Volume 50, Issue 1, Pages 14-16 (July 2006)

The review by Salonia et al. [1] raises an interesting new and neglected topic in urologic surgery—preservation of sexual function in women following urogynaecologic and oncologic pelvic surgical procedures.

Although commonly associated with treatment-related impairment of sexual function, data dedicated to investigating postoperative women's sexual health are scarce. Our knowledge regarding female sexual function is still in its initial stages, and many important unanswered questions in this area need to be investigated. In the clinical setting, female sexual responses have been difficult to quantify objectively and often are not readily visible or recognised. Diagnostic modalities, such as duplex Doppler ultrasound, vaginal pH, photoplethysmography, and genital sensory testing, can in some cases help the clinician to understand the pathophysiologic background mechanisms, but disadvantages such as invasiveness, cost, and lack of normative data have limited their accuracy and use. This fact further impedes our ability to objectively evaluate the postoperative underlying sexual and physiologic deficit and its correlation to the performed operative procedure.

Female sexual dysfunction (FSD) is currently an evolving new multidisciplinary field, is highly prevalent, and often underestimated. Only recently have urologists started to be involved in the management and research of this discipline. Depending on age it has been estimated that up to 40% of women have sexual complaints [2], including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation, and difficulty or inability to achieve orgasm. It is an age-related, progressive problem associated with several biologic, medical, and psychological factors. Pelvic surgery forms an important and an underestimated cause of sexual dysfunction in both sexes. Simple or radical cystectomy, sling procedures, simple or radical hysterectomy, and colorectal surgery are among the most important causes of organic FSD. Despite the fact that these are common surgical procedures for already some decades, only recently has FSD become a major quality-of-life issue in women undergoing these procedures.

In men and especially in the field of prostate cancer surgery, the issue of preservation of erectile function has undergone an incredible revolution over the past 20 yr, especially with advances in nerve-sparing and minimally invasive techniques. Walsh and Donker [3] made an outstanding advance when they reviewed the anatomy associated with the surgery and recognised that the aetiology of erectile dysfunction was related to autonomic nerve injury. They recognised that the autonomic nerve branches to the prostate, urethra, and corpora travel outside of the prostatic capsule and could be spared without adversely affecting disease control. Nerve-sparing prostatectomy is widely performed now and has become a routine procedure in patients with localised prostatic cancer in which nerve preservation does not impede the surgical eradication of the tumor. Recently, the same principals were applied for cystoprostatectomy surgeries also with encouraging results [4].

Many factors contribute to the popularity of this procedure, mainly the simplicity of the technique, the widespread increase in the performance of these surgical procedures in the era of prostate-specific antigen, the major disability that erectile dysfunction causes in men in this age group, and finally our ability to evaluate and treat men with erectile problems with the use of phosphodiesterase type 5 inhibitors.

It is logical to speculate that the so called “nerve-sparing operation” in women who undergo pelvic or genital procedures should have the same attention and concern as in men. Unfortunately, in women, many unsolved issues first need to be investigated before we will be able to recommend them to our patients. We first need to better evaluate the magnitude of the problem and to be able to evaluate which women will benefic from such procedures. Moreover, we need to be able to better assess the type of damage (neurogenic, vasculogenic, or functional) that occurred postoperatively. At present, our knowledge about the location of the nerves and blood vessels in the female pelvis, vital to normal sexual function, is vague. To perform such surgeries in women, we must identify precisely where the nerves and blood vessels to the vagina and clitoris are located. Finally, we need to define the advantages and risks of these procedures.

Probably the first procedure that deserves our attention and research is simple or radical hysterectomy. This procedure is the second most common pelvic operation in women (after Caesarean section), and is performed by urologists in nearly all radical cystectomy operations in women. Previous studies have shown that women undergoing hysterectomy are concerned about the potential negative effect on their sexual function [5]. Several reports have indicated that 13–37% of women undergoing hysterectomy report deterioration in their sexual function [5,6]. Others postulated that dyspareunia after hysterectomy might be attributable to shortening of the vagina [7].

Common sexual complaints after hysterectomy include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm, and decreased genital sensation. The impact of hysterectomy on sensation may be due to possible damage to the uterovaginal nerves. We have recently demonstrated quantifiable sensory loss in the vagina 6 mo after hysterectomy, but with preservation of the clitoral one [8]. Interestingly, only a minority of the women reported a decline in their sexual function. These findings highlight the relative importance of clitoral as compared to vaginal sensation in sexual function. Therefore, more basic research must be conducted to examine the effects of hysterectomy on physiologic and sensory mechanisms related to sexual functions.

Recently, interest has grown regarding sexual dysfunction following pelvic surgery. This increased awareness will hopefully lead to development of better surgical techniques, and postoperative sexual function will soon become a routine discussion within informed consent. Also, often underreported female sexual dysfunction is a significant problem after radical rectal and radical cystectomy surgery. Genitourinary dysfunction after pelvic surgery is presumed to be related to injury of the autonomic pelvic nerves. We have today some sporadic data suggesting that neurovascular preservation improves sexual function in women after surgery compared to the non–nerve-sparing group and may also improve the urinary continence following orthotopic neobladder substitution [9]. As stated in the current review [1], I would like to emphasise that nerve preservation is only one of the concepts that need to be borne in mind when postoperative sexual function is considered. The other, but not less important concepts, are type of urinary diversion or orthotopic bladder substitution, preservation of the anterior vaginal wall (to enhance lubrication) and anterior vaginal tubularisation (to preserve the depth of the vagina), avoidance of removing the distal urethra to minimise devascularisation of the clitoris, and avoidance of routine hysterectomy [10].

In conclusion, the overall number of reports about the postoperative anatomy and pathophysiology of women's sexual function or dysfunction is rising, but data are still restricted. Although significant anatomic and embryologic parallels exist between men and women, the multifactorial nature of FSD is clearly distinct from that of men. Similar to the impact of radical prostate surgery on male erectile function, pelvic surgical procedures in women can also negatively affect their sexual function. Preliminary facts suggest that nerve-sparing surgery in women can have some impact in improving sexual life postoperatively and should be performed when possible. Research is ongoing, but a woman's ability to enjoy sex after a pelvic operation is mandatory and depends, in part, on the type and extent of the surgery, the concomitant adjuvant treatment modalities, and her preoperative level of sensation and function.

From a clinical viewpoint, deficits in genital sensation are probably responsible for some cases of postoperative FSD. Development of new diagnostic tests and surgical techniques, which spare the genital nerves and vaginal and clitoral arterial supply and preserve the integrity of the vaginal wall, will be mandatory. Obviously, there is a tremendous need for more research in this field.

References

1. Salonia A, Briganti A, Dehò F, et al.. Women's sexual dysfunction: a review of the “surgical landscape”. Eur Urol. 2006;50:44–52.
2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States. Prevalence and predictors. JAMA. 1999;281:537–544. MEDLINE | CrossRef
3. Walsh PC, Donker PJ. Impotence following radical prostatectomy: insight into etiology and prevention. J Urol. 1982;128:492–497.
4. Stenzl A, Colleselli K, Poisel S, Feichtinger H, Pontasch H, Bartsch G. Rationale and technique of nerve sparing radical cystectomy before an orthotopic neobladder procedure in women. J Urol. 1995;154:2044–2049.
5. Helstrom L, Lundberg PO, Sorbom D, Backstrom T. Sexuality after hysterectomy: a factor analysis of women's sexual lives before and after subtotal hysterectomy. Obstet Gynecol. 1993;81:357–362.
6. Dodds DT, Potgeiter CR, Turner PJ, Scheepers GP. The physical and emotional results of hysterectomy: a review of 162 cases. S Afr Med J. 1961;35:53–54.
7. Jewett JF. Vaginal length and incidence of dyspareunia following total abdominal hysterectomy. Am J Obstet Gynecol. 1952;63:400–407.
8. Lowenstein L, Yarnitsky D, Gruenwald I, et al.. Does hysterectomy affect genital sensation?. Eur J Obstet Gynecol Reprod Biol. 2005;119:242–245.
9. Zippe C, Nandipati K, Agarwal A, Raina R. Sexual dysfunction after pelvic surgery. Int J Impot Res. 2005;18:1–18.
10. Burkhard FC, Studer UE. Orthotopic bladder substitution. Curr Opin Urol. 2000;10:343–349.

Yoram Vardi,
Rambam Medical Center and the Technion Institute of Technology, Haifa, Israel

published online 24 April 2006.

Please log-in or register in order to submit comments.

Powered by AkoComment!