Effect of midurethral sling (transobturator tape) surgery on female sexual function.

INTRODUCTION: Transobturator tapes (TOT) are frequently used in the management of female stress urinary incontinence (SUI). We evaluated the effect of TOT on sexual function in Indian women with stress urinary incontinence.
MATERIALS AND METHODS: 34 sexually active women (mean age 42.38 years) with SUI were evaluated before TOT placement for sexual function using the NSF-9 sexual scoring system questionnaire. The evaluation was repeated at the 3(rd), 6(th) and 12(th) months post surgery and then yearly.
RESULTS: There was significant improvement in scores in all domains of sexual function post-surgery. The frequency improved in 24 (70.5%) patients, lubricacy improved in 12 (57.1%) patients, orgasm improved in 21 (67.1%) patients, pain improved in 14 (70%) patients and, in leaking patients, sexual satisfaction improved in 85.7% while in non-leaking patients improvement was seen in 40%. Sexual relation was not satisfactory in 26 (76.4%) of the patients before surgery; of them, 21 (80%) patients had improved sexual satisfaction after surgery. De novo urgency and dyspareunia developed in one and two patients, respectively.
CONCLUSIONS: The TOT procedure has no significant negative impact on sexual function and it significantly improves female sexual function and overall sexual satisfaction in majority of the patients with SUI.

INTRODUCTION

Urinary incontinence (UI) is a common condition that affects approximately 27% (9–57%) of women worldwide.[1234] It has a negative impact on quality of life, especially in the domains of social, physiological, physical and sexual well-being.[456] The majority of the patients with UI have either stress or mixed incontinence.[5]

Health is understood as a state of full physical, psychological and social well being, not merely the absence of illness and ailments.[4] However, this landmark definition of health fails to highlight that sexual health is also a vital component for the psychological wellbeing of an individual. In patients with stress urinary incontinence (SUI), sexual health is considerably affected but this aspect of SUI is the least expressed by patients and more so least explored by the treating physician, especially among Indian patients. UI during sexual intercourse is a common symptom in patients with SUI.[6] It has been observed in various studies that incontinence has a great impact on all domains of sexual function, including sexual interest, comfort during sexual act and orgasm.[67]

The tension-free-vaginal-tape (TVT) procedure was introduced in 1995 and has revolutionized the surgical treatment of female SUI due to its simplicity, efficacy and minimal invasiveness.[89101112] However, this surgery may be associated with complications, which, at times, can be significant.[91011] The transobturator tape (TOT), which was introduced subsequently, has been reported to be associated with less morbidity than the TVT,[1314] although early studies showed doubtful benefit.[1215] Since its introduction, numerous reports confirmed its efficacy with an objective and a subjective cure rate of 80% and 92%, respectively, and low morbidity.[131617]

The effect of TOT on sexual function is not fully assessed although a few recent studies reported doubtful benefits.[1617] The present study is designed to assess the effect of TOT on sexual function in Indian women with SUI.

MATERIALS AND METHODS

In this ethical committee approved prospective observational study, all the patients who underwent the TOT procedure for SUI at our institution were included. Patients with documented SUI symptoms of grade 2 and grade 3 as per the Stamey incontinence scale[18] and who were leading an active sexual life were selected after demonstrating SUI by the cough stress test. Grades on the Stamey scale were defined as follows: 0 = dry; 1 = urine leakage with vigorous activity; 2 = urine leakage with minor activities; and 3 = urine leakage all the time regardless of the activity or position. Urine culture was obtained in all patients pre-operatively and any infection was treated.

Patients with mixed incontinence with predominant urge urinary incontinence (UUI), history of previous pelvic floor surgery, prolapse of uterus and uncontrolled urinary tract infections were excluded. Patients with significant co-morbid illnesses like chronic obstructive pulmonary disease and coronary artery disease, who were not leading an active sexual life, were excluded from the study.

Female sexual function was assessed in the following domains: Sexual desire, arousal, lubrication, orgasm, satisfaction and pain. Sexual function was assessed using ‘nine questions regarding sexual function in females’ (NSF-9) questionnaire which was constructed by Vroege[19] in Dutch language and later described in the English literature by the Francken et al.[20] Patients were assessed regarding urine leakage during the sexual act as well.

The NSF-9 is a standardized questionnaire that contains questions on sexual desire, frequency of sexual activity, lubrication, orgasm, pain during or after sexual activity and sexual satisfaction. We have added one question on urinary leakage during sexual activity. This questionnaire was originally developed to measure the influence of medication on sexual functioning; however, it has also been used in treatment modalities like percutaneous tibial nerve stimulation. The severity of symptoms is quantified using a five-point Likert scale. There is no sum score and only individual scores on each question are used.

All the surgeries were performed under spinal anesthesia using a polypropylene TOT tape by the senior consultant. The ‘outside in’ technique was used.[17] Intraoperative cystoscopy was performed in all patients. Patients were discharged the next day. At the follow-up visits, the following were assessed by the investigators:

Sexual function was assessed based on the NSF-9 questionnare at the 3rd, 6th and 12th months and then yearly

SUI on the cough stress test

Complications like retention (by evaluating post-void residual urine), hematuria, urinary tract infection and obturator neuralgia.

The scoring in each domain of sexual function was analyzed with the corresponding post-operative score. Statistical analysis was performed using SPSS version 16.0. Non-parametric tests and the Wilcoxon signed rank test were applied because the data were not normally distributed.

RESULTS

Fifty-one patients who underwent TOT from February 2008 to February 2013 were considered for the study. Forty-one patients came for follow-up. Four patients were excluded per the exclusion criteria. Of the remaining patients, one patient's spouse was chronically ill, another patient's spouse had died and a third patient had to be catheterized for retention. In this patient, the tape was divided later to relieve the obstruction but she went into retention again and was retained on a catheter (this patient found clean intermittent catheterization difficult to perform). The remaining 34 patients were included in our study.

No major perioperative complications occurred, except in one patient who had a bladder contusion as demonstrated by cystoscopy. The age of the patients varied from 26 to 54 years, with a mean age of 42.38 years. Parity ranged from 1 to 4. Six patients were post-menopausal. The follow-up period ranged from 1 to 5 years.

Before surgery, all patients had at least one episode of SUI every day. Nine patients had mixed incontinence with predominant stress incontinence. Among the mixed incontinence patients, all except three were cured of UUI as well. One patient developed de novo UUI. Three patients had almost stopped their sexual activity 6 months prior to surgery due to the leakage, pain and discomfort during the sexual act. The spouse was reluctant for sexual act in one patient [Table 1].

Table 1

Improvement in each domain of sexual function post-operatively

In comparison with the pre-operative assessment, post-operatively, at the third month, the average frequency of intercourse improved in 24 (70.5%) patients. In three (8%) patients, this decreased. In the remaining seven (20.5%) patients, there was no significant change in terms of frequency. In the subsequent visits at the sixth month and yearly, there was no significant change in the parameters. Thus, there was a statistically significant (P = 0.001) improvement in the frequency of sexual act post-operatively.

Before surgery, dryness of the vagina (lubricacy) was a problem on more than half of the occasions in 21 (62%) patients. Lubricacy was not a major problem in the remaining 13 (38%) patients. Ten of the affected patients reported better vaginal lubricacy post-operatively at the third month. At the sixth month, this improved in 12 (57.1%) patients (P = 0.005), and the result remained the same in the subsequent visits. Although the lubricacy score deteriorated slightly in two patients, their overall sexual satisfaction had improved.

Of the 34 patients, four patients complained of inability to reach orgasm. In 18 (55%) patients, orgasm was delayed. Four (12%) patients reported an early orgasm. Post-operatively, at the third month, two of the four patients who did not reach orgasm reached orgasm. Ten of the patients with delayed orgasm, two of the patients with early orgasm and seven of the patients with neutral orgasmic score improved. Overall, in 21 (61.7%) patients, the orgasmic score improved, they reported better orgasmic experience and there was no significant improvement in the subsequent follow-up.

Dyspareunia was present in 20 (59%) patients pre-operatively. This improved in 14 (70%) patients and persisted in six patients post-operatively at the third month of follow-up. Itching and burning sensation were other major complaints in patients who were having leakage during sex. Of the 14 improved patients, six patients had mild pain during intercourse in early visits; they became symptom free on subsequent yearly visits. Two patients developed de novo dyspareunia post-operatively, which subsided at the 1-year visit.

Sexual relation was not satisfactory in 26 (76.4%) of the patients before surgery. Of these, 20 (80%) patients had improved sexual satisfaction after surgery. Among other patients who had a neutral opinion about their sexual satisfaction, four reported improved satisfaction. Most of these patients complained that the fear of urine leak during intercourse was a cause for non-enjoyment pre-operatively.

Twenty four-(70.5%) patients had minimal to moderate urinary leakage during their intercourse. Of these patients, three were sexually satisfied even with leak. Twenty-one of the 24 leaking patients who were sexually unsatisfied before surgery improved post-operatively and 18 patients expressed that improvement was up to sexual satisfaction levels.

Five of the 10 non-leaking patients were unsatisfied in their sexual function pre-operatively; among them, three had improvement in their sexual function after surgery, out of which two reached sexual satisfaction levels. Thus, in leaking patients, sexual satisfaction improved in 85.7% of the patients and in non-leaking patients, improvement was seen in 40% of the patients [Figure 1].

Figure 1

Comparison of sexual satisfaction post-operatively between leaking and non-leaking patients

There was significant improvement in all the domains of sexual function (P < 0.005). Post-operatively, no significant SUI was noted in any of the patients. Better overall sexual function was noted in 26 patients (76.4%). One patient had obturator neuralgia, which was managed medically.

DISCUSSION

The TOT procedure is the standard surgical procedure for SUI.[212223] In our study, the mean patient age was 42.3 years, the age group that is sexually more active as opposed to other studies in which the mean age was higher. In the study by Arts de jong et al.,[13] the mean age of the patients was 52 (range: 37–78 years) years. In the study by Elzevier,[10] the mean age of the patients was 53.2 years. In the study by Demirkerson,[9] the mean patient age was 52 years.

The follow-up duration was for over 5 years, which is significant when compared with other studies in that this showed no significant deterioration in sexual function. In the study by Raziye Narin,[24] the duration of follow-up was 6 months and in that of Arts De Jong[13] it was 1 year.

The sexual satisfaction is a difficult parameter to study, especially in our conservative society. To the best of our knowledge, there are no studies assessing the sexual function after TOT in the Indian population. Our study revealed significant improvement in terms of frequency of sexual act and the quality of the act as an enjoyable painless experience. Elzevier et al.[10] reported that incontinence surgery can have a positive and negative outcome on sexual function. In the study by Demirkesen,[9] it was shown that sexual satisfaction was more adversely affected with midurethral sling surgery than Burch Colpo suspension. In the study by Yeni et al.,[11] both SUI and the TVT procedure negatively affected sexual function in women. Similar or slightly better results were noted in the studies of Raziye Narine[23] (0% improvement of libido and deterioration of 15%) and Sentilhes et al.[16] (31% improvement and 10% deterioration of sexual function). In a systematic review and meta-analysis of 18 studies analyzing 1578 women about the impact of incontinence surgeries on sexual function, Jha et al.[25] reported that in just over half of all women, there was no change of overall sexual symptoms after surgery (55.5%). The same analysis also showed that for midurethral tapes alone, there was no significant improvement of sexual function. In contradiction to this, our study showed a significant improvement in all the domains of sexual function.

Bekker et al.[26] showed that women with coital incontinence had a higher improvement in sexual satisfaction after surgery compared with women without coital incontinence, and Berthier et al.[27] reported that women with coital incontinence were more likely to report improvement of their sexual function after the TVT procedure. This was similar to our study, where 85.7% of the leaking unsatisfied patients expressed improvement compared with 40% of the non-leaking unsatisfied patients.

Se ung- June Oh et al. reported that coital incontinence and pain during intercourse were a major symptom in patients with SUI.[6] Dyspareunia, which was present in 59% of the patients pre-operatively in our study, reduced to 18% post-operatively. Achtari et al.[28] reported that reducing UI improved overall sexual function by increasing body image and self-esteem.

Abraham et al.[29] reported that sexual activities were affected in 63% of the SUI patients before surgery and improved to 27% after surgery. Leakage during coitus reduced from 63% pre-operatively to 11% post-operatively in patients who underwent colpo-suspension and TVT. Sexual activities were affected to an unsatisfactory level in 26 patients (76%), which improved in 24 (92.3%) patients to a better satisfaction score in the present study.

Elzevier et al.[30] reported that TOT caused more sexual dysfunction than tension-free vaginal tape because the TOT procedure causes more vaginal narrowing. Ten percent of the partners of women undergoing TOT experienced vaginal narrowing. However, Weber et al.[31] showed that patients’ symptoms did not correlate with objective measures of vaginal dimensions of introital caliber and vaginal length after incontinence surgery.

The anatomical course of TOT showed that the tape is not in contact with the major neurovascular structures. Delmas[32] showed that TOT constitutes an anatomically safer approach than minimally invasive retropubic tape techniques. Caruso et al.[33] studied the effect of TVT and TOT on clitoral blood flow and found that clitoral blood flow negatively changed after TVT, whereas TOT had no influence at all.

Our study included patients who had SUI without any other predominant pelvic diseases or prior pelvic surgery, and excluded patients with significant UUI. All women in our study were sexually active and were younger (mean age 42.38 years) in comparison with other studies. This could explain the higher cure rate of SUI and better sexual satisfaction. Arts- de Jong et al.[13] reported comparable results, but the follow-up in this study was only up to 1 year and, in their study, they included cases where other corrective surgeries like vaginal wall correction were performed along with TOT. Larger prospective studies using validated condition-specified scoring systems are needed to support our preliminary findings.

CONCLUSIONS

The TOT procedure has no significant negative impact on sexual function and it significantly improves female sexual function and overall sexual satisfaction in majority of the patients with SUI.