COMMENT

In this issue of the Int Braz J Urol, Sukgen and colleagues (¹1. Sukgen G, Altunkol A, Yigit A. Effects of mesh surgery on sexual function in pelvic prolapse and urinary incontinence. Int Braz J Urol. 2021;47:82-9.) presented the evolution of the Female Sexual function Index (FSFI) in a prospective series of 72 women who underwent correction of pelvic organ prolapse (POP), eventually associated to stress urinary incontinence (SUI), using a four-arm anterior mesh implant (Betamix POP4®, Betatech Medical, Turkey) with a transobturator fixation. The study only included patients with POP stage 3 or 4 according to the Pelvic Organ Prolapse Quantification system (POP-Q). Procedures varied based on the vaginal compartments involved and SUI concomitance. This study concluded that POP surgery using mesh implants was associated with a significant improvement in patient sexual function over one year follow-up.

The human sexual response, and women's in particular, is a multidimensional phenomenon (²2. [No authors]. World Health Organization (1992) ICD-10: International Statis- tical Classification of Diseases and Related Health Problems. World Health Organization, Geneva. 1992 [cited 2010 Mar 8]. [Internet]. Available at. <https://apps.who.int/iris/bitstream/10665/246208/1/9789241549165-V1-eng.pdf>
https://apps.who.int/iris/bitstream/1066... , ³3. [No authors]. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV [Internet]. 4th ed. Washington (DC): American Psychiatric Association; 1994 [cited 2010 Mar 8]. 866 p. Available from: http://www.psychiatryonline.com/DSMPDF/dsm-iv.pdf
http://www.psychiatryonline.com/DSMPDF/d... ). In patients with POP, association with urinary incontinence, the impairment of self-image and the sensation of vaginal enlargement and laxity makes the assessment of the impact of any treatment in sexual function quite complex. Although FSFI has been culturally adapted to several languages and represent an alternative for a comprehensive evaluation of sexual function (⁴4. Thiel Rdo R, Dambros M, Palma PC, Thiel M, Riccetto CL, Ramos Mde F. Tradução para português, adaptação cultural e validação do Female Sexual Function Index [Translation into Portuguese, cross-national adaptation and validation of the Female Sexual Function Index]. Rev Bras Ginecol Obstet. 2008;30:504-10. Portuguese.), it does not specifically assess vaginal symptoms (⁵5. Tamanini JT, Almeida FG, Girotti ME, Riccetto CL, Palma PC, Rios LA. The Portuguese validation of the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) for Brazilian women with pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:1385-91.), which is very relevant after POP surgery.

In Sukgen and colleagues study, a prosthesis with dual function was used, since, in patients with associated urinary incontinence, it was adjusted in anterior vaginal wall in order to reach the proximal aspect of the urethra. However, nowadays we are experiencing a trend for the use synthetic transvaginal implants only for repositioning the vaginal apex rather than more extensive prostheses, such as the one used by Sukgen and colleagues, and combine it with a midurehral sling implanted through another suburethral incision in case of concomitant SUI. The possible impact of this trend in sexual function is still to be stablished (¹1. Sukgen G, Altunkol A, Yigit A. Effects of mesh surgery on sexual function in pelvic prolapse and urinary incontinence. Int Braz J Urol. 2021;47:82-9.).

The relevance of urinary incontinence in female sexual function has already been extensively investigated (⁶6. Coksuer H, Ercan CM, Halilolu B, Yucel M, Cam C, Kabaca C, et al. Does urinary incontinence subtype affect sexual function? Eur J Obstet Gynecol Reprod Biol. 2011;159:213-7., ⁷7. Caruso S, Brescia R, Matarazzo MG, Giunta G, Rapisarda AMC, Cianci A. Effects of Urinary Incontinence Subtypes on Women's Sexual Function and Quality of Life. Urology. 2017;108:59-64.), thus, greater influence is given to urge urinary incontinence rather than stress urinary incontinence. As POP can be associated with both incontinence types, treatment can thereby improve sexual function.

As the anterior arms of the prosthesis used by the authors act as a midurethral sling, it is relevant to comment about the influence of synthetic sling implant on sexual function. This issue was recently assessed in a meta-analysis (⁸8. Szell N, Komisaruk B, Goldstein SW, Qu XH, Shaw M, Goldstein I. A Meta-Analysis Detailing Overall Sexual Function and Orgasmic Function in Women Undergoing Midurethral Sling Surgery for Stress Incontinence. Sex Med. 2017;5:e84-e93.), which concluded that although overall sexual function remained the same or improved for most women, improvements in orgasmic function were only observed in one third of cases after a midurethral sling procedure. The possible deterioration of orgasm in patients who underwent midurethral slings could be due to a denervation of the periurethral area resulting from the local dissection. In this sense, in 2017, Arslan and colleagues proposed a modification in the transobturatory sling technique, based on a minimal paraurethral dissection, in order to minimize the risk of sexual dysfunction (⁹9. Arslan B, Onuk O, Eroglu A, Gezmis TC, Aydin M. Female sexual function following a novel transobturator sling procedure without paraurethral dissection (modified-TOT). Int Braz J Urol. 2017;43:142-9.). In another study from Tepe and colleagues, sexual function was studied in a group of patients who underwent transobturator sling (TOT) plus vaginal hysterectomy versus Kelly colpoplasty plus vaginal hysterectomy for the treatment of urinary incontinence and uterine prolapse. Despite the potential effect of hysterectomy on sexual function, and the greater efficacy of TOT in the treatment of urinary incontinence, it was notable that the rate of the patients who had FSFI scores greater than 25, which indicated a better sexual function, was significantly higher in the group who underwent Kelly colpoplasty than TOT (¹⁰10. Tepe NB, Bayrak O, Ozcan HC, Ugur MG, Seckiner I. Comparison of the Kelly's plication and TOT simultaneously with vaginal hysterectomy, on the incontinence, and sexual functions. Int Braz J Urol. 2018;44:779-84.).

POP is considered more relevant than urinary and fecal incontinence for sexual aversion, sexual inactivity and general sexual dissatisfaction (¹¹11. Rogers RG, Pauls RN, Thakar R, Morin M, Kuhn A, Petri E, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction. Neurourol Urodyn. 2018;37:1220-40.). However, the effect of surgery for prolapse and incontinence on sexual function is difficult to assess in publications, as randomized studies are scarce, surgical techniques and outcome measure are very variable, and there is a lack of long-term follow-up. In addition, sexual dysfunction is usually a secondary outcome. In general, it is speculated that POP treatment through abdominal, laparoscopic or robotic approaches, even with a mesh implant, leads to lower frequency of sexual dysfunction compared to trasvaginal POP correction, due to the potential deleterious effect of the vaginal incision and dissection (¹²12. Astepe BS, Karsli A, Köleli I, Aksakal OS, Terzi H, Kale A. Intermediate-term outcomes of laparoscopic pectopexy and vaginal sacrospinous fixation: a comparative study. Int Braz J Urol. 2019;45:999-1007.,¹³13. Gupta P, Payne J, Killinger KA, Ehlert M, Bartley J, Gilleran J, et al. Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches. Int Urogynecol J. 2016;27:1919-24.). In Sukgen and colleagues study, they described a progressive improvement of the FSFI, with a low incidence of vaginal exposure, which can be attributed to the age of the patients, mostly in the menacme or climacteric, and to the limited follow-up period, which extended for at most 12 months.

Dyspareunia and chronic pelvic pain are identified as the most serious adverse effects of transvaginal prostheses, with a harmful effect on sexual function. In a recent meta-analysis, Liao and colleagues found that the rate of de novo dyspareunia was 9.9% versus 9.0% in patients who underwent correction using mesh versus native tissue, respectively, with no significant differences in score PISQ-12 (Pelvic Organ Prolapse / Urinary Incontinence Sexual Questionnaire) (¹⁴14. Liao SC, Huang WC, Su TH, Lau HH. Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials. J Sex Med. 2019;16:633-9.). In Sukgen and colleagues study, despite displaying higher rates of dyspareunia (15.2%) it did not prevent the improvement of the global FSFI score, which also corroborates the for the complexity nature of female sexuality.

In conclusion, patients’ expectations regarding their sexuality are changing intensely. As the demand for POP and incontinence treatments trend to increase in parallel, studies like Sukgen and colleagues’ one can stimulate relevant discussions in the scientific community about this relevant aspect of quality of life.

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