REVIEW

Pelvic Floor Dysfunction And Its Effect On Quality Of Sexual Life

Michelle Verbeek, MD,1 and Lynsey Hayward, BSc (Hons), MBChB (Hons), FRANZCOG, FRCOG2

ABSTRACT

Introduction: Pelvic floor disorders (PFD) are extremely common; 1 in 3 parous women will experience urinary
incontinence, 1 in 2 will develop pelvic organ prolapse, whereas 1 in 10 experience fecal incontinence. PFD are
often associated with a significant reduction in women’s psychological, social, and sexual well-being.
Aim: To review the current literature on sexual dysfunction related to PFD.
Methods: A literature search was conducted using PubMed and key words including sexual dysfunction,
prolapse, incontinence, pelvic floor dysfunction, and surgical repair.
Main Outcome Measure: The outcome was to identify the nature and severity of sexual dysfunction in women
with PFD.
Results: The prevalence of sexual dysfunction is estimated to be around 30e50% in the general population,
whereas in women with PFD, the reported incidence rises to 50e83%. The leading factors cited for the
reduction in a woman’s sexual experience included worries about the image of their vagina for women with pelvic
organ prolapse, dyspareunia and coital incontinence in women with urinary incontinence, and fear of soiling
when dealing with anal incontinence. Pelvic floor muscle training has been associated with an improvement in
sexual function. 11% of parous women will have surgery for pelvic organ prolapse, yet limited data are available
on the impact of surgical intervention on sexual function. Native tissue repair of pelvic organ prolapse is asso-
ciated with an improvement in sexual function, whereas posterior repair with levatorplasty and vaginal mesh
repair can increase the risk of postsurgical dyspareunia. Subtotal hysterectomy is not associated with improved
sexual function compared with traditional total hysterectomy.
Conclusion: It is clear there is an urgent need for further research on the effects of surgery for PFD on sexual
function. To date, most studies have focused on anatomic rather than functional outcomes. Verbeek M,
Hayward L. Pelvic Floor Dysfunction and Its Effect on Quality of Sexual Life. Sex Med Rev
2019;7:559e564.
Copyright
2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Sexual Dysfunction; Pelvic Organ Prolapse; Stress Urinary Incontinence; Urge Urinary Inconti-
nence; Fecal Incontinence; Pelvic Floor Disorders

INTRODUCTION About 40% of women are affected by POP,1 whereas 1 in 3 to

Millions of women worldwide are impacted by pelvic floor
dysfunction, yet personal shame and social taboos still prevent
open discussion on the topic. This review highlights the condi-
tions associated with pelvic floor disorders (PFD) such as urinary
incontinence (UI), fecal incontinence (FI), and pelvic organ
prolapse (POP), and their impact on women’s sexual life.
Received February 16, 2019. Accepted May 30, 2019.
1
Department of Obstetrics and Gynaecology, Middlemore Hospital, Auck-
land, New Zealand;
2
Department of Urogynaecology, Middlemore Hospital, Auckland, New
Zealand
Copyright ª 2019, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.sxmr.2019.05.007
Sex Med Rev 2019;7:559e564
4 women will experience UI and 1 in 10 will experience FI.2
PFD can have a profound effect on women’s social, sexual,
psychological, and financial well-being, resulting in social isola-
tion, loss of income, and poorer quality of life.
POP is defined as the abnormal descent or herniation of the pelvic
organs from their normal position, resulting in an abnormal sensation
or function.3 POP can be subclassified in terms of the affected
compartment; a descent of
1 of the anterior compartment
(cystocele), the posterior compartment (rectocele and enterocoele),
the uterus (cervix), or the apex of the vagina (after hysterectomy).3
PELVIC ORGAN PROLAPSE
Although many women with POP experience no symptoms,
others may notice a sensation of a bulge, heaviness, or dragging
559
560
pelvic pressure or have difficulty retaining a tampon. Advanced
POP may result in chafing, leading to skin ulceration or
bleeding. Anterior compartment prolapse may cause voiding
dysfunction, including urinary urgency, a poor or intermittent
urinary stream, incomplete emptying leading to urinary fre-
quency, nocturia, and increased risk of urinary tract infection;
advanced prolapse may result in ureteric obstruction.3,4 A pos-
terior compartment prolapse can result in incomplete or
obstructed defecation and fecal urgency or soiling.4 Sexual
dysfunction, difficulty with penetration, discomfort, and altered
body image are also associated with POP.5
Development of POP is multifactorial and includes anatomic,
physiological, genetic, lifestyle, and reproductive factors. The
most consistent risk factors include multiparity, delivery mode,
advancing age, and raised body mass index, whereas ethnicity,
smoking, and menopause have also been associated with the
development of POP.6,7
The exact prevalence of POP is unknown, but outcomes of
population-based research report that 36e90% of middle-aged
to older women have some degree of prolapse on examina-
tion,8,9 with 6e12% of these women being symptomatic.9e11
The anterior compartment prolapse is the most common site
for POP (34%), followed by the posterior compartment (19%),
apical (14%), and multi-compartment POP (14%). The preva-
lence of prolapse is predicted to rise in Western populations as a
result of an aging population and increasing obesity
(Figure 1).1,8,10e12 Women have an 11% lifetime risk of un-
dergoing surgical correction of POP, with the anterior
compartment being the most common site for repair at 40%.13
URINARY INCONTINENCE
UI is defined as the involuntary loss of urine. The most
common forms of incontinence include (i) stress urinary in-
continence (SUI), the loss of urine on effort or physical exertion,
coughing, sneezing, and exercising; (ii) urge urinary incontinence
(UUI), where there is involuntary urine loss associated with ur-
gency; and (iii) mixed urinary incontinence (MUI), which is a
combination of both stress and urge incontinence.3
Many think UI is confined to the elderly; however, a US
populationebased survey reported an overall prevalence of 17%
of UI in woman >20 years of age.14,15 The EPIC study found a
UI prevalence rate of 13%, with the most common being SUI at
6.4%, followed by MUI and UUI with rates of 2.4% and 1.5%,
respectively.2 The prevalence of UI was noted to increase with
age. Regarding the different types of UI, SUI was 3.7% in
women <39 years vs 8.0% in women >60 years, UUI was 1.0%
in women <39 years vs 2.5% in women >60 years, and MUI
was 1.0% women in <39 years vs 4.1% in women >60 years.2
Obesity, chronic cough, smoking, and aging are associated
with SUI; however, vaginal delivery causes the highest risk for
development of SUI.15e17 Handa et al17 found that women who
had only had caesarean births reported 40% less SUI (P < .01)
Verbeek and Hayward
compared with those with at
1 vaginal delivery, and the
SWEPOP study found that the risk of developing SUI was
67e71% higher after vaginal delivery than after caesarean sec-
tion.16 UUI often has no clear cause, but, based on personal
clinical experience, it may be associated with some medications,
caffeinated drinks, or urinary tract infections or triggered by
activities or sounds such as running water.
ANAL INCONTINENCE
Anal incontinence (AI) is defined as the involuntary loss of
flatus or of feces (FI), which can be solid or liquid, whereas coital
FI occurs with fecal leakage during vaginal intercourse 3. 2
population-based studies show a lifetime prevalence of
8.9e9.4% for FI,16,18 which increases with age, with 15.3% of
women aged
70 experiencing monthly episodes of FI.18
Childbirth trauma resulting in anal sphincter damage is the
major cause of FI in women, whereas instrumental delivery,
obesity, diarrhea, and the presence of multiple comorbidities also
have a role.16,18
SEXUAL DYSFUNCTION IN WOMEN SUFFERING
PELVIC FLOOR DISEASES (PFD)
PFD has been shown to have a negative impact on women’s
social, physical, sexual, and psychological well-being.19 Despite
the high incidence of PFD, the data exploring the effects of PFD
and surgical treatment of PFD on sexual function are limited,
and it is clear that more research is required; training of doctors
in this field is also a priority. National surveys in the United
States and United Kingdom reported that only 22% of urogy-
necologists regularly screen women for sexual dysfunction, with
23% reporting they never screened; time and lack of training
were cited as the biggest barriers.20,21
The World Health Organization definition of female sexual
dysfunction (FSD) includes “the various ways in which an in-
dividual is unable to participate in a sexual relationship as she
would.” 22 On the basis of population-bases studies, the preva-
lence of FSD can be estimated to be between 30e50%.23 For
women suffering with PFD, 50e83% of sexually active women
in this group reported some degree of FSD; this incidence of
FSD is higher than within the general population.5,15,19,24,25
Novi et al(26) compared women with and without POP
matched by age, ethnic background, parity, and hysterectomy
and menopausal status. A significant lower FSD (PISQ score)
was found in the study group compared with the control group,
whereas 30% were sexually inactive secondary to their POP
symptoms.26 In an observational study by Barber et al,27 one-
third of women reported that prolapse affected their ability to
have sexual relations. The most important factors for reduction
in a woman’s sexual experience included worries about the image
of their vagina, embarrassment, concerns about a partner’s
satisfaction, as well as discomfort associated with POP and
reduced genital sensation and fear of worsening the prolapse.27
Sex Med Rev 2019;7:559e564
PFD and Its Effect on SDF
Handa et al15 noted that women with advanced POP were
more likely to report decreased arousal (P < .01), infrequent
orgasm (P < .01), and increased dyspareunia (P < .01).
Compared with those with less-advanced POP, they were also
more likely to suffer with fecal or urinary incontinence. The
combined presence of POP and incontinence had a cumulative
negative effect on sexual dysfunction.26
SEXUAL DYSFUNCTION IN WOMEN SUFFERING
URINARY INCONTINENCE (UI)
Results from multiple studies have shown a decrease in sexual
well-being independent of the type of UI.27e31 Saloni et al(23)
reported that 46% of the patients, suffering from different types
of UI or lower urinary tract symptoms, had FSD using outcomes
from a validated questionnaire (Female Sexual Function Index).
The most common dysfunctions are dyspareunia (44%), hypo-
active sexual desire (34%), sexual arousal disorder (23%), and
orgasmic deficiency (11%). Results from different studies did not
conclude which type of incontinence is related to the highest rate
of female sexual dysfunction.27,30,31
Coital or orgasmic incontinence is a significant concern and
cause of embarrassment for many women and cited this as the
main cause of FSD in 68% of women with isolated SUI.29
Conversely, dyspareunia and lubrication issues were the most
important complaints in patients with UUI at 34%.32
SEXUAL DYSFUNCTION IN WOMEN SUFFERING
WITH AI
For many women, AI is a devastating symptom associated
with shame, embarrassment, and social isolation. Studies looking
at the effect of AI on sexual function are limited; however,
women with AI were found to have decreased sexual desire,
sexual satisfaction, arousal lubrication, and orgasm compared
with those without.33e35 Fear of soiling during intercourse,
embarrassment, and dyspareunia were the major impactors on
sexual function. Women with AI report higher rates of FSD
compared with those with UI, although the rate of sexual activity
was similar.33,34 A reasonable explanation is that women
suffering from this condition adopt coping strategies to reduce
the impact of AI on sexual function.33,34
TREATMENT OF POP AND UI AND ITS EFFECT ON
SEXUAL FUNCTION
Pelvic Floor Muscular Training
Evidence on the efficacy of pelvic floor muscular training
(PFMT) for improving sexual function is limited. PFMT has
been shown to improve sexual desire, performance during coitus
and the ability to achieve an orgasm but without an effect on
arousal in women with UI.36,37 PFMT has also been found to
reduce coital incontinence and increase sexual satisfaction in
women with SUI.38 Whereas Lowenstein et al37 showed that
Sex Med Rev 2019;7:559e564
561
Figure 1. A longitudinal study of menopausal women: Lifetime
cumulative prevalence for cystocele, rectocele, and uterine prolapse
among women who entered the study without prolapse (n ¼ 281
women). Lifetime cumulative prevalence is defined as any prolapse
that is observed at any time during the follow-up period.12
women with a strong pelvic muscle contraction scored higher in
orgasmic and arousal domains of the Female Sexual Function
Index compared with women with weak pelvic floor.
Pessary Use and Its Effect on Sexual Function
Literature assessing the effects of pessaries on sexual function
in women with prolapse is sparse and conflicting. 2 prospective
studies suggested that desire, lubrication, and sexual function
improved significantly with vaginal pessary use.39 However, the
women also used vaginal estrogen therapy for atrophy, which is
likely to account for the improvement in lubrication.40 Similar
effects were observed in another prospective trial comparing
outcomes of vaginal pessaries vs surgery in women with symp-
tomatic pelvic organ prolapse in sexual function and quality of
life parameters.41 Conversely, Lowenstein et al42 reported that
sexual function did not improve with pessary use, whereas sur-
gical management gives a significant improvement for prolapse.
Botox and UUI
There are limited but promising data on the effect of Botox
injection of the detrusor on female sexual function. Miotla et al43
and Balzarro et al44 both noted an improvement of the sexual
function of women diagnosed with an overactive bladder,
although their study population was small.
Surgery
Despite the vagina being a sexual organ, most of the literature
relating to outcomes of PFD surgery focuses on anatomic rather
than functional outcomes or presence or absence of dyspareunia
rather than sexual well-being and function. Different data,
including a Cochrane analysis, found that surgical repair of
prolapse is associated with improvements in sexual function and
dyspareunia related to prolapse.45,46 Native tissue repair for
pelvic organ prolapse (anterior repair, posterior repair, uterosacral
ligament suspension, sacrospinous ligament suspension) showed
562
improved sexual function as assessed by preoperative and post-
operative validated questionnaires (PISQ-31 and 12, FSFI,
ePAQ, and P-QOL). The absence of well-designed randomized
controlled trials means this evidence should be viewed with
caution.47 The improvement in sexual function after prolapse
surgery have been attributed to reduced physical symptoms and
improved sexual body image.42 Both Weber et al48 and the
Cochrane review49 noted improvements in sexual function after
anterior repair irrespective of surgical technique (native tissue
repair or mesh).
A systematic review for incontinence surgery and an analysis of
Value of Urodynamics Prior to Stress Incontinence Surgery using
questionnaires validated by the Dutch Society of Urogynaecology
showed no significant improvement of sexual function for mid-
urethral tapes alone, although a significant improvement of
coital incontinence after continence surgery was found.50,51
Vaginal mesh for POP repair has been associated with both
dyspareunia and hispareunia (usually due to mesh exposure). A
systemic review of vaginal prolapse repair using graft materials
from 1950e2010 showed an incidence of 9.1% of postoperative
dyspareunia independent of graft type. The significance of these
data is limited because of the use of unvalidated measurements
and unknown preoperative dyspareunia rates.45 Other studies
report de novo dyspareunia rates of 7% in the anterior
compartment compared with 4% with native tissue alone
(P
.05).48,49 Traditionally posterior compartment repair is
most associated with de novo dyspareunia secondary to levator
plication and consequent vaginal narrowing; as a result, this
procedure has largely been abandoned 4. Posterior repair without
levator plication was associated with either no change or a
reduction in dyspareunia rates without a significant difference
between native tissue or grafting in 2 studies.45,52 Despite
reporting de novo dyspareunia after posterior repair, Komesu
et al 53 found that women reported an overall improvement of
their sexual life after surgery.
It has been postulated that retaining the cervix at hysterectomy
offers better postoperative sexual function in terms of orgasm,
potentially due to reduced neurologic disruption and absence of
vault scarring.54 However, a recent review of 3 randomized
control trials found an improvement in sexual function after
hysterectomy independent of the retention or removal of the
cervix.55e57 Uterine preservation does not positively affect sexual
experience, according to a randomized control trial comparing
sexual satisfaction after sacrospinous hysteropexy vs vaginal
hysterectomy.58 whereas Gé et al59 noted an enhancement of the
orgasm with hysterectomy.
CONCLUSION
We can conclude that FSD caused by PFD is a global issue
and one that is likely to increase along with life expectancy. The
perception of sexual satisfaction depends on many complex in-
teractions, the role of surgery, and the best surgical techniques to
Verbeek and Hayward
improve sexual function and satisfaction are still to be deter-
mined. Clearly there is still a huge need for research in this area
whereas education of health care professionals is also urgently
required. The standardization of outcome measures is also a
priority.
Corresponding Author: Michelle Verbeek, MD, Dept. Ob-
stetrics and Gynaecology, Middlemore Hospital, Auckland, New
Zealand. Tel: 0221021260; E-mail: verbeekmichelle@hotmail.
com
Conflicts of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Michelle Verbeek; Lynsey Hayward
(b) Acquisition of Data
Michelle Verbeek; Lynsey Hayward
(c) Analysis and Interpretation of Data
Michelle Verbeek; Lynsey Hayward
Category 2
(a) Drafting the Article
Michelle Verbeek; Lynsey Hayward
(b) Revising It for Intellectual Content
Michelle Verbeek; Lynsey Hayward
Category 3
(a) Final Approval of the Completed Article
Michelle Verbeek; Lynsey Hayward
REFERENCES
1. Hendrix SL, Nygaard I, Aragaki A, et al. Pelvic organ prolapse
in the women’s health initiative: Gravity and gravidity. Am J
Obstet Gynecol 2002;186:1160-1166.
2. Irwin DE, Milsom I, Hunskaar S, et al. Population-based survey
of urinary incontinence, overactive bladder, and other lower
urinary tract symptoms in five countries: Results of EPIC
study. Euro Urol 2006;50:1306-1314.
3. Haylen BT, Freeman RM, de Ridder D, et al. An International
Urogynecological Association (IUGA)- Internatinal Continence
Society (ICS) Joint Report into the terminology for female
pelvic floor dysfunction. Neurourol Urodyn 2010;29:4-20. Int
Urogynecol J 2010;21:5e26.
4. Ulrich D, Dwyer P, Rosamilia A, et al. The effect of vaginal
pelvic organ prolapse surgery on sexual function. Neurourol
Urodyn 2015;34:316-321.
5. Roos AM, Thakar R, Sultan AH, et al. Pelvic floor dysfunc-
tion: Women’s sexual concerns unraveled. J Sex Med 2014;
11:743-752.
6. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse.
Lancet 2007;369:1027-1038.
Sex Med Rev 2019;7:559e564
PFD and Its Effect on SDF
7. Vergeldt TF, Weemhoff M, IntHout J, et al. Risk factors for
pelvic organ prolapse and its recurrence: A systematic review.
Int Urogynecol J 2015;26:1559-1573.
8. Swift SE. The distribution of pelvic organ support in a popu-
lation of female subjects seen for routine gynecologic health
care. Am J Obstet Gynecol 2000;183:277-285.
9. Slieker-ten Hove MCP, Pool-Goudzwaard AL, Eijkemans MJC,
et al. Pelvic floor muscle function in a general population of
women with and without pelvic organ prolapse. Int Urogy-
necol J 2010;21:311-319.
10. Rortveit G, Brown JS, Thom DH, et al. Symptomatic pelvic
organ prolapse: Prevalence and risk factors in a population-
based, racially diverse cohort. Obstet Gynecol 2007;
109:1396-1403.
11. Tegerstedt G, Maehle-Schmidt M, Nyrén O, et al. Prevalence of
symptomatic pelvic organ prolapse in a Swedish population.
Int Urogynecol J Pelvic Floor Dysfunct 2005;16:497-503.
12. Hand VL, Garrett E, Hendrix S, et al. Progression and remis-
sion of pelvic organ prolapse: A longitudinal study of meno-
pausal women. Am J Obstet Gynecol 2004;190:27-32.
13. Olsen L, Smith VJ, Bergstrom JO, et al. Epidemiology of
surgically managed pelvic-organ prolapse and urinary incon-
tinence. Obstet Gynecol 1997;89:501-506.
14. Wu JM, Vanghan CP, Googde PS, et al. Prevalence and trends
of symptomatic pelvic floor disorders in US women. Obstet
Gynecol 2014;123:141-148.
15. Handa VL, Cundiff G, Chang HH, et al. Female sexual function
and pelvic floor disorders. Obstet Gynecol 2008;111:1045-
1052.
16. Gyhagen M, Bullarbo M, Nielsen TF, et al. Prevalence and risk
factors for pelvic organ prolapse 20 years after childbirth: A
national cohort study in singleton primiparae after vaginal or
caesarean delivery. BJOG 2013;120:152-160.
17. Handa VL, Harvet L, Fox HE, et al. Parity and route of delivery:
Does caesarean delivery reduce bladder symptoms later in life?
Am J Obstet Gynecol 2004;191:463-469.
18. Whitehead WE, Borrud L, Goode PS, et al. Fecal incontinence
in US adults: Epidemiology and risk factors. Gastroenterology
2009;137:512-517.
19. Abed H, Rahn DD, Lowenstein L, et al. Incidence and man-
agement of graft erosion, wound granulation, and dyspareunia
following vaginal prolapse repair with graft materials: A sys-
tematic review. Int Urogynecol J 2011;22:789-798.
20. Pauls RN, Kleeman SD, Segal JL, et al. Practice patterns of
physician members of the American Urogynecologic society
regarding female sexual dysfunction: Results of a national
survey. Int Urogynecol J Pelvic Floor Dysfunct 2005;
16:460-467.
21. Roos AM, Thakar R, Sultan AH. Female sexual dysfunction:
Are urogynecologists ready for it? Int Urogynecol J Pelvic
Floor Dysfunct 2009;20:89-101.
22. World Health Organisation (ICD-10). International Statistical
Classification of Diseases and Related Health problems.
Geneva: WHO; 1992.
Sex Med Rev 2019;7:559e564
563
23. Salonia A, ZamniG, Nappi RE, et al. Sexual dysfunction is
common in women with lower urinary tract symptoms and
urinary incontinence: Results of a cross-sectional study. Eur
Urol 2004;45:642-648.
24. Geiss IM, Umek WH, Dungl A, et al. Prevalence of female
sexual dysfunction in gynecologic and urogynecologic patients
according to the international consensus classification. Urol-
ogy 2003;62:514-518.
25. Handa VL, Harvey L, Cundiff GW, et al. Sexual function among
women with urinary incontinence and pelvic organ prolapse.
Am J Obstet Gynecol 2004;191:751-756.
26. Novi JM, Jeronis S, Morgan MA, et al. Sexual function in
women with pelvic organ prolapse compared to women
without pelvic organ prolapse. J Urol 2005;173:1669-1672.
27. Barber MD, Visco AG, Wyman JF. Sexual function in women
with urinary incontinence and pelvic organ prolapse. ACOG
2002;99:281-289.
28. Sutherst J, Brown M. Sexual dysfunction associated with
urinary incontinence. Urol Int 1980;35:414-416.
29. Walters MD, Taylor S, Schoenfeld LS. Psychosexual study of
women with detrusor instability. Obstet Gynecol 1990;
75:22-26.
30. Caruso S, Brescia R, Matarazzo MG, et al. Effects of urinary
incontinence subtypes on women’s sexual function and quality
of life. Urology 2017;108:59-64.
31. Weber AM, Walters MD, Schover LR, et al. Sexual function in
women with uterovaginal prolapse and urinary incontinence.
Obstet Gynecol 1995;85:483-487.
32. Su CC, Sun BY, Jiann BP. Association of urinary incontinence
and sexual function in women. Int J Urol 2015;22:109-113.
33. Pauls RN, Rogers RG, Parekh M, et al. Sexual function in
women with anal incontinence using a new instrument: The
PISQ-IR. Int Urogynecol J 2015;26:657-663.
34. Imhoff LR, Brown JS, Creasman JM, et al. Fecal incontinence
decreases sexual quality of life, but does not prevent sexual
activity in women. Dis Colon Rectum 2012;55:1059-1065.
35. Cichowski SB, Komesu YM, Dunivan GC, et al. The association
between fecal incontinence and sexual activity and function in
women attending a tertiary referral center. Int Urogynecol J
2013;24:1489-1494.
36. Melville JL, Katon W, Delaney K, et al. Urinary incontinence in
US women: A population-based study. Arch Intern Med
2005;165:537-542.
37. Lowenstein L, Gruenwald I, Gartman I, et al. Can stronger
pelvic muscle floor improve sexual function. Int Urogynecol J
2010;21:553-556.
38. Sacomori C, Cardoso FL. Predictors of improvement in sexual
function of women with urinary incontinence after treatment
with pelvic floor exercises: A secondary analysis. J Sex Med
2015;12:746-755.
39. Kuhn A, Bapst D, Stadlmayr W, et al. Sexual and organ
function in patients with symptomatic prolapse: Are pessaries
helpful? Fertil Steril 2010;91:553-556.
564
40. Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal
atrophy in postmenopausal women. Cochrane Database Syst
Rev 2006;4:CD001500.
41. Abdool Z, Thakkar R, Sultan AH, et al. Prospective evaluation
of outcome of vaginal pessaries versus surgery in women with
symptomatic pelvic organ prolapse. Int Urogynecol J 2011;
22:273-278.
42. Lowenstein L, Gamble T, Sanses TV, et al. Changes in sexual
function after treatment for prolapse are related to the
improvement in body image perception. J Sex Med 2010;
7:1023-1028.
43. Miotla P, Cartwright R, Skorupska K, et al. Impact of intra-
vesical Onabotulinum toxin A on sexual function in women
with OAB. Neurourol Urodynam 2017;36:1564-1569.
44. Balzarro M, Rubilotta E, Braga A, et al. Onabotulinum toxin A
detrusor injection improves female sexual function in women
with overactive bladder wet syndrome. Eur J Obstet Gynecol
Reprod Biol 2018;225:228-231.
45. Thompson JC, Rogers RG. Surgical management of pelvic
organ prolapse and its impact on sexual function. Sex Med
Rev 2016;4:213-220.
46. Glavind K, Larsen T, Lindquist AS. Sexual function in women
before and after surgery for pelvic organ prolapse. Acta
Obstet Gynecol Scand 2015;94:80-85.
47. Jha S, Gray T. A systematic review and meta-analysis of the
impact of native tissue repair for pelvic organ prolapse on
sexual function. Int Urogynecol J 2015;26:321-327.
48. Weber AM, Walters MD, Piedmonte MR, et al. Anterior col-
porrhaphy: A randomized trial of three surgical techniques.
Am J Obstet Gynecol 2001;185:1299-1304.
49. Maher C, Baessler K, Barber M, et al. Surgical management of
pelvic organ prolapse. In: Abrams C, Khoury W, eds. 5th In-
ternational Consultation on incontinence. Paris: Health Publi-
cation Ltd; 2013.
Verbeek and Hayward
50. Jha S, Ammenbal M. Impact of incontinence surgery on sexual
function: A systematic review and meta-analysis. J Sex Med
2012;9:34-43.
51. Mengerink BB, Van Leijsen SA, Vierhout ME, et al. The impact
of midurethral sling surgery on sexual activity and function in
women with stress urinary incontinence. J Sex Med 2016;
13:1498-1507.
52. Mowat A, Maher D, Baessler K, et al. Surgery for women with
posterior compartment prolapse. Cochrane Database Syst
Rev 2018;3:CD012975.
53. Komesu YM, Rogers RG, Kammerer-Doak DN, et al. Posterior
repair and sexual function. Am J Obstet Gynecol 2007;
197:101-106.
54. Kilkku P, Gronroos M, Hirvonen T, et al. Supravaginal uterine
amputations versus hysterectomy: Effects on libido and
orgasm. Acta Obstet Gynecol Scand 1983;62:147-152.
55. Kupperman M, Summitt RL, Varner RE, et al. Sexual func-
tioning after total compared with supracervical hysterectomy:
A randomised trial. Obstet Gynecol 2005;105:1309-1318.
56. Flory N, Bissonnette F, Amsel RT, et al. The psychosocial
outcomes of total and subtotal hysterectomy: A randomised
controlled trial. J Sex Med 2006;3:483-491.
57. Berlit S, Tuschy B, Wuhrer A, et al. Sexual functioning after
total versus subtotal laparoscopic hysterectomy. Arch Gyne-
col Obstet 2018;298:337-344.
58. Jeng CJ, Yang YC, Tzeng CR, et al. Sexual functioning after
vaginal hysterectomy or transvaginal sacrospinous uterine
suspension for uterine prolapse: A comparison. J Reprod Med
2005;50:669-674.
59. Gé P, Vaucel E, Jarnoux M, et al. Étude de la sexualité des
femmes après hystérectomie totale versus subtotale par voie
cœlioscopique au CHU de Nantes. Gynecol Obstet Fertil 2015;
43:533-540.
Sex Med Rev 2019;7:559e564