Sexual function surgery
A patient’s perspective
Since having my daughter I have lost a lot of sensation during intercourse. At the time of her birth I had three different people saying to me, “you need stitches,” but I didn’t get any. Now I avoid intercourse because of that reason. It feels like everything is lower, feels like a prolapse, feels like everything is falling downwards. I can see a little lump at the entrance and I didn’t see that prior to having my daughter. There’s also a skin tear and tag at the entrance where it healed. I saw some doctors but I was told someone would care for me and love me for who I am. But I’m too embarrassed so how will I meet someone, and then it’s uncomfortable.
What is female sexual dysfunction?
Female sexual function is very complex and, despite increasing research, little is really understood about it. Any abnormality of female sexual function can be described as female sexual dysfunction and this may be temporary, prolonged or unresolved in the long term.
It is recognised that biological, psychological and psychosocial factors influence sexual function.
When there is an abnormality that impacts negatively on the affected woman this is sexual dysfunction and a personal distress component becomes manifested.
There are numerous classifications of female sexual dysfunction. The most commonly accepted are still undergoing constant review and refinement.
Female sexual dysfunction is often divided into 4 broad categories:
- Sexual desire disorders.
- Sexual arousal disorders.
- Sexual orgasm disorders.
- Sexual pain disorders.
All of these categories are themselves complex and have several subdivisions and definitions within them.
What is sexual function surgery?
Surgery for sexual dysfunction must aim to improve sexual dysfunction disorders that have their root in a physically identifiable cause. In order to achieve this, the principle of surgery is to restore anatomy to as close to normal as possible.
Whilst the resolution of physical problems may result in psychological benefits, surgery is highly unlikely to be beneficial for women whose primary problem has a psychological, psychiatric, hormonal or endocrinological aetiology.
Pelvic floor dysfunction can result in sexual dysfunction
Conditions that may be improved by surgery include some types of:
- Sexual aversion disorder
Phobic aversion to, and avoidance of, sexual contact with a sexual partner, which must be persistent and causes personal distress. For example, resulting from:
- Urinary incontinence.
- Pelvic organ prolapse.
- Labial discomfort or elongation.
- Vaginal lesions.
- Sexual arousal disorder
Inability to attain/maintain sufficient sexual excitement, causing personal distress. For example resulting from:
- Vaginal wall relaxation.
- Perineal body detachment.
- Pelvic floor muscle detachment.
- Sexual pain disorder
Dyspareunia – Genital pain associated with sexual intercourse. For example resulting from:
- Scarred introitus/perineum.
- Elongated labia.
- Uterine and vaginal wall prolapse.
- Puborurethral ligament detachment.
Vaginismus – Involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress. Limited to circumstances where the vaginismus is triggered by pain that has a physical rather than psychological basis.
Women who suffer from urinary incontinence often have low self esteem and an abnormality of body image related to this. They fear smelling of urine and often think that others are aware of their smell. They may have, or fear, leakage of urine during intercourse and, when the leakage occurs, this may be a result of the physical movement (stress incontinence) or due to an overactive bladder (urgency incontinence). The need to remove an incontinence pad prior to having intimate relationships is not conducive to a good libido. Cure of urinary incontinence is associated with an improvement in libido and sexual function.
Pelvic organ prolapse
Pelvic organ prolapse is associated with dyspareunia, reduced sensation during intercourse, urinary and faecal incontinence, sensation of a bulge within the vagina, pelvic and lower back ache and poor body image. Some women, in addition to the physical symptoms of the prolapse, worry that their partner will see or feel the prolapse and this can restrict intimacy to the point of cessation. Correction of pelvic organ prolapse may improve libido and self confidence.
Perineal body detachment
Perineal body detachment is a common consequence of spontaneous and instrumental (forceps/Ventouse) vaginal delivery. As the baby’s head is delivered it stretches and tears the muscles of the levator ani muscle and as crowning takes place the most distal part of the vaginal area, the perineal body becomes disrupted. The result is an open, patulous vaginal entrance. Symptoms resulting from this include reduced ability to grip during intercourse, the impression of an open, wide vaginal entrance, an appearance that has changed from what it looked like previously and vaginal wind. The perineum (area between vaginal entrance and anal margin) can become scarred as a result of a spontaneous tear or performance of an episiotomy changing the aesthetics of the area or producing uncomfortable scar tissue or skin tags.
Vaginal wall relaxation
Vaginal wall relaxation is a form of pelvic organ prolapse. In fact, to distinguish between the two can become a matter of semantics. My view is that vaginal wall relaxation refers to a type of pelvic organ prolapse where the vaginal epithelium becomes stretched and the surface area increases. When a prolapse of the vaginal walls occurs without relaxation of the vaginal epithelium, the ruggae tend to be lost and the vagina looks smooth. When relaxation occurs without much in the way of muscle or fascial defects, the ruggae are maintained and the overfolding appearance of the vagina may appear exaggerated. Symptoms commonly associated with vaginal wall relaxation include reduced sensation during intercourse, increased vaginal discharge and vaginal wind.
Labial aesthetics & discomfort
Both the labia minora (‘inner lips’) and labia majora (‘outer lips’) can undergo changes which produce discomfort and concern about the change in appearance. Skin changes include thickening (hypertrophy), elongation and hyperpigmentation (become darker). Labia minora hypertrophy and elongation can result in infolding and discomfort during intercourse. The labia majora do not elongate in the same way as the minora, but the skin does stretch and sag resulting in an appearance that can make some women very self conscious and, through embarrassment, avoid situations that might lead to intimacy. Labia minora tears can occur during childbirth and often, it is the discomfort during intercourse, rather than aesthetics that drives women to seek a resolution.
Vaginal lesions and skin tags
There are numerous causes of vaginal lesions and skin tags. They can be broadly divided into congenital (from birth) and acquired causes. Some of the most common congenital lesions will be those which impact on the development of vaginal epithelium resulting in abnormal connections between various parts of the vaginal epithelium. This can result in a septated vagina and skin bridges. Acquired lesions range from poorly understood conditions such as lichen sclerosus, infections such as exophytic warts and blocked glands resulting in Bartholin’s cysts.
Painful intercourse is a very complex complaint and can be caused by numerous different medical conditions. In some cases there will be more than one cause for pain. The site of the pain can help towards making a diagnosis. Deep dyspareunia is pain thought to be located deep within the vagina and superficial dyspareunia is pain that is felt at the entrance to the vagina. Common causes of deep dyspareunia include uterine and vaginal wall prolapse and endometriosis, particularly when there are deposits on the utero-sacral ligaments or Pouch of Douglas. Superficial dyspareunia can result from scars or tears at the forchette, infolding of elongated labia, thickened or elongated hymenal remnants.
In the most severe cases of vaginismus, access to the vagina is not possible at all and the highly toned vaginal walls clamp down completely. In less severe cases, intercourse can take place but remains painful enough for it to be prohibitive and frustrating for those affected. Vaginismus is distinct from dyspareunia but may be the outcome of recurrent dyspareunia. Dyspareunia is not necessary for vaginismus to be diagnosed as some women will have such a raised anxiety related to contact with their genital area that contraction of their pelvic floor muscles would not allow even a single digit examination. There is often a psychological component to vaginismus so review by a psychologist is often beneficial. Pelvic floor rehabilitation through relaxation therapies with an appropriately trained physiotherapist should be part of treatment. Graded vaginal dilators can prove to be very beneficial. Botox injected into the levator muscles has an increasingly recognised role and usually does not need to be repeated. In severe vaginismus, where other avenues have been explored without success, and where the levator muscles remain hypertonic, selective division of some of those muscle fibres can provide relief or resolution.