FEMALE UROLOGY

Sexual function after using tension-free vaginal tape for the surgical treatment of genuine stress incontinence
Maaita M, Bhaumik J, Davies, AE
BJU Int. 2002; 90:540-3

• Objective: To determine whether the use of the tension free vaginal polypropylene tape (TVT) procedure for the treatment of genuine stress incontinence (GSI) affects sexual activity.
• Patients and methods: Sixty-seven women treated by insertion of a TVT between September 1998 and March 2001 for GSI were sent questionnaires 6-36 months after surgery to determine any urinary symptoms, sexual activity, patient satisfaction and the use of hormone-replacement therapy.
• Results: The questionnaire was returned by 57 patients (87%); 43 (76%) reported being sexually active and 14 (25%) were not. Of the former, 31 (72%) reported no change in sexual function after surgery and only two reported an improvement; six (14%) reported that sexual function was worse and four did not reply to the questions. The patients reporting that sexual function was worse cited loss of libido as the main reason. No patients complained of dyspareunia.
• Conclusions: There was no significant change in sexual function or activity after the TVT procedure and patients can thus be reassured that this operation will not affect their sex life.
  
  
• Editorial Comment
  The authors describe the impact on sexual function from the placement of the tension-free vaginal polypropylene tape (TVT) for female urinary stress incontinence. Through questionnaire interview with their patients, the authors determined the change in sexual function after TVT surgery, in addition to the causes of sexual inactivity, and the time required to resume sexual activity.
  This paper is very important for it addresses a topic that is only as of late been receiving attention as a complication of uro-gynecological surgery. It is notable that the authors found that the TVT surgery had no pronounced impact on sexual activity. In addition, the authors found that sexual inactivity was most often attributed to the lack of partner and the loss of libido, and not to anatomic alterations; a finding often found in the male population as well. Classically, the authors have pointed out that vaginal surgery may be detrimental to sexual activity because of anatomic changes, such as narrowing or scarring, as well as operative failure. The authors did not find any anatomic alteration post-operatively on either the 6 week or 6 month post-surgical examination. Perhaps this can help explain the lack of discernable impact of the TVT on sexual function.
  The potential detrimental effect of gynecological surgery on sexual function has been addressed before with other vaginal operations. These have ranged from vulvectomy for carcinoma and well anti-incontinence operations to reconstructive operations with the use of Martius flap and vesicovaginal fistula repair (1-4). When compared to these operations, perhaps the limited effect on sexual function can be attributed to the limited dissection associated with the TVT. In past discussions on transvaginal urethrolysis, issues regarding potential nerve damage with a suprameatal technique have been debated (5).
  The TVT is often offered to younger patients due to the attractiveness of its limited invasiveness. Urologic surgeons may feel more comfortable offering this operation [now] in view of the limited effect on sexual function that this article reports. Further expansion of research in this area may include an analysis of the partners’ view of post-operative sexual function impact, as well the role of biothesiometry in those patients with altered sexual function.

References
1. Elkins TE, DeLancey JO, McGuire EJ: The use of modified Martius graft as an adjunctive technique in vesicovaginal and rectovaginal fistula repair. Obstet Gynecol. 1990; 75:727-33.
2. Webster GD, Guranick ML, Amundsen CL: Use of the Martius labial fat pad as an adjunct in the management of urinary fistulae and urethral obstruction following anti-incontinence procedures. J Urol. 2000; 163:76 (Abst.).
3. Green MS, Naumann RW, Elliott M, Hall JB, Higgins RV, Grigsby JH. Sexual dysfunction following vulvectomy. Gynecol Oncol. 2000; 77:73-77.
4. Petrou SP, Jones J, Parra RO: Martius flap harvest site: patient self-perception. J Urol. 2002; 167:2098-9.
5. Petrou SP, Brown JA, Blaivas JG: Suprameatal transvaginal urethrolysis. J Urol. 1999; 162: Letter to the Editor (Reply by Authors).

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA