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Sexual Activity and Dyspareunia After Pelvic Organ Prolapse Surgery: A 5-Year Nationwide Follow-up Study

Open AccessPublished:October 12, 2022DOI:https://doi.org/10.1016/j.euros.2022.09.014

      Abstract

      Background

      Even though surgery generally improves sexual function and alleviates dyspareunia related to pelvic organ prolapse (POP), knowledge of the long-term effects is scarce.

      Objective

      To describe changes in sexual activity and dyspareunia rates after POP surgery and to identify potential risk factors for the occurrence of dyspareunia.

      Design, setting, and participants

      This was a prospective longitudinal cohort study of women aged over 18 yr undergoing POP surgery in Finland during 2015. Out of 3515 participants, sexual activity and dyspareunia data were available at baseline, 6 mo, 2 yr, and 5 yr for 79%, 68%, 63%, and 57%, respectively.

      Intervention

      Native tissue, transvaginal mesh, and abdominal mesh repair.

      Outcome measurements and statistical analysis

      Rates of sexual activity and dyspareunia were assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at baseline and at 6 mo, 2 yr, and 5 yr after surgery. As a secondary outcome, risk factors for overall, persisting, and de novo dyspareunia were assessed using logistic regression models.

      Results and limitations

      The proportion of sexually active women increased from 40.7% to 43% after surgery. Preoperative dyspareunia resolved in >50% of cases during the first 6 mo, irrespective of the surgical approach. De novo dyspareunia rates were low at all time points (1.9–3.1%). Several potential risk factors associated with preoperative and postoperative dyspareunia were identified: younger age, lower preoperative body mass index, lower prolapse stage at baseline, either pelvic pain or dyspareunia at baseline, prior surgery (stress urinary incontinence surgery, posterior colporrhaphy, POP surgery, hysterectomy), and posterior repair.

      Conclusions

      Dyspareunia is significantly reduced after POP repair irrespective of the surgical approach. However, multiple factors seem to be associated with persisting and de novo symptoms, which should be considered in preoperative counseling.

      Patient summary

      Our 5-year follow-up study demonstrates that surgery to repair pelvic organ prolapse (POP) in women improves sexual activity and reduces painful intercourse. Multiple factors, such as preoperative pain, previous POP surgery, and prolapse stage, may be associated with painful intercourse after surgery.

      Keywords

      1. Introduction

      Pelvic organ prolapse (POP) is a complex and multifactorial condition, resulting in physical changes to women’s genitalia, negatively affecting their body image and reducing libido and genital sensation [
      • Roos A.M.
      • Thakar R.
      • Sultan A.H.
      • Burger C.W.
      • Paulus A.T.G.
      Pelvic floor dysfunction: women’s sexual concerns unraveled.
      ,
      • Abed H.
      • Rahn D.D.
      • Lowenstein L.
      • Balk E.M.
      • Clemons J.L.
      • Rogers R.G.
      Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review.
      ]. Studies have reported 50–83% incidence of sexual dysfunction among women with pelvic floor disorders such as POP [
      • Roos A.M.
      • Thakar R.
      • Sultan A.H.
      • Burger C.W.
      • Paulus A.T.G.
      Pelvic floor dysfunction: women’s sexual concerns unraveled.
      ,
      • Abed H.
      • Rahn D.D.
      • Lowenstein L.
      • Balk E.M.
      • Clemons J.L.
      • Rogers R.G.
      Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review.
      ,
      • Handa V.L.
      • Harvey L.
      • Cundiff G.W.
      • Siddique S.A.
      • Kjerulff K.H.
      Sexual function among women with urinary incontinence and pelvic organ prolapse.
      ,
      • Geiss I.M.
      • Umek W.H.
      • Dungl A.
      • Sam C.
      • Riss P.
      • Hanzal E.
      Prevalence of female sexual dysfunction in gynecologic and urogynecologic patients according to the International Consensus Classification.
      ,
      • Verbeek M.
      • Hayward L.
      Pelvic floor dysfunction and its effect on quality of sexual life.
      ], whereas the estimated prevalence in general female population is approximately 30–50% [
      • Salonia A.
      • Zanni G.
      • Nappi R.E.
      • et al.
      Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study.
      ]. Furthermore, it has been found that advanced prolapse is correlated with a higher rate of dyspareunia [
      • Handa V.L.
      • Harvey L.
      • Cundiff G.W.
      • Siddique S.A.
      • Kjerulff K.H.
      Sexual function among women with urinary incontinence and pelvic organ prolapse.
      ].
      Prolapse surgery generally improves sexual function, including alleviation of dyspareunia [
      • Verbeek M.
      • Hayward L.
      Pelvic floor dysfunction and its effect on quality of sexual life.
      ,
      • Thompson J.C.
      • Rogers R.G.
      Surgical management for pelvic organ prolapse and its impact on sexual function.
      ]. However, vaginal tissue scarring and changes in vaginal anatomy may increase postoperative sexual dysfunction and result in increased or de novo dyspareunia. Mesh complications, such as mesh shrinkage, erosion, and extensive fibrosis, are also a plausible cause of postoperative dyspareunia.
      The incidence of postoperative dyspareunia varies in the literature, depending on the surgical approach. Posterior colporrhaphy, especially combined with either Burch colposuspension or levator plication, and transvaginal mesh (TVM) repair (especially posterior mesh repair) have been associated with a higher risk of postoperative dyspareunia [
      • Thompson J.C.
      • Rogers R.G.
      Surgical management for pelvic organ prolapse and its impact on sexual function.
      ,
      • Ulrich D.
      • Dwyer P.
      • Rosamilia A.
      • Lim Y.
      • Lee J.
      The effect of vaginal pelvic organ prolapse surgery on sexual function.
      ,
      • Weber A.M.
      • Walters M.D.
      • Piedmonte M.R.
      Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence.
      ]. In addition, the occurrence of preoperative dyspareunia is strongly associated with postoperative dyspareunia [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ]. Most previous studies did not report preoperative dyspareunia rates, making it difficult to distinguish between persisting and de novo dyspareunia [
      • Fatton B.
      • de Tayrac R.
      • Letouzey V.
      • Huberlant S.
      Pelvic organ prolapse and sexual function.
      ]. Furthermore, sexual function is often under-reported [
      • Karmakar D.
      Commentary on “Sexual function after robot-assisted prolapse surgery: a prospective study”.
      ] or reported as a secondary outcome [
      • Thompson J.C.
      • Rogers R.G.
      Surgical management for pelvic organ prolapse and its impact on sexual function.
      ], and follow-up for most studies has been short [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ,
      • Fatton B.
      • de Tayrac R.
      • Letouzey V.
      • Huberlant S.
      Pelvic organ prolapse and sexual function.
      ,
      • Espuña M.
      • Puig M.
      • Carmona F.
      De novo dyspareunia after pelvic organ prolapse surgery.
      ,
      • Tyagi V.
      • Perera M.
      • Guerrero K.
      • Hagen S.
      • Pringle S.
      Prospective observational study of the impact of vaginal surgery (pelvic organ prolapse with or without urinary incontinence) on female sexual function.
      ].
      In this prospective nationwide cohort study, we describe changes in sexual activity and dyspareunia rates during 5-yr follow-up after native tissue repair (NTR), TVM, and abdominal mesh (AM) surgery for POP. To improve preoperative counseling, our secondary aim was to identify potential risk factors for the occurrence of dyspareunia.

      2. Patients and methods

      2.1 Setting

      This was a primary analysis of women enrolled in the Finnish Pelvic Organ Prolapse Surgery Survey Study (FINPOP), a nationwide longitudinal cohort (ClinicalTrial.gov NCT02716506). A total of 41 of the 45 Finnish hospitals performing POP surgery in 2015 participated in recruitment of the study population.
      The study was organized and funded by the Finnish Society for Gynecological Surgery. Additional funding was received from the Finnish Cultural Foundation, state research funding, and the Finnish Society of Obstetrics and Gynecology Research. The research ethics committee of the Northern Savo Hospital District (reference number 5/2014), the Ministry of Social Affairs and Health, and the institutional review board of each participating hospital approved the protocol. The ethical standards for human experimentation established by the Declaration of Helsinki of 1964 and revised in 2013 were followed. Each participant gave written informed consent.

      2.2 Inclusion criteria and data collection

      The study design and data collection have already been described in detail [
      • Mattsson N.K.
      • Karjalainen P.
      • Tolppanen A.M.
      • et al.
      Methods of surgery for pelvic organ prolapse in a nationwide cohort (FINPOP 2015).
      ]. Preoperative and operative data were obtained from questionnaires filled out by patients and surgeons. The degree of prolapse was assessed by surgeons at baseline using the simplified Pelvic Organ Prolapse Quantification (POP-Q) system [
      • Swift S.
      • Morris S.
      • McKinnie V.
      • et al.
      Validation of a simplified technique for using the POPQ pelvic organ prolapse classification system.
      ]. The participants were asked to fill out validated questionnaires in either Finnish [
      • Mattsson N.K.
      • Nieminen K.
      • Heikkinen A.M.
      • et al.
      Validation of the short forms of the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) in Finnish.
      ] or Swedish [
      • Teleman P.
      • Stenzelius K.
      • Iorizzo L.
      • Jakobsson U.
      Validation of the Swedish short forms of the Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).
      ] at baseline and at 6 mo, 2 yr, and 5 yr after surgery: The Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).

      2.3 Data handling and analysis

      The PISQ-12 questionnaire evaluates sexual function in women with urinary incontinence and/or pelvic organ prolapse [
      • Rogers R.G.
      • Coates K.W.
      • Kammerer-Doak D.
      • Khalsa S.
      • Qualls C.
      A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12).
      ]. Sexual activity and dyspareunia were assessed using a screening question (Supplementary Fig. 1) and item number 5 of the PISQ-12 questionnaire at baseline and at each time point during the 5-yr follow-up. Definitions of sexual activity, dyspareunia, and pelvic pain are shown in Fig. 1.
      Figure thumbnail gr1
      Fig. 1Definitions of sexual activity, dyspareunia, and pelvic pain. PFDI-20 = Pelvic Floor Distress Inventory; PISQ-12 = Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. aSupplementary Fig. 1. bInternational Urogynecological Association (IUGA)/International Continence Society (ICS)
      [
      • Rogers R.
      • Pauls R.N.
      • Thakar R.
      • et al.
      An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the sexual health in women with pelvic floor dysfunction.
      ]
      .
      Only women who had responded to the screening question or had at least partly filled out the PISQ-12 questionnaire were included in the analysis. We report the rates of sexually active women overall and with or without pain, as well as overall, resolved, persisting, and de novo dyspareunia at each time point for the entire study population and the three surgical subgroups (NTR, TVM, and AM). The surgical methods used in the FINPOP cohort have already been reported by Mattsson et al. [
      • Mattsson N.K.
      • Karjalainen P.
      • Tolppanen A.M.
      • et al.
      Methods of surgery for pelvic organ prolapse in a nationwide cohort (FINPOP 2015).
      ].
      Baseline and surgical characteristics were compared between women with and without dyspareunia at baseline using a χ2 test or Fisher’s exact test for categorical measures, and a Student t test for continuous measures. A χ2 test or Fisher’s exact test was used for between-group comparisons at each time point. The generalized estimated equation method was used to assess differences between surgical groups over time.
      Logistic regression analysis was used to assess risk factors for overall and persisting dyspareunia at baseline and at 6 mo, 2 yr, and 5 yr after surgery using clinically important baseline characteristics and those that were significant on bivariate analysis. For de novo dyspareunia, multivariable models were constructed only for 6-mo and cumulative 5-yr follow-up data, as univariate modeling showed no statistically significant predictive factors at 2-yr and 5-yr follow-up. We evaluated possible collinearity between different variables using Spearman’s ρ testing (with r > 0.4 as a cutoff; Supplementary Table 1). Strongly correlated predictors were not included in the same model.
      The data were analyzed using SPSS version 27.0 (SPSS Inc., Chicago, IL, USA). The mean and standard deviation are reported for normally distributed continuous variables. Odds ratio (OR) estimates are reported with the 95% confidence interval (CI). A p value <0.05 was considered statistically significant for all analyses.

      3. Results

      Table 1 shows the baseline and surgical characteristics of the study population. Baseline data for sexual activity status and dyspareunia were available for 2785 (79%) of the 3515 women enrolled in the FINPOP trial. Data availability during the 5-yr follow up is shown in Fig. 2.
      Table 1Baseline and surgical characteristics of women with and without preoperative dyspareunia
      Parameter
      Results for continuous variables are presented as the mean ± standard deviation.
      No dyspareunia

      (N = 2579)
      Dyspareunia

      (N = 206)
      Total

      (N = 2785)
      p value
      Age (yr)63.9 ± 10.360.0 ± 10.863.6 ± 10.4<0.001
      Weight (kg)72.1 ± 11.671.9 ± 11.872.0 ± 11.80.847
      Body mass index (kg/m2)26.9 ± 4.127.0 ± 4.126.9 ± 4.10.740
      Parity (n)2.6 ± 1.42.8 ± 1.42.6 ± 1.40.084
      Current smoker, n (%)234 (9.1)16 (7.8)250 (9.0)0.613
      Diabetes, n (%)243 (9.4)20 (9.7)263 (9.4)0.901
      Estrogen replacement therapy, n (%)0.013
       Local1794 (69.8)124 (60.5)1918 (69.1)
       Oral118 (4.6)7 (3.4)125 (4.5)
       Both158 (6.1)17(8.3)175 (6.3)
      POP-Q stage, n (%)<0.001
       116 (0.6)2 (1.0)18 (0.6)
       21292 (50.1)133 (64.6)1425 (51.2)
       3–41261 (48.9)71 (34.5)1332 (47.8)
      POP-Q point Ba ≥0, n (%)1627 (63.1)116 (56.3)1743 (62.6)0.046
      POP-Q point Bp ≥0, n (%)1105 (42.8)94 (45.6)1199 (43.1)0.375
      POP-Q point C ≥0, n (%)1009 (39.1)63 (30.6)1072 (38.5)0.011
      Baseline pelvic pain, n (%)443 (17.2)73 (35.4)516 (18.5)<0.001
      Prior POP surgery, n (%)640 (24.8)54 (26.2)694 (24.9)0.676
      Prior hysterectomy, n (%)834 (32.3)82 (39.8)916 (32.9)0.031
      Prior SUI surgery, n (%)
      Preoperative data on the type of prior SUI surgery were only available for four women: three prior Burch colposuspensions and one prior tension-free vaginal tape procedure.
      137 (5.3)21 (10.2)158 (5.7)0.006
      Prior anterior colporrhaphy, n (%)410 (15.9)28 (13.6)438 (15.7)0.427
      Prior posterior colporrhaphy, n (%)289 (11.2)27 (13.1)316 (11.3)0.424
      Prior mesh surgery, n (%)71 (2.8)5 (2.4)76 (2.7)0.833
      Type of surgery, n (%)0.272
       Native tissue repair2086 (80.9)166 (80.6)2252 (80.9)
       Transvaginal mesh repair310 (12.0)20 (9.7)330 (11.8)
       Abdominal mesh repair183 (7.1)20 (9.7)203 (7.3)
      Concomitant hysterectomy, n (%)1037 (40.2)76 (36.9)1113 (40.0)0.375
      Concomitant SUI surgery, n (%)22 (0.9)3 (1.5)25 (0.9)0.426
      POP-Q = Pelvic Organ Prolapse Quantification; POP = pelvic organ prolapse; SUI = stress urinary incontinence.
      a Results for continuous variables are presented as the mean ± standard deviation.
      b Preoperative data on the type of prior SUI surgery were only available for four women: three prior Burch colposuspensions and one prior tension-free vaginal tape procedure.
      Figure thumbnail gr2
      Fig. 2Flow diagram of study enrollment and data availability. POP = pelvic organ prolapse; PISQ-12 = Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. aBaseline sexual activity and dyspareunia data were not available for all women.

      3.1 Sexual activity

      At baseline, 1133 women (40.7%) were sexually active, of whom 85 (7.5%) had pain (Table 2). At 6-mo follow-up, the proportion of sexually active women had increased by 3%. This change was only significant in the NTR group (p = 0.006). At 5-yr follow-up the number of sexually active women had significantly decreased in all surgical groups in comparison to baseline. When considering only women with complete follow up data (n = 1570), the percentage of sexually active women overall and within surgical subgroups remained similar (data not shown). The proportion of women reporting sexual inactivity due to pain decreased by more than half after surgery.
      Table 2Sexual activity, dyspareunia, and de novo dyspareunia during 5-yr follow-up
      Patients, n/N (%)p value
      TotalNative tissue repairTransvaginal mesh repairAbdominal mesh repairBetween groups
      Differences between groups at each time point were assessed using either a χ2 test or Fisher’s exact test.
      Change over time
      Generalized estimated equation testing was used to assess differences between surgical groups over time.
      Sexually active
      Answered “Yes” to “Are you sexually active” OR did not answer but completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire at least in part.
      0.517
       Baseline1133/2785 (40.7)945/2252 (42.0)100/330 (30.3)88/203 (43.3)<0.001
      Significant difference between NTR and TVM (pairwise testing, p < 0.001). Significant difference between TVM and AM (pairwise testing, p = 0.003).
       6 mo1028/2390 (43.0)
      Statistically significant change from baseline (p < 0.05).
      852/1911 (44.6)
      Statistically significant change from baseline (p < 0.05).
      99/296 (33.4)77/183 (42.1)0.001
      Significant difference between NTR and TVM (pairwise testing, p < 0.001).
       2 yr880/2217 (39.7)717/1755 (40.9)92/290 (31.7)71/172 (41.3)0.012
      Significant difference between NTR and TVM (pairwise testing, p = 0.003). Significant difference between TVM and AM (pairwise testing, p = 0.044).
       5 yr708/1993 (35.5)
      Statistically significant change from baseline (p < 0.05).
      599/1603 (37.4)
      Statistically significant change from baseline (p < 0.05).
      54/234 (23.1)
      Statistically significant change from baseline (p < 0.05).
      55/156 (35.5)
      Statistically significant change from baseline (p < 0.05).
      <0.001
      Significant difference between NTR and TVM (pairwise testing, p < 0.001). Significant difference between TVM and AM (pairwise testing, p = 0.011).
      SAP
      Sexually active women reporting dyspareunia often/always during intercourse.
      0.144
       Baseline85/1133 (7.5)72/945 (7.6)5/100 (5.0)8/88 (9.1)0.545
       6 mo55/1028 (5.4)49/852 (5.8)3/99 (3.0)2/77 (2.6)
      Statistically significant change from baseline (p < 0.05).
      0.408
       2 yr46/880 (5.2)
      Statistically significant change from baseline (p < 0.05).
      36/717 (5.0)
      Statistically significant change from baseline (p < 0.05).
      8/92 (8.7)2/71 (2.8)0.227
       5 yr30/708 (4.3)
      Statistically significant change from baseline (p < 0.05).
      26/599 (4.3)
      Statistically significant change from baseline (p < 0.05).
      2/54 (3.7)2/55 (3.6)1.00
      SIDP
      Not sexually active due to pain or not sexually active for another reason AND often/always experience pain during intercourse.
      0.812
       Baseline121/1652 (7.3)94/1307 (7.2)15/230 (6.5)12/115 (10.4)0.386
       6 mo48/1362 (3.5)
      Statistically significant change from baseline (p < 0.05).
      38/1059 (3.6)
      Statistically significant change from baseline (p < 0.05).
      6/197 (3.0)4/106 (3.8)
      Statistically significant change from baseline (p < 0.05).
      0.896
       2 yr41/1337 (3.1)
      Statistically significant change from baseline (p < 0.05).
      34/1038 (3.3)
      Statistically significant change from baseline (p < 0.05).
      3/198 (1.5)
      Statistically significant change from baseline (p < 0.05).
      4/101 (4.0)
      Statistically significant change from baseline (p < 0.05).
      0.323
       5 yr46/1285 (3.6)
      Statistically significant change from baseline (p < 0.05).
      33/1004 (3.3)
      Statistically significant change from baseline (p < 0.05).
      7/180 (3.9)6/101 (5.9)0.324
      Overall DYSP0.540
       Baseline206/2785 (7.4)166/2357 (7.4)20/330 (6.1)20/203 (9.9)0.272
       6 mo103/2390 (4.3)
      Statistically significant change from baseline (p < 0.05).
      88/1911 (4.6)
      Statistically significant change from baseline (p < 0.05).
      9/296 (3.0)
      Statistically significant change from baseline (p < 0.05).
      6/183 (3.3)
      Statistically significant change from baseline (p < 0.05).
      0.369
       2 yr87/2217 (3.9)
      Statistically significant change from baseline (p < 0.05).
      70/1755 (4.0)
      Statistically significant change from baseline (p < 0.05).
      11/290 (3.8)6/172 (3.5)
      Statistically significant change from baseline (p < 0.05).
      0.960
       5 yr76/1993 (3.8)
      Statistically significant change from baseline (p < 0.05).
      59/1603 (3.7)
      Statistically significant change from baseline (p < 0.05).
      9/234 (3.8)8/156 (5.1)
      Statistically significant change from baseline (p < 0.05).
      0.668
      Persisting DYSP
      Only women with reported baseline dyspareunia and paired data available at each time point were included.
      0.208
       6 mo33/165 (20.0)24/135 (17.8)4/16 (25.0)5/14 (35.7)0.209
       2 yr27/144 (18.8)22/112 (19.6)2/16 (12.5)3/16 (18.8)0.930
       5 yr19/136 (14.0)
      Statistically significant change versus 6 mo (p < 0.05).
      11/107 (10.3)
      Statistically significant change versus 6 mo (p < 0.05).
      3/14 (21.4)5/15 (33.3)0.032
      Significant difference between NTR and AM (pairwise testing, p = 0.010).
      De novo DYSP
      Dyspareunia first reported after surgery or other intervention [41].
      <0.001
       6 mo66/2141 (3.1)61/1716 (3.6)5/264 (1.9)0/175 (0)0.023
      Significant difference between NTR and AM (pairwise testing, p = 0.007).
       2 yr38/1993 (1.9)
      Statistically significant change versus 6 mo (p < 0.05).
      29/1589 (1.8)
      Statistically significant change versus 6 mo (p < 0.05).
      7/251 (2.8)2/153 (1.3)
      Statistically significant change versus 6 mo (p < 0.05).
      0.510
       5 yr35/1784 (2.0)
      Statistically significant change versus 6 mo (p < 0.05).
      29/1444 (2.0)
      Statistically significant change versus 6 mo (p < 0.05).
      5/203 (2.5)1/137 (0.7)
      Statistically significant change versus 6 mo (p < 0.05).
      0.518
      DYSP = dyspareunia; SAP = sexually active with pain; SIDP = sexually inactive due to pain; NTR = native tissue repair; TVM = transvaginal mesh; AM = abdominal mesh.
      a Differences between groups at each time point were assessed using either a χ2 test or Fisher’s exact test.
      b Generalized estimated equation testing was used to assess differences between surgical groups over time.
      c Answered “Yes” to “Are you sexually active” OR did not answer but completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire at least in part.
      d Significant difference between NTR and TVM (pairwise testing, p < 0.001). Significant difference between TVM and AM (pairwise testing, p = 0.003).
      e Statistically significant change from baseline (p < 0.05).
      f Significant difference between NTR and TVM (pairwise testing, p < 0.001).
      g Significant difference between NTR and TVM (pairwise testing, p = 0.003). Significant difference between TVM and AM (pairwise testing, p = 0.044).
      h Significant difference between NTR and TVM (pairwise testing, p < 0.001). Significant difference between TVM and AM (pairwise testing, p = 0.011).
      i Sexually active women reporting dyspareunia often/always during intercourse.
      j Not sexually active due to pain or not sexually active for another reason AND often/always experience pain during intercourse.
      k Only women with reported baseline dyspareunia and paired data available at each time point were included.
      l Statistically significant change versus 6 mo (p < 0.05).
      m Significant difference between NTR and AM (pairwise testing, p = 0.010).
      n Dyspareunia first reported after surgery or other intervention
      • Rogers R.
      • Pauls R.N.
      • Thakar R.
      • et al.
      An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the sexual health in women with pelvic floor dysfunction.
      .
      o Significant difference between NTR and AM (pairwise testing, p = 0.007).
      Women in the TVM group were significantly less likely to be sexually active at baseline compared to both the NTR and AM groups and remained so throughout the 5-yr follow-up. The surgical groups did not differ in the proportions of women who were sexually active with pain or sexually inactive due to pain. There was no significant difference between the surgical groups in the change in the proportion of sexually active women over time (p = 0.517).

      3.2 Dyspareunia

      At baseline, 206 (7.4%) of 2785 women reported dyspareunia (Table 2). Women reporting baseline dyspareunia were significantly younger and less likely to use local or oral estrogen replacement therapy in comparison to those without dyspareunia (Table 1). They were also more likely to report baseline pelvic pain or have undergone prior hysterectomy or incontinence surgery and a lower prolapse stage at baseline.
      A 6 mo after surgery the dyspareunia rate had decreased significantly from 7.4% to 4.3%. In the NTR and AM groups the rate remained significantly lower throughout the 5-yr follow-up in comparison to baseline. There were no significant differences in dyspareunia rates between the surgical groups at any time point, nor was the change over time among surgical groups significantly different during the 5-yr follow-up.
      The highest rate of dyspareunia resolution was at 6 mo after surgery, with 132 women (64%) reporting symptom resolution. During further follow-up, an additional 37 women reported resolution of their dyspareunia (NTR 27, TVM 5, and AM 5). Dyspareunia persisted in 52 women (25%) during follow-up. However, 12 women (36%) with persisting dyspareunia at 6 mo reported resolution of their symptoms at 2 yr, and a further six (18%) with persisting dyspareunia at 6 mo and 2 yr reported resolution of their symptoms at 5 yr.
      Younger age, lower prolapse stage, baseline pelvic pain, prior hysterectomy, and prior incontinence surgery were associated with baseline dyspareunia (Table 3 and Supplementary Tables 2 and 3). Lower prolapse stage at baseline, baseline dyspareunia, prior posterior colporrhaphy, and posterior repair predicted the occurrence of dyspareunia at 6 mo after surgery. Baseline dyspareunia was the only factor associated with postoperative dyspareunia at 2-yr follow-up. Lower preoperative body mass index (BMI), baseline dyspareunia, and posterior repair were related to a higher risk of dyspareunia at 5 yr.
      Table 3Factors predictive for overall, persisting, and de novo dyspareunia.
      Baseline dyspareuniaDyspareunia at 6 moPersisting dyspareunia at 6 moDe novo dyspareunia at 6 mo
      OR (95% CI)aOR (95% CI)
      Adjusted for age, BMI, parity, current smoker, MDP of any compartment, pelvic pain at baseline, prior hysterectomy, prior mesh repair, prior SUI surgery, prior anterior colporrhaphy, and prior posterior colporrhaphy (complete data shown in Supplementary Table 3).
      OR (95% CI)aOR (95% CI)
      Adjusted for age, BMI, parity, current smoker, MDP of any compartment, dyspareunia at baseline, pelvic pain at baseline, prior SUI surgery, prior posterior colporrhaphy, anterior repair, posterior repair, and concomitant hysterectomy (complete data shown in Supplementary Table 3).
      OR (95% CI)aOR (95% CI)
      Adjusted for age, BMI, parity, current smoker, MDP of any compartment, pelvic pain at baseline, prior POP surgery, apical repair, and posterior transvaginal mesh (complete data shown in Supplementary Table 5).
      OR (95% CI)aOR (95% CI)
      Adjusted for age, BMI, parity, current smoker, MDP of any compartment, prior SUI surgery, anterior repair, posterior repair, concomitant hysterectomy, and concomitant SUI surgery (complete data shown in Supplementary Table 7).
      Age0.96 (0.95–0.98)0.97 (0.95–0.98)0.97 (0.95–0.98)0.98 (0.96–1.00)0.98 (0.95–1.01)0.99 (0.95–1.03)0.96 (0.94–0.98)0.97 (0.95–0.99)
      MDP of any compartment0.84 (0.76–0.93)0.87 (0.78–0.97)0.69 (0.59–0.80)0.77 (0.65–0.91)0.65 (0.50–0.86)0.72 (0.54–0.97)0.74 (0.61–0.89)0.77 (0.63–0.94)
      Dyspareunia at baselineNA7.72 (4.93–12.07)6.36 (3.85–10.52)NANA
      Pelvic pain at baseline2.65 (1.95–3.58)2.65 (1.92–3.66)1.74 (1.11–2.71)1.19 (0.72–1.98)2.25 (1.08–4.67)2.17 (1.00–4.70)NA
      Prior hysterectomy1.35 (1.01–1.80)1.94 (1.36–2.77)0.90 (0.59–1.38)1.88 (0.95–3.75)0.63 (0.35–1.11)
      Prior POP surgery1.08 (0.78–1.49)1.22 (0.79–1.89)2.24 (1.12–4.50)2.40 (1.11–5.20)0.96 (0.54–1.70)
      Prior SUI surgery1.96 (1.22–3.18)1.89 (1.12–3.19)2.01 (1.05–3.85)1.40 (0.66–3.00)1.08 (0.25–4.53)2.37 (1.10–5.08)2.72 (1.46–5.06)
      Prior posterior colporrhaphy1.16 (0.76–1.77)1.12 (0.66–1.88)1.67 (1.01–2.82)2.54 (1.40–4.60)2.04 (0.88–4.75)1.69 (0.89–3.21)
      Posterior repairNA2.08 (1.36–3.18)2.30 (1.37–3.85)1.22 (0.61–2.44)2.87 (1.62–5.07)2.72 (1.45–5.06)
      OR = odds ratio; aOR = adjusted odds ratio; CI = confidence interval; MDP = most distal point; POP = pelvic organ prolapse; SUI = stress urinary incontinence; NA = not available (no cases for this variable); – = variable not included in the multivariable model; BMI = body mass index.
      The bolded figures indicate statistical significance in both uni- and multivariable analysis (i.e. OR and aOR are significant).
      a Adjusted for age, BMI, parity, current smoker, MDP of any compartment, pelvic pain at baseline, prior hysterectomy, prior mesh repair, prior SUI surgery, prior anterior colporrhaphy, and prior posterior colporrhaphy (complete data shown in Supplementary Table 3).
      b Adjusted for age, BMI, parity, current smoker, MDP of any compartment, dyspareunia at baseline, pelvic pain at baseline, prior SUI surgery, prior posterior colporrhaphy, anterior repair, posterior repair, and concomitant hysterectomy (complete data shown in Supplementary Table 3).
      c Adjusted for age, BMI, parity, current smoker, MDP of any compartment, pelvic pain at baseline, prior POP surgery, apical repair, and posterior transvaginal mesh (complete data shown in Supplementary Table 5).
      d Adjusted for age, BMI, parity, current smoker, MDP of any compartment, prior SUI surgery, anterior repair, posterior repair, concomitant hysterectomy, and concomitant SUI surgery (complete data shown in Supplementary Table 7).
      Lower prolapse stage at baseline and baseline pelvic pain were predictors for persisting dyspareunia throughout the 5-yr follow-up (Table 3 and Supplementary Tables 4 and 5). In addition, prior POP surgery predicted dyspareunia persisting at 6-mo follow-up, and prior hysterectomy predicted dyspareunia persisting at 5-yr follow-up.

      3.3 De novo dyspareunia

      Overall, 139 women reported de novo dyspareunia during the 5-yr follow-up period (Table 2). At 6-mo follow-up, 3.6% of women in the NTR group reported de novo dyspareunia, with the only significant difference in comparison to the AM group (0%). The de novo dyspareunia incidence had decreased significantly in the NTR group at 2 yr and 5 yr in comparison to 6 mo after surgery. This decrease remained significant throughout the 5-yr follow-up in comparison to the other surgical groups.
      Younger age, lower prolapse stage, prior incontinence surgery, and posterior repair were identified as risk factors for de novo dyspareunia at 6 mo after surgery (Table 3 and Supplementary Tables 6 and 7). Only posterior repair was associated with a higher risk of cumulative de novo dyspareunia incidence during 5-yr follow-up. Women who had an AM repair had a lower risk of de novo dyspareunia in comparison to NTR (OR 0.26, 95% CI 0.08–0.82).

      4. Discussion

      The impact of POP surgery on sexual activity and function remains controversial, with many studies reporting improvement, while others showed either no difference or even a deterioration in sexual function postoperatively [
      • Fatton B.
      • de Tayrac R.
      • Letouzey V.
      • Huberlant S.
      Pelvic organ prolapse and sexual function.
      ]. Our longitudinal follow-up study reveals improvements in both sexual activity and dyspareunia after POP repair. We also identified several factors associated with preoperative and postoperative dyspareunia: younger age, lower preoperative BMI, lower prolapse stage at baseline, either pelvic pain or dyspareunia at baseline, prior surgery (stress urinary incontinence [SUI] surgery, posterior colporrhaphy, POP surgery, hysterectomy), and posterior repair.
      The proportion of women who were sexually active was significantly higher at 6 mo than at baseline, after which the rate steadily decreased. Other studies have reported similar trends, albeit with shorter follow-up [
      • Gupta P.
      • Payne J.
      • Killinger K.A.
      • et al.
      Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches.
      ,
      • Anglès-Acedo S.
      • Ros-Cerro C.
      • Escura-Sancho S.
      • et al.
      Sexual activity and function in women with advanced stages of pelvic organ prolapse, before and after laparoscopic or vaginal mesh surgery.
      ]. The proportion of women who were sexually active increased significantly only in the NTR group, but the smaller number of women in the other surgery groups may explain this. We also did not observe significant differences between the surgical subgroups over the 5-yr follow-up, supporting the hypothesis that an increase also occurred in the other groups. The proportions of women who were sexually active at each time point and within each surgical subgroup remained similar when analyzing only women with complete follow-up data, indicating that the results were not affected by those lost to follow-up.
      It is widely accepted that several concomitant factors, such as menopausal status, medications, multimorbidity, changes in libido, and relationship status, could interfere with postoperative assessment of sexual activity and function in the long term. Therefore, it seems that the optimal period for assessment of postoperative sexual function lies between 6 and 12 mo after surgery [
      • Fatton B.
      • de Tayrac R.
      • Letouzey V.
      • Huberlant S.
      Pelvic organ prolapse and sexual function.
      ]. Considering the aforementioned confounders, it is evident that the cause of lower sexual activity rates after 6-mo follow-up is multifactorial and no definite conclusions on the long-term effects of POP surgery on sexual activity can be drawn. However, the significant postoperative decrease in the proportions of women who were sexually active with pain and sexually inactive due to pain indicate long-term improvements in sexual dysfunction related to POP.
      The preoperative dyspareunia rates were low in our study, decreased by more than half postoperatively, irrespective of surgical approach, and remained significantly lower throughout the 5-yr follow-up in comparison to baseline. In total, 82% of women obtained symptom resolution during 5-yr follow-up, with no significant differences between the surgical groups. Slightly higher rates of baseline dyspareunia (14–29%) but similar trends postoperatively have been reported [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ,
      • Gupta P.
      • Payne J.
      • Killinger K.A.
      • et al.
      Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches.
      ,
      • Anglès-Acedo S.
      • Ros-Cerro C.
      • Escura-Sancho S.
      • et al.
      Sexual activity and function in women with advanced stages of pelvic organ prolapse, before and after laparoscopic or vaginal mesh surgery.
      ]. In addition, the rates of de novo dyspareunia were low and comparable to the prevalence of 0–9% reported in the literature [
      • Antosh D.D.
      • Kim-Fine S.
      • Meriwether K.V.
      • et al.
      Changes in sexual activity and function after pelvic organ prolapse surgery: a systematic review.
      ].
      Vaginal dryness and dyspareunia affect approximately one-third of women going through menopausal transition [
      • Santoro N.
      Perimenopause: From research to practice.
      ]. A cross-sectional study of 500 peri- and postmenopausal women revealed higher dyspareunia incidence in the perimenopausal group than in the menopausal group (18% vs 8%) [
      • Inayat K.
      • Danish N.
      • Hassan L.
      Symptoms of menopause in peri and postmenopausal women and their attitude towards them.
      ]. In our study, younger age was associated with baseline dyspareunia and de novo symptoms at 6-mo follow-up. Women with baseline dyspareunia were significantly younger than those without dyspareunia, indicating that they were more likely to still be experiencing perimenopausal symptoms. They were also less likely to use local or oral estrogen replacement therapy, which alleviate the symptoms of menopausal transition.
      We found that lower prolapse stage was associated with the presence of preoperative and postoperative dyspareunia, as well as persisting and de novo dyspareunia at 6 mo after surgery. A smaller genital hiatus size has been associated with lower prolapse stage [
      • Dunivan G.C.
      • Lyons K.E.
      • Jeppson P.C.
      • et al.
      Pelvic organ prolapse stage and the relationship to genital hiatus and perineal body measurements.
      ,
      • Nemeth Z.
      • Farkas N.
      • Farkas B.
      Can we define excess vaginal space? Genital hiatus size and prolapse severity are correlated with cube pessary size.
      ,
      • Muñiz K.S.
      • Voegtline K.
      • Olson S.
      • Handa V.
      The role of the genital hiatus and prolapse symptom bother.
      ,
      • Siahkal S.F.
      • Iravani M.
      • Mohaghegh Z.
      • Sharifipour F.
      • Zahedian M.
      • Nasab M.B.
      Investigating the association of the dimensions of genital hiatus and levator hiatus with pelvic organ prolapse: a systematic review.
      ], and Lukacz et al. [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ] reported an association between smaller genital hiatus size and postoperative dyspareunia. In addition, the sensation of the vaginal introital caliber being too tight has been related to postoperative dyspareunia [
      • Ulrich D.
      • Dwyer P.
      • Rosamilia A.
      • Lim Y.
      • Lee J.
      The effect of vaginal pelvic organ prolapse surgery on sexual function.
      ]. By contrast, Handa et al. [
      • Handa V.L.
      • Harvey L.
      • Cundiff G.W.
      • Siddique S.A.
      • Kjerulff K.H.
      Sexual function among women with urinary incontinence and pelvic organ prolapse.
      ] reported that higher rates of dyspareunia were associated with advanced POP stages. However, advanced POP stages have been associated with reduced genital sensation [
      • Barber M.D.
      • Visco A.G.
      • Wyman J.F.
      • Fantl J.A.
      • Bump R.C.
      Sexual function in women with urinary incontinence and pelvic organ prolapse.
      ], which could account, at least in part, for our results.
      Preoperative pain and dyspareunia have previously been associated with persisting symptoms in several studies [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ,
      • Withagen M.I.
      • Vierhout M.E.
      • Hendriks J.C.
      • Kluivers K.B.
      • Milani A.L.
      Risk factors for exposure, pain, and dyspareunia after tension-free vaginal mesh procedure.
      ]. Our results also show a strong association between baseline pelvic pain and persisting dyspareunia after POP surgery. Remarkably, the association between baseline and postoperative dyspareunia remained significant throughout the 5-yr follow-up. Prior studies in the fields of anesthesia and surgery have reported preoperative pain as a significant predictor of postoperative pain, while the presence and duration of preoperative pain has been associated with the development and persistence of chronic postsurgical pain [
      • Ip H.Y.V.
      • Abrishami A.
      • Peng P.W.H.
      • Wong J.
      • Chung F.
      Predictors of postoperative pain and analgesic consumption: a qualitative systematic review.
      ,
      • VanDenKerkhof E.G.
      • Peters M.L.
      • Bruce J.
      Chronic pain after surgery: time for standardization? A framework to establish core risk factor and outcome domains for epidemiological studies.
      ].
      Previous studies have shown that hysterectomy is related to improvements in sexual function and lower rates of dyspareunia [
      • Verbeek M.
      • Hayward L.
      Pelvic floor dysfunction and its effect on quality of sexual life.
      ,
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ,
      • Fatton B.
      • de Tayrac R.
      • Letouzey V.
      • Huberlant S.
      Pelvic organ prolapse and sexual function.
      ]. Controversially, we found that prior hysterectomy was a risk factor for baseline dyspareunia and persisting symptoms at 5-yr follow-up. Also, unlike Lukacz et al. [
      • Lukacz E.S.
      • Sridhar A.
      • Chermansky C.J.
      • et al.
      Sexual activity and dyspareunia 1 year after surgical repair of pelvic organ prolapse.
      ], prior POP surgery was associated with persisting dyspareunia at 6-mo follow-up. Prior POP surgery was also associated with baseline dyspareunia on bivariate analysis; however, owing to collinearity it was not included in the multivariable model. Even though higher dyspareunia rates have been reported after TVM repair [
      • Antosh D.D.
      • Dieter A.A.
      • Balk E.M.
      • et al.
      Sexual function after pelvic organ prolapse surgery: a systematic review comparing different approaches to pelvic floor repair.
      ], we found that neither TVM nor AM repair was a risk factor for baseline or postoperative dyspareunia. Interestingly, AM repair was associated with a significantly lower risk of de novo dyspareunia during 5-yr follow-up in comparison to NTR.
      Dyspareunia following POP surgery has often been attributed to posterior colporrhaphy with levator plication [
      • Weber A.M.
      • Walters M.D.
      • Piedmonte M.R.
      Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence.
      ,
      • Kahn M.A.
      • Stanton S.L.
      Posterior colporrhaphy: its effects on bowel and sexual function.
      ]. Even though levator plication has largely been abandoned, a higher risk of postoperative dyspareunia remains a concern after traditional posterior compartment repair, especially when combined with Burch colposuspension [
      • Verbeek M.
      • Hayward L.
      Pelvic floor dysfunction and its effect on quality of sexual life.
      ,
      • Weber A.M.
      • Walters M.D.
      • Piedmonte M.R.
      Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence.
      ,
      • Komesu Y.M.
      • Rogers R.G.
      • Kammerer-Doak D.N.
      • Barber M.D.
      • Olsen A.L.
      Posterior repair and sexual function.
      ]. Posterior repair and prior SUI surgery, but not concomitant SUI surgery, were strongly associated with baseline and de novo dyspareunia in our study. Even though it has been reported that chronic pain after SUI surgery is a rare outcome [
      • Karmakar D.
      • Dwyer P.L.
      • Murray C.
      • Schierlitz L.
      • Dykes N.
      • Zilberlicht A.
      Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence—results from a large comparative study.
      ], dyspareunia, worsening of orgasm and satisfaction, and sling revisions because of pain have been reported in several studies comparing SUI procedures [
      • Liapis A.
      • Bakas P.
      • Creatsas G.
      Burch colposuspension and tension-free vaginal tape in the management of stress urinary incontinence in women.
      ,
      • Unger C.A.
      • Rizzo A.E.
      • Ridgeway B.
      Indications and risk factors for midurethral sling revision.
      ,
      • Jang H.C.
      • Jeon J.H.
      • Kim D.Y.
      Changes in sexual function after the midurethral sling procedure for stress urinary incontinence: long-term follow-up.
      ,
      • Yeni E.
      • Unal D.
      • Verit A.
      • Kafali H.
      • Ciftci H.
      • Gulum M.
      The effect of tension-free vaginal tape (TVT) procedure on sexual function in women with stress urinary incontinence.
      ]. Unfortunately, we lack sufficient data on the type of prior SUI surgery to analyze this further.
      The strengths of this study are the large nationwide study population and the use of validated condition-specific questionnaires. To the best of our knowledge, only a few studies have reported sexual activity status, dyspareunia, and de novo dyspareunia rates for such a long follow-up period. However, we did not ask the patients about their relationship status and we have no information on how much bother the presence of dyspareunia caused for these women. In addition, some women may have undergone reoperation for recurrent POP, which naturally could influence sexual function. Unfortunately, at the time of this study we lacked sufficient data on reoperations. Owing to the low rate of de novo dyspareunia in our study population, it is likely that there was insufficient power for detection of predictive factors after 6-mo follow-up.

      5. Conclusions

      On the basis of our findings and the literature, it seems clear that POP surgery has beneficial effects on women’s sexual wellbeing. Posterior POP repair remains a significant risk factor for the occurrence of dyspareunia, while preoperative dyspareunia and pelvic pain should be taken into consideration in patient counseling and surgical planning. So far, the mechanisms underlying the relationship between dyspareunia and prolapse stage and prior SUI surgery remain unknown.
      Author contributions: Olga Wihersaari had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
      Study concept and design: Wihersaari.
      Acquisition of data: Wihersaari, Karjalainen, Mattsson.
      Analysis and interpretation of data: Wihersaari, Tolppanen.
      Drafting of the manuscript: Wihersaari.
      Critical revision of the manuscript for important intellectual content: Jalkanen, Nieminen, Tolppanen, Karjalainen, Mattsson.
      Statistical analysis: Wihersaari, Tolppanen.
      Obtaining funding: Wihersaari, Karjalainen.
      Administrative, technical, or material support: Karjalainen, Tolppanen.
      Supervision: Jalkanen.
      Other: None.
      Financial disclosures: Olga Wihersaari certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.
      Funding/Support and role of the sponsor: Financial support for this study was provided by the Finnish Society for Gynecological Surgery (a nonprofit organization), the Finnish Cultural Foundation, state research funding, and the Finnish Society of Obstetrics and Gynecology Research. The sponsors played a role in the design and conduct of the study and in collection of the data.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

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