual dysfunction is a common, wall anatomically controls most of the

sexually excited when having sexual underestimated complaint in women vaginal caliber secondary to its relation-

intercourse increased by 18.4% after with POP and SUI, and treatment ship to the levator ani and genital hiaVR (preoperative 58.3% vs. postopera- should be tailored to improving sexual tus, and repair of this wall is a major tive 76.7%, p = 0.032). In addition, function and QOL."7 Cardozo et al. also portion of most rejuvenation-type pro-

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Gynecology SURGICAL TECHNOLOGY INTERNATIONAL XXIV

Table II Compare PISQ-12 between preoperative and postoperative in vaginal rejuvenation (n = 60)

PISQ-12

Preoperative mean (SD)

Postoperative mean (SD)

P value*

1. How frequently do you feel sexual desire?

2.6 (1.0)

2.6 (0.9)

0.795

2. Do you climax when having sexual intercourse with your partner?

1.7 (1.4)

2.2 (1.4)

0.012

3. Do you feel sexually excited when having sexual activity with your partner?

2.8 (1.0)

3.2 (1.0)

0.004

4. How satisfied are you with the variety of sexual activities in your current sex life?

2.3 (1.1)

2.93 (1.1)

0.001

5. Do you feel pain during intercourse?

6. Are you incontinent of urine with sexual activity?

7. Does fear of incontinence restrict your sexual activity?

8. Do you avoid sexual intercourse because of bulging in the vagina?

9. When you have sex with your partner, do you have negative emotional reactions such as fear, disgust, shame or guilt? 10. Does your partner have a problem with erections that affects your sexual activity? 11. Does your partner have a problem with premature ejaculation that affects your sexual activity? 12. Compared to orgasms that you have had in the past, how intense are the orgasms you have had in the past 6 months?

2.6 (1.2) 2.9 (1.3) 2.8 (1.3) 3.2 (1.1) 2.4 (1.4) 3.1 (1.1) 3.3 (1.1) 1.1 (1.0)

3.0 (1.3) 3.9 (0.5) 3.9 (0.5) 3.8 (0.6) 3.6 (1.0) 3.5 (1.1) 3.6 (1.1) 2.3 (0.7)

0.055 ................
................

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