Long-term quality of life and sexual function after vaginal surgery for apical prolapse

Abstract

Introduction: Uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) are common native tissue repairs for apical pelvic organ prolapse (POP). Each has its distinct anatomic variation that could impact sexual function. Despite similar anatomic and functional success, comparative data on impact on quality of life (QOL) and sexual function for these approaches are lacking. Objective: To describe the long-term effect of vaginal apical POP with stress urinary incontinence (SUI) surgery on QOL, sexual function, and body image; and to compare these outcomes between ULS and SSLF.<br><br>Methods: This was a secondary analysis of a randomized trial of ULS vs. SSLF and behavioral therapy vs. usual care in women with SUI and stage 2 or greater POP.(1) Outcomes were assessed at baseline, and 6, 12, and 24 monthsnths post-operatively. The Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) with their 3 subscales and the SF-36 were used to assess conditionspecific and generic QOL, respectively. Sexual function was assessed using the Prolapse/Incontinence Sexual Function Questionnaire (PISQ-12), sexual activity and dyspareunia rates (defined by response of “usually or always” to “Do you feel pain during sexual intercourse?” for sexually active women or a response of “usually or always” to “Does fear of pain during sexual intercourse restrict your activity?” for those women who were not sexually active). De novo dyspareunia was reported in asymptomatic sexually active women at baseline, who were a) still sexually active but reported dyspareunia or b) not active due to fear of pain at follow up. Treatment for dyspareunia was also assessed. Body image was evaluated using a modified Body Image Scale.(2) Summary scores for each scale and for the dichotomous outcomes (sexual activity, de novo dyspareunia) were analyzed to detect statistically significant changes over time (and by surgical group) using linear and generalized linear models. Models included surgical and behavioral treatments, age, prior hysterectomy status, time, and interactions between both treatment effects and time as covariates.Minimal clinically important difference (MCID), when not available, was assessed using an estimate of 0.5 standard deviation.(3)<br><br>Results: Most (82 %) of the 374 women randomized to ULS (188) or SSLF (186) had QOL outcomes available at 2 years. Participants had a mean age of 57.2 years with a median of 3 vaginal deliveries and mean BMI of 28.8. Most (84 %) women were White; 66 % were postmenopausal and 57 % had stage 3 POP. Overall, generic QOL did not change significantly over time, but all condition-specific QOL measures showed clinically and statistically significant improvements from baseline at each post-operative time point (Fig, p<0.01). In sexually active women, adjusted mean PISQ-12 scores worsened slightly from baseline (17.8), by 5.9 and 4.9 points at 12 and 24 mo, respectively (p=0.02). Sexual activity rates remained similar across time points (53 to 59 %) with new onset of activity after surgery in up to 27 % and discontinuation of activity occurring in up to 17 % by 24 months. Dyspareunia rates decreased from 25 % at baseline to 10 % at 6, 8 % at 12, and 14 % at 24 months (p=0.07). De novo dyspareunia occurred in 6, 5, and 8%at 6, 12, and 24 months, respectively. No patient with dyspareunia required treatment in the first year and only 2/59 (3 %) were treated by year 2. Body image scores improved by up to 2.4 from a mean of 3.8 out of 15 possible points (p<0.01). There were no clinically important differences between surgical groups for any of the outcomes as measured by MCID.<br><br>Conclusions: While generic QOL did not change, conditionspecific QOL, overall sexual activity/pain, and body image improved after native tissue apical POP repair. There were no clinically meaningful differences between ULS and SSLF. Surgeons can counsel women regarding the similarity of these outcomes following either approach.