Sexual dysfunction is a major concern for women with pelvic organ prolapse (POP). Surgical treatment of POP is generally associated with an improvement in sexual function, however, the primary focus is mainly on sexually active women, while postoperative deterioration in sexual function and the effects of surgery on sexually inactive women are less often reported. The aims of this longitudinal cohort study were to describe changes in sexual activity and function as well as satisfaction in quality of sexual life after POP surgery.

This nationwide prospective cohort study included 3515 women aged over 18 years undergoing POP surgery in Finland during 2015. Sexual activity status and reasons for inactivity were reported at baseline and at 6 months, 2 years, and 5 years after surgery. Quality of sexual life was assessed at baseline and after native tissue, transvaginal mesh and abdominal mesh surgeries using validated questionnaires: The generic health-related quality of life instrument (15D) and The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12). The global and item-by-item sexual function scores were calculated overall and for each surgical subgroup separately at each timepoint. Satisfaction of current condition, the effect of state of health on sexual activity, and worst symptoms of POP were reported for sexually active and inactive women separately.

Sexual activity status was available for 2785 women at baseline, of which 1133 (40.7%) were sexually active and 1652 (59.3%) were sexually inactive. The baseline characteristics of sexually active and inactive women differed significantly by age (p<.001), BMI (p=.003), parity (p<.001), the use of estrogen replacement therapy (p<.001), the occurrence of prior hysterectomy (p<.001) and diabetes (p<.001) as well as type of prolapse (p<.001-.003) and surgical intervention (p<.001). Partner-related factors and lack of sexual desire were most often reported as reasons for sexual inactivity at baseline and during follow-up (Figure 1). Of all sexually active women, 97% had sufficient data for PISQ analysis at baseline, with a mean overall score of 33.6±5.8. At 6-month follow-up a statistically significant (p<.001) increase to 36.4±5.2 in mean global score was observed, after which no significant change was detected. No differences between surgical approaches in sexual function scores were detected. The change in global sexual function score was clinically significant (modified PISQ minimum important difference ≥6) at 6-month follow up in all surgical groups, while at 2-year follow-up only in native tissue repair group and at 5-year follow-up only in abdominal mesh group.
Paired PISQ-12 data was available for 787 (71.5%) sexually active women at 6 months, of which 70% reported improvement and 19.6% deterioration in sexual function. Worsening in sexual function was mainly associated with behavioral-emotive and partner-related factors (Figure 2). Despite the decrease in overall PISQ-12 score, avoidance due to fear of incontinence and orgasm intensity remained similar after POP surgery, and women reported avoiding sexual intercourse less often because of bulging in the vagina. 
Both sexually active and inactive women reported bulging in the vagina as the worst symptom at baseline, whereas urinary incontinence was the main cause of bother at 6-month and 5-year follow-up. Most women (93.4% of sexually active and 92.9% of sexually inactive) reported at least slight improvement in current condition at 6 months after surgery. The effect of state of health on sexual activity improved considerably after POP surgery for both sexually active and inactive women: preoperatively 38.9% of sexually active and 31.2% of sexually inactive women reported no adverse effect while at 6 months after surgery the proportions increased to 68.0% and 65.1% respectively. The rate of sexually inactive women reporting sexual activity almost impossible or impossible decreased from 17.9% at baseline to 8% at 6-month postoperative follow-up.

The rate of sexually active women increased and sexual function mostly improved after POP surgery. No significant differences were found in sexual function scores between native tissue and mesh surgeries and long-term follow-up data seem promising especially after abdominal mesh surgery. Partner-related factors were a major cause for sexual inactivity while the deterioration in sexual function scores among sexually active women were also mainly associated with decrease in partner-related and behavioral-emotive domains. Surgery alleviates physical symptoms, especially sensation of bulge, related to POP for both sexually active and inactive women, which most likely is the main reason for improvement in postoperative sexual function. The state of health had notably less impact on sexual activity after POP surgery for both sexually active and inactive women and women in both groups reported improvement in current condition during follow-up.

Sexual function and quality of life improved after POP surgery irrespective of surgical approach and for both sexually active and inactive women. Partner-related factors as well as behavioral and emotive factors play an important role in the occurrence of sexual dysfunction among both sexually active and inactive women and should be considered in preoperative counseling.

Continence 7S1 (2023) 100847
DOI: 10.1016/j.cont.2023.100847