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EPIDEMIOLOGY & RISK FACTORS

The Impact of Sacrospinous Hysteropexy and Vaginal Hysterectomy With


Suspension of the Uterosacral Ligaments on Sexual Function in Women
With Uterine Prolapse: A Secondary Analysis of a Randomized
Comparative Study
Renée J. Detollenaere, MD,1,3 Ilse A. M. Kreuwel, MD,2 Jeroen R. Dijkstra, MD,1 Kirsten B. Kluivers, MD, PhD,3 and
Hugo W. F. van Eijndhoven, MD, PhD1

ABSTRACT

Introduction: Studies on pelvic organ prolapse (POP) surgery show conflicting evidence regarding the impact of
uterus preservation and hysterectomy on sexual function and no large randomized trials with long-term follow-up
have been published on this topic.
Aims: The aim of this secondary analysis was to evaluate and compare sexual function after sacrospinous hyster-
opexy and vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse.
Methods: This is a secondary analysis of the SAVE U trial data, a multicenter trial in 4 nonuniversity hospitals in the
Netherlands comparing sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral ligaments
in primary surgery of uterine prolapse stage II or higher. Primary outcome of the original study was recurrent prolapse
stage II or higher of the uterus or vaginal vault (apical compartment) evaluated by POP-Q examination in combination
with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months follow-up. Secondary
outcomes were overall anatomical recurrences, functional outcome, complications, hospital stay, postoperative recovery,
and sexual functioning. Data from patients who had completed the POP/urinary incontinence sexual questionnaire
(PISQ-12) at baseline and 24 months after surgery were used in the present trial. Total, subscale, and individual question
analyses were performed. The SAVE U trial is registered in the Dutch trial registry, number NTR1866.
Main Outcome Measures: Differences and changes in sexual function 24 months after surgery, measured by
the PISQ-12 questionnaire.
Results: Between November 2009 and March 2012, 208 women were randomized between sacrospinous
hysteropexy (n ¼ 103) and vaginal hysterectomy with suspension of the uterosacral ligaments (n ¼ 105). Of
these, 99 women completed questionnaires at baseline and after 24 months follow-up and were included in the
present study. During a follow-up period of 24 months, no significant differences in total PISQ-12 scores were
observed between the groups. After both interventions the item “avoidance of intercourse due to prolapse”
significantly improved, as did the physical subscale of the PISQ-12 questionnaire.
Conclusion: There was no statistically significant difference in overall sexual functioning (total PISQ-12 scores)
between uterus-preserving sacrospinous hysteropexy and vaginal hysterectomy with suspension of the uterosacral
ligaments after a follow-up period of 24 months.
J Sex Med 2016;13:213e219. Copyright  2016, International Society for Sexual Medicine. Published by Elsevier
Inc. All rights reserved.
Key Words: Hysterectomy; Uterus Preservation; Sexual function; Hysteropexy; PISQ-12

Received August 16, 2015. Accepted December 9, 2015.


1
Department of Obstetrics and Gynecology, Isala, The Netherlands; INTRODUCTION
2
Department of Obstetrics and Gynecology, University Medical Centre Pelvic organ prolapse (POP) is one of the most common
Groningen, Groningen, The Netherlands;
3
benign gynecological disorders, with an increasing incidence due
Department of Obstetrics and Gynecology, Radboud University Nijmegen
to increased life expectancy. The lifetime risk for POP surgery is
Medical Centre, Nijmegen, The Netherlands
up to 20% and approximately 16% to 30% of patients need
Copyright ª 2016, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. repeat surgery because of recurrent POP or urinary incon-
http://dx.doi.org/10.1016/j.jsxm.2015.12.006 tinence.1e5 Up to 60% of sexually active women with POP

J Sex Med 2016;13:213e219 213


214 Detollenaere et al

awaiting pelvic reconstructive surgery reported that their sex life results have been published previously.17 In short, women with
was negatively affected by their prolapse and 1 cohort study that symptomatic uterine prolapse POP-Q stage II or higher (uterine
included 1267 sexually active women reported that women with prolapse 1 cm above the hymen or beyond) requiring surgery were
POP had lower scores on the Pelvic Organ Prolapse Urinary randomly assigned to sacrospinous hysteropexy and vaginal hyster-
Incontinence Sexual Questionnaire short form (PISQ-12) than ectomy in an open-label multicenter non-inferiority trial.18 The
woman without POP.6,7 surgical procedures were performed according to guidelines
In general sexual function improves after POP surgery, described in previous trials.17,18 Patients with previous pelvic floor
although there are some studies that have shown conflicting or POP surgery, known malignancy or abnormal cervical smears, a
evidence.8e10 POP has anatomical, functional, and psychological wish to preserve fertility, language barriers, presence of immuno-
aspects. The physical and anatomical cure of POP may result in logical or hematological disorders interfering with recovery after
less physical bother during sexual intercourse. On the other surgery, abnormal ultrasound findings of the uterus or ovaries or
hand, POP surgery may be accompanied by negative side effects. abnormal uterine bleeding, and those who were unwilling to return
Vaginal narrowing and scarring as well as damage to vasculari- for follow-up were excluded from the study.
zation and innervation can lead to sexual dysfunction including Gynecological consultation prior to surgery included pelvic
dyspareunia, vaginal dryness, and/or orgasmic problems, and ultrasonography to exclude uterine or ovarian disease, a cervical
therefore diminished satisfaction and frequency of intercourse. smear test and vaginal inspection in 45 semi-upright position for
Associated dysfunctions such as stress urinary incontinence staging uterovaginal prolapse by POP-Q examination. Preopera-
during intercourse may change after surgery and thus also may tive urodynamic evaluation was only performed when indicated.
change the perception of sexuality. Surgical repair of POP may During the first 6 weeks after surgery, patients kept a diary to
relieve symptoms by improvement of women’s body image.11,12 evaluate postoperative pain measured by the Visual Analogue Scale
It is known that the type or route of hysterectomy (abdominal vs (VAS) score. All patients consulted the hospital for follow-up/
vaginal hysterectomy) does not play a role in sexual function after POP-Q examination at 12 months after surgery and annually
hysterectomy.13 Controversy exists regarding the effect of uterus thereafter. At baseline and at the follow-up visit all patients
preservation vs hysterectomy in POP repair on sexual function. completed the validated disease-specific quality of life question-
Two randomized controlled trials measured sexual function after naires: Short Form-36 (SF-36), Urogenital Distress Inventory
sacrospinous hysteropexy vs vaginal hysterectomy and found no (UDI), Defecatory Distress Inventory (DDI), and Incontinence
differences between the 2 groups.14,15 However, no validated Impact Questionnaire (IIQ).19e21 Patients were considered to be
questionnaires were used in these studies and follow-up was only sexually active if they responded “yes” to the question “are you
performed after 6 and 12 month follow-up with limited sample having sexual contact with your partner?” To assess sexual func-
size. Another prospective cohort study by Constantini et al tioning, the PISQ-12, translated from the validated questionnaire
assessing uterus-sparing surgery vs hysterectomy with sacrocolpo- but not validated for Dutch language, was used. Data from patients
pexy showed that 12 months after surgery, uterus preservation was who had completed the PISQ-12 at baseline and 24 months after
associated with a greater improvement in the desire, arousal, and surgery were used in the present trial. This PISQ-12 questionnaire
orgasm sexual domains.16 No large randomized trials with long- is a shorter version of the original PISQ questionnaire and is
term follow-up are available evaluating sexual functioning after validated for assessment of sexual function in women with
uterus preservation vs hysterectomy in treatment of uterine pro- POP.22,23 PISQ-12 individual question scores range from 0 to 4.
lapse. This is the report on a secondary analysis of a large ran- Total PISQ-12 scores range from 0, which represents poorest
domized clinical trial comparing sexual function after sacrospinous sexual function, to 48, best sexual function. A questionnaire was
hysteropexy and vaginal hysterectomy with suspension of the considered valid if there were no more than 2 missing items and
uterosacral ligaments in treatment of uterine prolapse. total scores were corrected for the number of answered questions.
The behavioral/ emotive subscale was calculated using questions 1,
2, 3, 4, and 9 (desire, arousal, emotions), the physical subscale by
AIMS
questions 5, 6, 7, and 8 (pain, urinary and/or fecal incontinence,
The aim of this secondary analysis was to evaluate and and bulge symptoms) and the partner-related subscale by questions
compare sexual function in women who were randomized be- 10, 11, and 12 (erection, premature ejaculation, and intensity of
tween sacrospinous hysteropexy vs vaginal hysterectomy with orgasm).
suspension of the uterosacral ligaments in treatment of uterine
Data were entered and registered using a web-based applica-
prolapse stage II or higher.
tion facilitated by the Dutch consortium for studies in women’s
health and reproductivity (www.studies-obsgyn.nl). The trial was
METHODS approved by the medical ethical committee of Isala hospital
The SAVE U trial was designed to compare surgical failure after (MEC 09-625) and the local ethical committees of the partici-
12 months follow-up between sacrospinous hysteropexy and vaginal pating centers. The trial was registered: trialregister.nl, number
hysterectomy with suspension of the uterosacral ligaments. These NTR1866.

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Sexual Function After Sacrospinous Hysteropexy and Vaginal Hysterectomy for Uterine Prolapse: A RCT 215

MAIN OUTCOME MEASURES illness and/or problems (erectile dysfunction), and 1 did not
specify a reason. After 24 months, 5 women after sacrospinous
In this study sexual function at 24 months follow-up as
hysteropexy and 4 women after vaginal hysterectomy with ute-
measured with the PISQ-12 was considered the primary
rosacral ligament suspension were lost to follow-up for various
outcome. The primary outcome in the original study was
reasons and 10 women did not fill out the questionnaire.
recurrent prolapse POP-Q stage II or higher in the apical
compartment (uterus or vaginal vault) with bothersome bulge Table 1 shows baseline characteristics stratified by sexual ac-
symptoms or repeat surgery for recurrent apical prolapse at 12 tivity. In sexually active women there were no differences in
months follow-up. Secondary outcomes were functional baseline characteristics between the interventions. Women who
outcome, quality of life, complications, hospital stay, post- were not sexually active were significantly older (P < .01) and
operative recovery, and sexual functioning. had higher-stage uterine prolapse (P < .01). In total, 99 women
completed the PISQ-12 questionnaire both at baseline and after
24 months follow-up. No differences in baseline characteristics
Statistical Analyses were found between sacrospinous hysteropexy (n ¼ 43) and
All statistical analyses were performed using SPSS for Win- vaginal hysterectomy (n ¼ 56).
dows version 22.0.0.1 (IBM Inc, Armonk, NY, USA). To
compare mean continuous data within groups, paired sample t In Table 2 total PISQ-12 scores and individual items are shown
tests were used, and for comparison between groups, indepen- at baseline and after 24 months follow-up. No significant differ-
dent sample t tests were used. Pearson’s c2 or Fisher’s exact test ences in total PISQ-12 scores were found at baseline and after 24
were used for categorical variables. Women were found to have months between the intervention and control groups. PISQ-12
an improvement in PISQ-12 score in case the postoperative score scores improved significantly after 24 months in both groups.
was at least 1 point higher than the preoperative score, and An independent sample t test on the difference between the groups
deterioration was defined as at least 1 point lower than the in change of preoperative minus postoperative scores also revealed
preoperative score.24 no statistical significant difference after 24 months follow-up (P ¼
.80). A significant improvement was found in both groups with
The aim of the original study was to determine if sacrospinous respect to the PISQ-12 item “avoidance of intercourse due to
hysteropexy was noninferior to vaginal hysterectomy with sus- prolapse.” Significant improvement also was observed in the
pension of the uterosacral ligaments after 12 months follow-up. physical subscale in both groups. Statistically significant differ-
Therefore sample size calculation for this secondary analysis was ences (but no improvement as the scores were not 1 point higher
also based on the noninferiority principle. As we expected the than the preoperative score) were found in both groups regarding
total PISQ-scores to be equal after 24 months with a standard PISQ-12 items: “occurrence of urinary incontinence,” “negative
deviation of 5.7 points,24 34 patients, 17 in each group, were emotional reactions,” and “orgasmic level” (both interventions).
required to be 80% sure that the lower limit of a 1-sided 95% After sacrospinous hysteropexy fear of incontinence was signifi-
confidence interval will be above the noninferiority limit of 5 cantly lower. The behavioral/emotive subscale in the hysterectomy
points, as this difference was found to be clinically relevant. To group and the partner-related subscale in the sacrospinous hys-
determine clinical relevance of statistically significant changes in teropexy group were significantly higher after 24 months but did
PISQ-12 sores and subscales, we calculated effect sizes (ESs) not meet the definition of improvement.
using Cohen’s d. ESs were defined as small if Cohen’s d ¼ 0.2,
medium if d ¼ 0.5, and large when d  0.8. P values < .05 were Anatomical success (defined as no prolapse beyond the hymen,
considered statistically significant. no bothersome bulge symptoms, and no repeat surgery after 24
months) was similar in women who completed PISQ question-
naires: 32 of 42 women (76.2%) in the sacrospinous hysteropexy
RESULTS group and 38 of 53 women (71.7%) in the vaginal hysterectomy
Between November 27, 2009 and March 12, 2012, 208 group (P ¼ .62).
women with uterine prolapse stage II or higher were randomly
assigned to sacrospinous hysteropexy (n ¼ 103) or vaginal hys-
DISCUSSION
terectomy (n ¼ 105). Details on follow-up and numbers of
sexual active women during follow-up are shown in Figure 1. In the present study sexual function evaluated by the PISQ-12
Two patients in the sacrospinous hysteropexy group did not fill questionnaire improved significantly after surgery (overall PISQ-
out the questionnaire. Women were sexually inactive at baseline 12 scores) but was not different between sacrospinous hyster-
because of the following reasons: no partner including widow opexy and vaginal hysterectomy with suspensions of the utero-
(n ¼ 21, 29.6%), age (n ¼ 1, 1.4%), partner-related illness (n ¼ sacral ligaments during a follow-up period of 24 months.
6, 8.5%), prolapse (n ¼ 5, 7.0%), reason unknown (n ¼ 37, Improvement was found in the avoidance of sexual intercourse
49.3%). Seven women became sexually inactive after 24 months due to prolapse and the physical subscale of the PISQ-12 after
follow-up (3.7%), of whom 3 stated that they became widowed, both procedures. The percentage of women who became sexually
3 reported that their sexual inactivity was due to partner-related inactive after 24 months was similar.

J Sex Med 2016;13:213e219


216 Detollenaere et al

Figure 1. Number of sexually inactive women at baseline and after 24 months follow-up.

A recent systematic review concluded that sexual functioning Uterus preservation was associated with a greater improvement.
is significantly improved and dyspareunia significantly reduced However, limitations of that study were the nonrandomized
after native tissue prolapse surgery.10 Likewise, a study using the design and no use of a condition-specific questionnaire in the
PISQ-12 questionnaire to study the effect of POP surgery on evaluation of sexual function.6 A cohort study among 1267
sexual functioning showed an improvement in sexual function.25 women reported that women with POP had lower PISQ-12
Sexual functioning after POP surgery with and without hyster- scores than controls.7 That study found that POP had no ef-
ectomy was compared in a nonrandomized prospective trial. fect on certain aspects of sexual function such as orgasm and

Table 1. Baseline Characteristics Sexually Active and Sexually Inactive Women


Sexually active (n ¼ 135) Sexually inactive (n ¼ 70)

Sacrospinous Vaginal Sacrospinous Vaginal


hysteropexy hysterectomy Overall hysteropexy hysterectomy Overall
(n ¼ 63) (n ¼ 72) (n ¼ 135) (n ¼ 37) (n ¼ 33) (n ¼ 70) P*

Age (y) 59.4 (7.4) 58.8 (9.4) 59.1 (8.5) 68.1 (8.2) 68.3 (7.5) 68.2 (7.8) <.01
Body mass index 25.8 (3.0) 25.6 (2.9) 25.7 (2.9) 26.1 (3.9) 26.6 (4.5) 26.4 (4.1) .19
Parity 2.8 (0.2) 2.9 (1.2) 2.9 (1.2) 2.8 (2.0) 2.9 (1.0) 2.9 (1.3) .99
Smoking 9/56 (16.1) 5/62 (8.1) 14/118 (11.9) 4/32 (12.5) 4/28 (14.3) 8/60 (13.3) .75
Preoperative uterine <.01
prolapse stage:
2 42/63 (66.7%) 52/72 (72.2%) 94/135 (69.6%) 23/37 (62.2%) 14/33 (42.4%) 37/70 (52.9%)
3 17/63 (27.0%) 18/72 (25.0%) 35/135 (25.9%) 11/37 (29.7%) 11/33 (33.3%) 22/70 (31.4%)
4 4/63 (6.3%) 2/72 (2.8%) 6/135 (4.4%) 3/37 (8.1%) 8/33 (24.2%) 11/70 (15.7%)
VAS general health 72.9 (15.6) 72.5 (18.1) 72.7 (16.9) 70.4 (17.5) 70.1 (19.6) 70.2 (18.4) .37
(0-100)†
UDI prolapse (0-100)‡ 52.6 (26.4) 54.0 (27.7) 53.3 (27.0) 51.0 (29.1) 60.8 (26.4) 55.7 (28.0) .57
SUI§ 27/63 (43%) 30/73 (41%) 57/135 (42%) 20/37 (54%) 13/32 (41%) 33/69 (48%) .45
UUI§ 28/63 (44%) 28/71 (39%) 56/134 (42%) 16/36 (44%) 16/32 (50%) 32/68 (47%) .48
Obstipation 26/63 (41%) 20/72 (28%) 46/135 (34%) 9/37 (24%) 8/32 (25%) 17/69 (25%) .17
Data are presented as mean (SD) or number (%); percentages were calculated using non-missing data.
VAS ¼ visual analogue scale score; SUI ¼ stress urinary incontinence; UDI ¼ urogenital distress inventory; UUI ¼ urge urinary incontinence.
*P values calculated using independent t test or Fisher’s exact test comparing sexually active and sexually inactive women.
†VAS general health: 0 ¼ worst quality of health and 100 ¼ best quality of health.
‡UDI: 0 ¼ no symptoms or not bothersome and 100 ¼ most bothersome symptoms.
§Positive answer to the specific question from the UDI in combination with a response ‘somewhat bothered’ to ‘very much bothered’ to the question
“how much does this bother you?”.

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Sexual Function After Sacrospinous Hysteropexy and Vaginal Hysterectomy for Uterine Prolapse: A RCT 217

Table 2. Total PISQ-12 Scores At Baseline and After 24 Months Follow-Up


Sacrospinous Hysteropexy (n ¼ 43) Vaginal Hysterectomy (n ¼ 56)

Effect Effect
Baseline 24 months P size Baseline 24 months P size

Total PISQ-12 score*,† 33.7 (5.5) 36.8 (4.6) P < .01 0.61 34.7 (5.0) 37.5 (3.3) P < .01 0.66
PISQ-12 subscale and individual question
scores:
Behavioral/emotive‡ 13.7 (2.5) 14.5 (2.2) .08 - 13.6 (2.5) 14.5 (1.6) <.01 0.43
Q1. Sexual desire 1.9 (0.9) 1.9 (0.9) 1.0 - 2.1 (0.7) 2.2 (0.7) .86 -
Q2. Climax (orgasm) 2.5 (1.0) 2.8 (0.9) .11 - 2.6 (1.0) 2.5 (0.8) .32 -
Q3. Sexual excitement 2.8 (0.8) 2.8 (0.7) 1.0 - 2.8 (0.7) 2.8 (0.5) .57 -
Q4. Sexual satisfaction with sexual 3.2 (0.7) 3.1 (0.6) .58 - 3.0 (0.8) 3.1 (0.6) .06 -
activities
Q9. Negative emotional reactions 3.3 (0.9) 3.7 (0.6) <.01 0.52 3.2 (1.1) 3.8 (0.5) <.01 0.70
(fear, disgust, shame, guilt) during
sexual activity
Physical§ 12.1 (2.9) 14.7 (1.3) <.01 1.16 12.9 (2.5) 14.6 (1.5) <.01 0.82
Q5. Pain during intercourse 2.9 (1.1) 3.0 (1.0) .47 - 2.8 (1.2) 3.0 (1.0) .18 -
Q6. Urinary incontinence during sexual 3.5 (0.9) 3.9 (0.3) .01 0.60 3.7 (0.7) 3.8 (0.4) .04 0.18
activity
Q7. Fear of incontinence (urinary or fecal) 3.5 (1.1) 3.9 (0.4) .02 0.48 3.7 (0.7) 3.9 (0.4) .05 -
during sexual activity
Q8. Avoidance of intercourse due to 2.4 (1.4) 3.9 (0.5) <.01 1.42 2.7 (1.2) 3.9 (0.4) <.01 1.34
prolapse
Partner relatedk 8.0 (1.5) 8.9 (1.5) <.01 0.60 8.1 (1.6) 8.3 (1.9) .42 -
Q10. Erection problems of partner 3.3 (0.9) 3.4 (0.9) .32 - 3.3 (0.8) 3.3 (0.9) .76 -
Q11. Premature ejaculation of partner 3.6 (0.7) 3.7 (0.6) .60 - 3.4 (0.8) 3.3 (0.9) .39 -
Q12. Comparison of orgasmic level 1.0 (0.7) 1.7 (0.7) <.01 1.0 1.4 (0.7) 1.8 (0.8) .02 0.53
between past and present
Data are presented as mean (SD). Total PISQ-12 scores ranges from 0, which represents poorest sexual function, to 48, best sexual function. P value: paired
sample test baseline score and follow-up score, effect size: small Cohen’s d ¼ 0.2, medium if d ¼ 0.5, large if d  0.8.
PISQ-12 ¼ pelvic organ prolapse/urinary incontinence sexual questionnaire.
*Not shown: independent sample t test on the differences between groups in total PISQ-12 scores showed no difference at baseline (difference 1 point,
95% CI 3 to 1.1, P ¼ .35) and after 24 months (difference 0.7 point, 95% CI -2.3 to 0.9, P ¼ .37).
†Not shown: independent sample t test on the difference between groups in change of preoperative minus postoperative follow-up score showed no
statistical significant difference (P ¼ .80).
‡Behavioral/emotive subscale: questions 1, 2, 3, 4, and 9 (desire, arousal, emotions).
§Physical subscale: questions 5, 6, 7, and 8 (pain, urinary and/or fecal incontinence and bulge symptoms).
kPartner related subscale: questions 10, 11, and 12 (erection, premature ejaculation, and intensity of orgasm).

sexual satisfaction. In our study, we confirmed that POP surgery Recently this questionnaire has been validated for the Dutch
does not significantly improve these aspects. There was no sig- language.26 However, the PISQ-12 has limitations. Roos et al
nificant change in the following individual items: sexual desire, showed that the PISQ is complete in representing the positive
orgasm, sexual excitement, and sexual satisfaction. However, effects of surgery but most negative effects are not included.27
improvement after surgery in our study can be explained by the They concluded that with the cure of POP and/or UI after
improvement in the avoidance of sexual intercourse due to surgery it is logical that questions such as “Do you avoid sexual
prolapse and physical cure. intercourse because of bulging in the vagina?”, “Are you incon-
The strength of this study is the randomized design. As far as tinent of urine with sexual activity?”, and “Does fear of incon-
we know, this is the first large randomized study reporting on tinence restrict your sexual activity?” improved, which was also
sexual functioning after uterus preservation and hysterectomy 2 the case in our study. However, negative aspects of surgery such
years after surgery. In addition, we used the best available as fear of damaging the repair, disappointing result after surgery,
condition-specific and validated questionnaire. The PISQ and its and pain due to surgery are missing in the questionnaire. The
short form PISQ-12 were the only validated female sexual International Urogynecological Association (IUGA) published a
function questionnaires specifically developed to assess sexual revised version of the PISQ: PISQ-IUGA-revised (PISQ-IR).
function in women with POP and UI at the time of the study. This questionnaire also addresses the impact of pelvic floor

J Sex Med 2016;13:213e219


218 Detollenaere et al

dysfunction on a women’s decision not to be sexually active and involvement of N. van Rijn for assistance with data collection
also creates a condition-specific measure of sexual function for and administrative support.
women with anal incontinence. However, the PISQ-IR fails to
Corresponding Author: Renée J. Detollenaere, MD, Isala,
address the possible negative effects of surgery. Another disad-
Department of Obstetrics and Gynecology, PO Box 10500,
vantage was that only sexual function in sexual active women is
evaluated in the questionnaire. Sexually inactive women were not 800 GK Zwolle, The Netherlands. Tel: þ316 14682330;
E-mail: r.j.detollenaere@isala.nl
asked about their satisfaction being sexually inactive. With longer
follow-up, changes unrelated to surgery may influence sexual Conflict of Interest: The authors report no conflicts of interest.
function as well, especially in a group of aging women. For
example, possible reasons to become sexually inactive are aging, Funding: The SAVE U trial received an unrestricted grant from
illness, and becoming a widow, which are unrelated to surgery. the Isala research foundation. The funding source did not play
In our study, we did not ask for these factors, which would have any role in the design and conduct of the study; in the collection,
been appropriate when evaluating sexual function in an aging management, analysis, or interpretation of the data; or in the
group. preparation, review, or approval of the manuscript.
Women’s self-perceived body image and degree of bother from
POP may influence total PISQ-12 scores. It is thus interesting to STATEMENT OF AUTHORSHIP
know if uterus preservation is associated with better body image Category 1
after POP surgery than hysterectomy and whether uterus pres- (a) Conception and Design
ervation thereby improves sexual function. Recent studies show Renée J. Detollenaere; Hugo W.F. van Eijndhoven
that the majority of women disagree with a statement that the (b) Acquisition of Data
uterus is important for body image and sexuality. A study among Renée J. Detollenaere; Hugo W.F. van Eijndhoven
213 women seeking care for POP symptoms reported on pa- (c) Analysis and Interpretation of Data
tients’ attitudes toward the uterus and the role in surgery.28 The Renée J. Detollenaere; Ilse A.M. Kreuwel; Jeroen R. Dijkstra;
Hugo W.F. van Eijndhoven; Kirsten B. Kluivers
authors found that women had relatively neutral attitudes on the
uterus being beneficial to sexuality or femininity. A recent study Category 2
by our research group demonstrated that 80% of women referred (a) Drafting the Article
to a gynecologist for POP complaints thought that uterus pres- All authors
ervation vs hysterectomy would have no effect on sexuality and (b) Revising It for Intellectual Content
body image (article under review). All authors
Taking women’s preferences and beliefs into account in Category 3
combination with the results of the PISQ-12 questionnaires, we (a) Final Approval of the Completed Article
argue that uterus preservation and vaginal hysterectomy are both All authors
adequate treatments for POP with regard to improvement of
sexual functioning. Based on our study women can be
adequately counseled on sexual functioning after both in- REFERENCES
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CONCLUSIONS
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There was no difference in improvement of sexual functioning of reoperation for surgically treated pelvic organ prolapse
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ACKNOWLEDGMENTS
5. Olsen AL, Smith VJ, Bergstrom JO, et al. Epidemiology of
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J Sex Med 2016;13:213e219

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