A Validated Tool Would Greatly Enhance Future Research on the Impact of Surgery on Sexual Function

In women, both sexual dysfunction (SD) and pelvic floor disorders are common problems, which have a negative impact on quality of life (QoL). Sexuality is an important component of the overall QoL. ¹ It is broadly accepted that urinary incontinence (UI) has a negative effect on QoL and sexual function (SF), resulting in a variety of symptoms. Among the most common sexual complaints in women with UI are low desire, vaginal dryness, and dyspareunia. ^2,3 It should be noted that similar complaints are seen in women with SD without UI. ⁴ In women with UI, the actual symptoms are accompanied many times by fear of odor, embarrassment, shame, loss of self-esteem, and fear or actual occurrence of incontinence during intercourse.

In the current issue of this journal, Pastore et al. ⁵ investigated the change in QoL and SF in women treated for pure stress urinary incontinence (SUI) using tension-free transobturator suburethral tape (TVT-O) and single-incision sling procedures. This is among the first studies to compare these two procedures with regard to SF. Female SF was assessed preoperatively and postoperatively (3 to 12 months follow-up) using the female sexual function index (FSFI). In their study, both slings showed a high rate of continence without any major complications. SF improved significantly in all the six FSFI domains, with no statistically significant difference between the two treatment groups. ⁶

The current evidence on the impact of UI surgery on SF is limited. Studies show conflicting results, ranging from overall improvement, through no change, to even deterioration. ⁶ A recent systematic review and metaanalysis including 21 studies evaluated the impact of UI surgery on SF. Despite the fact that the pooled results suggested an increased likelihood of improvement in SF compared with deterioration, more than half of the women who underwent surgery for UI experienced no change in SF. ⁴ The variable results between studies may be a reflection of differences in population characteristics, differences in treatment, or differences in the measurement of outcome.

Over recent years, in urogynecology, the use of general or condition-specific questionnaires as tools for evaluating the QoL and SF of patients has strengthened in scientific research as well as in clinical practice. This is because of the growing interest in subjective clinical evaluation methods among health providers and health researchers. Questionnaires measure subjective information in an objective manner and as such they provide reproducible methods for evaluating female SF. Patients' opinions on their state of health are given value. ^6,7 There is a consensus among QoL researchers in the field of UI that patients themselves are the best judges in evaluating their own QoL. ⁸ Early studies mostly used nonvalidated SF questionnaires. Over the past decade, various questionnaires have been constructed and subdivided into general or condition-specific types. Condition-specific SF questionnaires are designed to assess changes in sexual health specifically caused by a certain condition, for example, SUI. Because of their length, such questionnaires may be inefficient and consequently difficult to apply in clinical practice, or even in scientific research. ^6,7 Many such questionnaires have modified short versions (short forms) that have emerged accordingly.

Although studies using validated questionnaires are preferred to attain objectively obtained reproducible data regarding female SF, we need to be cautious in interpreting these data. The international continence society has graded commonly used questionnaires into highly recommended questionnaires (Grade A), recommended questionnaires (Grade B), and questionnaires with potential (Grade C). ⁹ Interestingly, in the previously mentioned systematic review and metaanalysis, ⁴ Grade A questionnaires were not used in any of the studies that were included in the review. Some used Grade B questionnaires like the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) that is a validated condition-specific questionnaire. ¹⁰ However, others used Grade C questionnaires like the FSFI, a 19-item questionnaire that has been developed as a brief, multidimensional self-report instrument for assessing the key dimensions of SF in women. It was developed on a female sample of normal controls and age-matched subjects who met DSM-IV^®-TR criteria for female SD. It provides scores on six domains of SF (desire, arousal, lubrication, orgasm, satisfaction, and pain) as well as a total score. ¹¹ This questionnaire (also used by Pastore et al. ⁵ in this issue of the journal) is a general (not condition specific) questionnaire that was not validated on women with SUI.

Condition-specific SF questionnaires were validated to discriminate between women with and without SD, within the group of women suffering from SUI. Indeed, in some studies, questionnaires have shown responsiveness to change after surgery. ^5,12,13 After UI surgery, new aspects such as dyspareunia, worries about doing damage, onset of new symptoms, unsatisfactory surgical results, or development of complications become relevant because of the treatment. Hence, a state following SUI surgery is a new clinical condition, necessitating a new condition-specific validated SF questionnaire. It may be that these questionnaires even those that are condition specific for SUI are not optimal to detect SF after surgery because these new aspects are not represented in the SF questionnaire. By neglecting the negative impact that pelvic floor surgery may have on SF on its own accord, evaluation following surgery might be too positive. ⁶

Although the results presented by Pastore et al. ⁵ are encouraging, the improvement in SF established with the use of the FSFI is unfortunately unreliable. In the future, studies should aim to either confirm or reject SF questionnaires as a validated tool for diagnosing SF after surgery. When counseling women before surgery, providing information regarding the impact of surgery on SF is mandatory. A validated tool would greatly enhance future research on the impact of surgery on SF.