Choking the chicken has risks.

Masturbation

When it comes to sexual pleasure, masturbation can both help and hurt your sexual satisfaction. For those of you uncertain exactly what masturbation entails,  masturbation is the term for genital self-stimulation.

The downside of masturbation? Reaching orgasm through masturbation can make orgasm difficult to achieve with a partner.

Men can develop what is called “delayed ejaculation”, where it’s difficult — or even impossible — to orgasm during partner sex because he’s man-handled himself to the point where orgasm occurs only through the EXACT pressure, friction and rhythm from his own hand, something a partner’s hand, mouth, vagina or anus simply cannot replicate. Further, the instant gratification from masturbating can be so appealing that one loses interest in sex with a partner.

Sex Addiction & Pornography

Internet-fueled pornography addiction lends a modern day wrinkle to the ramifications of masturbation, where men (usually) become so acclimated to the variety and instant, rapid fire gratification potential of online pornography that they become sexual anorexics when it comes to real-time sex with a real live woman. How sad! There’s even a website devoted to this social blight: Partners of Sex Addicts Resource Center that offers help for porn-addiction and related issues. Porn masturbation sex addiction is ruining relationships with such voraciousness that the courts are clogged with the detritus of porn-rocked marriages suffering from cybersex addicted spouses.

Women run the risk of developing their own version of “delayed ejaculation” finding themselves in a similar predicament where orgasm is possible only through genital self-stimulation, without which anorgasmia takes over, making partner-sex, well, “anti-climatic”….

Onanism

Traditionally reviled in Judeo-Christian societies, ejaculating outside of the reproductive parts of a woman was a mortal sin for which Onan, second son of Judah, was struck dead prematurely by Yahweh Himself for “spilling his seed upon the ground”. References to the evil and inevitable effects of “Onanism” in Victorian-era health manuals included cerebral palsy (they had a different name for it back then), mental retardation and birth defects of all varieties, not to mention insanity and infertility in the afflicted self-abusers. Oye!

The upside of masturbation (beyond male hydraulics)? Contemporary sex science shows that masturbation can help men control orgasm and avoid premature ejaculation, –and can help both men and women feel more confident about sexuality by allowing you to discover the variety of maneuvers your partner finds advantageous.

The moral (don’t act like you didn’t see this coming) of the masturbation story? Use it, don’t abuse it.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vaginal prolapse surgery with synthetic and non-synthetic graft material -

Concerns about the use of graft material, particularly Prolene mesh, continue to mount after the most recent FDA warning on mesh in vaginal surgery.  These diligent authors from Michigan, Texas, Massachussetts, Washington State, New Mexico and Israel combed the international medical literature in all languages from 1950 to present, looking for data on adverse events when graft material is used at the time of vaginal prolapse repair. Three common problems, erosion (graft eroding through the vaginal skin so that it is palpable to touch and/or visible to the examining eye), granulation tissue (“proud flesh” commonly found in wounds as they heal inside and outside of the body), and dyspareunia (painful sex) were the key factors under review.

Granulation, Erosion, Dyspareunia and Prolapse Organ Prolapse Surgery with Graft Materials

What they found is that rates of each of the three complications did not differ between synthetic (such as non-absorbable Prolene or absorbable  Vicryl mesh) vs non-synthetic (such as porcine [Surgisis] or bovine [Xenform] or human cadaver-based) graft material, and that reportage with regard to sexual problems was so spotty and incomplete that it was difficult to figure out if women with sexual pain after surgery had sexual pain before surgery with the problem persisting after reconstruction, or whether it was clear that the surgery definitely caused the dyspareunia (sexual pain).

Of the more than 2000 mauscripts considered, less than 200 were included and most did not report on all three of these possible complications. In more recent years, the reportage tended to be consistent with our modern-day concerns, as one might expect the case to be.

Bottom line: there are no guarantees. Grafts reduce prolapse recurrence rates, but come with their own set of headaches.

To mesh or not to mesh?

Synopsis for the Journal of Sexual Medicine from original manscript published in the July 2011 issue of the International Urogynecology Journal:

Abed H, Rahn DD, Lowenstein L, Balk EM, Clemons JL, Roberts RG

Incidence and management of graft eriosion, wound granulation and dyspareunia following vagianl prolapse repair with graft maeriasl: a stematic review.

Int Urogynecol J (2011) 22:789-98.

This metanalysis reviewed global data published from 1950-2010 from papers  reporting adverse events after vaginal prolapse repairs using graft materials. 2260 citations were identified using Medline search terms including vaginal or uterine prolapse, rectocele, surgical mesh, cystocele, and similar pelvic  floor terms. After review of each, data from 196 manuscripts was included in this analysis. Graft erosion was reported in 110 studies (10.3%) with similar rates for synthetic and biologic grafts.  Diagnosis of erosion occurred between 6 weeks and 12 months. The most common risk factor for erosion was concomitant hysterectomy, as well as patient age, smoking and diabetes, surgeon experience, and use of T incision of vaginal skin during dissection. Granulation tissue as reported in 7.8% of the 16 papers reporting on this outcome in series using a single type of graft material. While not statistically significant, the reported rate of granulation was higher with biologic graft material than with synthetic/permanent graft material (9.1% and 6.8%, respectively). Spontaneous resolution of granulation tissue and resolution with suture removal and silver nitrate treatment were reported treatment options.

Dyspareunia was reported in 71 papers with overall incidence of 9.1%, rates similar between synthetic and biologic grafts, with risk factors including posterior repair and mesh erosion. Listed treatments included vaginal estrogen cream and excision of eroded mesh. The authors point out that many of these studies did not limit reportage to sexually active women, nor make clear whether the painful sex was persistent or de novo. They also remind the readers that dyspareunia is known to occur with native tissue repairs also, operations where no graft material of any sort is used. The authors go on to report that most of the studies did not including what proportion of women sere sexually active, how may had pre-existing sexual dysfunction and how many benefited from improved sexual function. They state that as more studies use the validated quality of life Pelvic Organ Prolapse / Urinary Incontinence Sexual Questionnaire, the quality of  data on the impact of pelvic floor surgery on sexual function will improve in accuracy and clinical relevance.

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Vaginal Prolapse Surgery, Vaginal Contour and Female Sexual Function

This is another manuscript I reviewed for the Journal of Sexual Medicine, published by colleagues from The Mayo Clinic in the International Urogynecology Journal July 2011 issue. These authors looked carefully at the possibility of change in vaginal contour resulting from pelvic organ prolapse surgery with regards to female sexual function. They measured vaginal length and width before, immediately after (patient still in the operating room under anesthesia, case finished), and 6 months after surgery. The women completed a validated questionnaire for prolapse, incontinence and sexual function in women called the PISQ-12 before and 6 months after surgery. In summary, vaginas were a bit shorter and a bit narrower after surgery, and sexual function quality of life questionnaire scores did not change, nor did sexual satisfaction or lack thereof correlate to vaginal measurements either before or after surgery.  This helpful study will no doubt be repeated in various fashion as we in the field of urogynecology do our best to adhere to the mandate of “primum non nocere” (first, do no harm).

Once you’ve done this:

Childbirth - good thing they're so cute

You might need this:

Cutting & Sewing - 2 darts and a dash of facing, voila!

To get back to this:

Anatomy in 3-D - the vagina in relation to the rest of you

Journal summary:

Ochhino JA, Trabuco EC, Heisler CA, Klingele CJ, Gebhart JB.

Changes in vaginal anatomy and sexual function after vaginal surgery.

Int Urogynecol J (2011) 22:799-804

The authors enrolled 92 women undergoing vaginal reconstruction prolapse surgery in study including pre- and post-surgery completion of a validated sexual function questionnaire (PISQ-12) and in measurement of vaginal contour before, immediately after, and 6 months after surgery in order to determine whether changes in vaginal length and caliber correlate to changes in sexual function. All but one of the women was white. 72.8% were menopausal and 16.3% had undergone one prior prolapse operation. 47.8% were sexually active before surgery with a preoperation PISQ-12 score of 33.5. Pre-operation vaginal length was 10.4 cm on average with mean caliber 3.2 cm. Some women had intentional coning (narrowing) of the top of the vagina to correct excessive laxity and some did not – those undergoing coning (N=14) were evaluated separately from those who did not (N=78) for post-op vaginal contour measurements.

Immediately after surgery while still anesthetized, vaginal length of women with no coning was reduced to 7.9 cm with caliber 3.0 cm while coned patients measured 6. 8 cm length with caliber 2.8 cm. At 6 months postop, the no-cone women measured 8.7 cm length with 2.8 cm caliber while coned women continued to measure 6.8 cm length with .2 cm caliber.

74 women completed the PISQ-12 prolapse-incontinence-sexual function questionnaire at 6 months post-surgery, with 52.6% sexually active. Only 34 sexually active women completed the questionnaire before and after surgery, and in this group no change in score was demonstrated (33.4 vs 34.7). Further, no correlation was found between pre0operation score and vaginal length or caliber or between post operation score and vaginal length or caliber. The authors did not comment on the drop-out rate for questionnaire completion. They point out that, according to this data in this first study to look at changes in vaginal contour as correlates to sexual function, changes in vaginal dimensions does not seem to affect sexual function in women who were sexually active before and after the pelvic organ prolapse operation.

Level of evidence: III Count: 325 words

Content is copyright protected on date of online publication. Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Painful sex after menopause

Hello Dr. R,

I am a 51 year old that has pain upon entry, visited my doctor and he is suggesting a perineoplasty, is that the same procedure as a Fenton’s?  Is there anything else that wouldn’t be as invasive? I do not want to take hormones and I am not ready for my sexual life to be over.  Once the opening is loosened up a bit it doesn’t hurt as long as I use a lubricant. Would this be a senario for a perineoplasty?  Thank you so much!

Painful sex (dyspareunia) after menopause is best treated with a dose of creativity - rush not to the knife!

Dyspareunia: perspective from a urogynecologist

Hello L,

Without examining you, it is impossible to know if a perineoplasty is your only treatment option for painful sex (dyspareunia). I strongly suggest you seek second opinions from urogynecology specialists in your area, which you may locate through American Urogynecologic Society. Therapies may include vaginal estrogen, dilators, pelvic floor physical therapy, pelvic floor electrical stimulation, valium vaginal suppositories, or some combination there-of.  You may consider perineoplasty and Fenton’s to be synonymous for this indication. Keep us posted…

Dr R

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Labiaplasty, cosmetic gynecologic surgery, female sexual function and anatomy of the female vulva

Vulvar anatomy circa 1798. Some things never change. Thank goodness...

Every two months I report for on scientific manuscripts in the recent medical literature for the Journal of Sexual Medicine that pertain to female sexual function. In an anatomic study of vulvar anatomy published in the journal of the American Urogynecologic Society, scientists took a close look at the microscopic goings on of labia minora. The controversy over labiaplasty and other forms of cosmetic gynecologic surgery rages on, with proponents on both sides claiming “fair” and “foul” in equal measure.

The clitoris has erectile function

Unless you believe in the G-Spot orgasm and are of the opinion that there is a difference between “internal/vaginal” and “external/clitoral” orgasms for women, you’re probably in agreement with most physiologists and anatomists that the female orgasm emanates from the clitoris, the organ in the body with the highest density of sensory nerves and an intense erectile response to sexual stimulation. That’s right, ladies. Your clitoris gets a woody every time you have an orgasm, or even get aroused.  The role of labia majora and labia minora in this erectile and orgasmic function is so poorly understood it’s almost criminal. Seriously – do you know how much is understood about male sexual function and role of erectile tissue in a man’s sexual pleasure? They’ve written books about it. An entire pharmaceutical industry is making $$bajillions catering to it. Courses are taught, books are written, Medicare PAYS FOR IT (all of it) right down to the fancy shmancy-est of prosthetic penile implants.

Labia minora: high density of nerve function and blood flow

So this study took a look at the micro-anatomy of labia minora. Few studies have reported any meaningful data on labiaplasty’s (surgical reduction of labia minora) impact on sexual function. There is one study by a renowned cosmetic genital surgeon who reported that out of 166 women undergoing combined labiaplasty and clitoral hood reduction, 38 reported better sexual pleasure and 9 reported a worse, or a negative impact on sexual function, from the procedure. This raises the question that it may be possible for genital cosmetic operations done to improve sexual function may actually have the opposite effect…

Being that the subjects in this particular study were all cadavers, evaluating sexual function was not possible. But the researchers did find a high density of nerve fibers on both the outer and inner surfaces of labia minora in all specimens, in addition to a high density of blood vessels, in excess of that needed to maintain the skin of the labia, indicating a high likelihood that the blood vessels of the labia minora play some role in the sexual response and possibly in the engorgement and erectile function of the clitoris, although these points remain to be proved in studies on live women.

Remember, one study does not an absolute fact make. This area of gynecologic surgery is in evolution, and this anatomy study is one important contribution to that body of literature that will permit, over time, for meaningful conclusions to be made.

Here’s the summary to appear in the Journal of Sexual Medicine sometime this fall:

Ginger VAT, Cold CJ, Yang CC.

Structure and innervation of the labia minora: more than minor skin folds.

2011 Female Pelvic Medicine & Reconstructive Surgery  17:4, 180-3.

Eight fresh cadaveric vulvar specimens were fixed and stained to report the histologic features of the labia minora with regard to female sexual function.

Labia were highly variable in appearance. Labia minora were thin in relation to majora, and in some cases fused. No labia minora contained fatty component, as do the labia majora. After fixation and histologic staining, the inner labum minus were found to be  covered by a basket-weave keratin type dermis.. The substance included numerous vascular structures surrounded by connective collagen and no smooth muscle, thereby making the labia minora vascular tissue non-erectile.  Elastin was abundant, as were neural elements with no difference in distribution of neural elements between the lateral and medial sides of the labia minora. There was a central core of neural elements long the length of the labia, traveling alongside vascular structures to form the neuro-anatomic substrate where sexual arousal results in labial engorgement. Neural elements were sparse with in the labia majora.  Histologic images are included to illustrate these findings. The authors go on to comment on genital labioplasty done for aesthetic or functional reasons, reiterating that reports of diminished sexual responsiveness are documented in at least one series of 166 women undergoing labiaplasty and clitoral hood reduction, where 9 reported negative effect on sexual sensation in contrast to 38 reporting improved sexual sensations.  They note that among reports on labia minora structure, very little mention is made of possible function. They comment that the specimens obtained for hits study were likely, but not know for certain, to be from menopausal women in which degenerative changes would have been present and that despite this, a high density of neural and vascular elements were found in the labia minora of the specimens evaluated.  They finish by stating that “Biochemical and molecular studies may further elucidate (the labia minora’s) role in the female sexual response,… which are specialized vascular structures with densely distributed neural elements providing anatomic substrate for changes observed during sexual arousal”.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

FEMALE SEXUAL DYSFUNCTION & ANDROGEN DEFICIENCY

Just because you’ve gone through menopause doesn’t mean sex—and the DESIRE for sex—should stop.

Ten years ago, a sex study published in Journal of the American Medical Association found that 43% of women suffer from sexual dysfunction at some point…compared to just 31% of men.

To be fair, and clear, the conclusions drawn from this study continue to be hotly debated since publication, as many in the healthcare profession raised concerns about the medicalization of women’s sexuality and the integrity of this study’s conclusions, which many specialists consider exaggerated.

That said, many women find the age related decrease in sexual urges disturbing and distressing.

Traditionally, a woman reporting problems with libido finds herself thwarted in her efforts to restore prior sexual appetites, as the medical profession is notorious for telling women they have to “live with it”.

Testosterone is good for girls AND boys

Despite this, the only FDA-approved treatments for problems between the sheets—Viagra, Cialis, and Levitra—target men.

This is why Procter and Gamble introduced Intrinsa, a testosterone patch medication designed to treat female sexual dysfunction, or FSD, caused by natural reductions in testosterone as women approach age 50. Low testosterone can affect libido and sexual arousal.

FSD involves any condition involving the inability to become or remain aroused during sex, the inability to achieve an orgasm,  and/or the presence of pain during intercourse. Not all of these symptoms are due to testosterone deficiency. The symptoms of FSD are often more prominent during hormonally vulnerable periods, like menopause or during lactation and breast feeding. Menopause can occur naturally with age, or abruptly when a woman’s ovaries are removed surgically.

Intrinsa is targeted at women who have undergone the menopausal transition and who are suffering sexually as a result of the age-related, inevitable drop in testosterone levels. Intrinsa  is a clear, egg-shaped patch which adheres to the skin on a woman’s belly that works by releasing small, controlled amounts of testosterone into a woman’s bloodstream.

Testosterone is a “masculine” sex hormone which is produced by a woman’s ovaries and adrenal gland. A woman’s testosterone level drops with most with birth control pills, and always with natural or surgical menopause. By age 45 or so, most women’s testosterone levels have decreased  by 50% from peak levels in the mid-20′s!

The theoretical clinical benefit to increasing serum levels of testosterone in the blood is to  reduce libido and arousal symptoms of FSD. Being a patch, Intrinsa CAN cause side effects, such as rash, redness, itching, and irritation at the patch site.

More importantly, testosterone is a powerful hormone, to be used with the greatest of caution and fastidious monitoring. More is NOT better! Because testosterone is a male sex hormone, overdosing may cause extremely troubling and potentially irreversible side effects such as: deepening of the voice, an increase in facial hair, enlargement of the clitoris, weight gain, cardiovascular conditions and hair loss.

Despite Intrinsa’s promise to effectively treat sexual dysfunction, however, the US FDA rejected the medication in 2004, citing a need for more studies. As a result, Proctor and Gamble took Intrinsa to Europe, where it is available by prescription. If you want to try Intrinsa, clear it with your doctor and hop the red-eye. Otherwise, women in the States suffering arousal disorder-type sexual dysfunction can talk to their gynecologist about diagnosing and treating androgen deficiency syndrome…a fancy term for “low testosterone”, that may be treatable with off-label applications of currently available hormone preparations on this side of the pond.

PELVIC ORGAN PROLAPSE:

NO DIFFERENCE IN SEXUAL QUALITY OF LIFE BETWEEN PROLAPSE PATIENTS CHOOSING PESSARY VS SURGERY.

Ladies, it's all about choice

Pelvic organ prolapse is a condition where the organs around the vagina are out of place – bladders drop (called cystocele), rectums bulge forward and sometimes out of the vaginal opening (rectocele), and/or the uterus drops down, literally falling out of the vagina turning everything inside out when its severe (uterine prolapse).  When prolapse is so bad that things are bulging out between the vaginal labia (yup, it happens) most women are uncomfortable to want to do something about it.
With severe prolapse, whatever the prolapsing part(s), and it’s usually more than one thing out of place, there are 2 choices – reconstructive surgery, or a vaginal prosthesis called a pessary.  A pessary is a vaginal widget that holds things up where they need to be when it’s inside. They come in all shapes and sizes – the easiest pessaries are ring-shaped. They’re easy because women can remove and insert them easily and reliably without assistance. Ring pessaries are sort of like contraceptive diaphragms in terms of insertion and removal. But sometimes, due to weak, thin Kegel muscles or uterine prolapse so severe that it pushes the rings out, sturdier pessaries, such as Gellhorns, donuts and Gehrungs, are the only ones that stay in.

Some women don’t like pessaries – or can’t find any that fit comfortably. They usually opt for prolapse surgery that puts all the organs back into position. The surgery can be complicated and, as with all surgeries, results can be less than perfect, making pessaries a viable option for women who are poor surgical candidates or simply don’t want to undergo extensive soft-tissue reconstructive surgery.

These British researchers undertook the task of looking at whether or not either treatment choice, surgery or pessary, affected sexual quality of life.  In data published in the March 2011 issue of the International Urogynecology Journal, they  found some interesting trends – women choosing surgery were younger, and at first glance seemed to have better sexual quality of life than their pessary using sisters, but when the statistician removed age differences, the sexual quality of life was the same between the two groups. Interestingly, 31 women who started with pessary didn’t like it and switched to surgery. Not much is said about them as the study design excluded data of patients who switched groups after the initial choice of treatment.

Here’s the study summary written for the June 2011 literature review for Journal of Sexual Medicine:

Abdool Z, Thakar R, Sultan AH, Oliver RS

Prospective evaluation of outcomes of vaginal pessaries versus surgery in women with symptomatic pelvic organ prolapse.

Int Urogynecol J (2011)22:273-78.

A prospective, non-randomized design compared women with prolapse opting for pessary management vs reconstructive surgery of pelvic organ prolapse, using baseline  and 1 year quality of life data, including but not limited to sexual function (Sheffield Pelvic Organ Prolapse Quality of Life questionnaire-SPS-Q).

Women referred to the Urogynaecology unit of Mayday University Hospital in Surrey, England were evaluated and counseled regarding prolapse management.  Each completed the SPS-Q, a 13 item quality of life assessment tool addressing impact of prolapse on bladder, bowel and sexual function using four-point ordinal response scales (never, occasionally, most of the time, all of the time), validated and sensitive to changes in clinical status. Women choosing pessary were first fitted for ring pessaries; the most user-friendly. If rings did not work, gellhorn or donut pessaries were fitted for sexually inactive women, and cubes fitted for sexually active women, as cubes are easily removed for sexual activity.

Patients were excluded if they underwent incontinence surgery or switched from pessary to surgery (N=89) either due to use of pessary as interval measure in preparation for surgery (N=58), or because pessary was too problematic, prompting a change of heart in favor of prolapse surgery (N=31).

554 women entered the trial, 359 with pessary and 195 choosing surgery. Women excluded from final analysis numbered 195 in the pessary group and 88 in the surgery group.  The final analysis was carried out on women completing questionnaire at 1 year who either underwent surgery as first option or were still using pessary at 1 year, 46% of the pessary group and 55% of the surgical patients.

Mean age was higher in the pessary group (68 vs 60 yrs). Other demographic measures were equivalent. At 1 year there was statistically significant improvement in sexual function in both pessary and surgery patients, in addition to similar improvement in bladder, bowel and prolapse symptoms. Frequency of intercourse was better in the surgical group (54% vs 46% p=0.028), however this sexual frequency difference faded when controlling for age.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Prolene Mesh and Pelvic Organ Prolapse

Cystocele, rectocele, erosions, sex, mesh shrinkage, folding and thickening

You can’t make this stuff up.

Prolene mesh is the product name for a permanent plastic mesh with many implantation applications in reconstructive surgery. Prolene mesh is used to fix large and small abdominal hernias, inguinal hernias, hernias of the diaphragm; it’s used to resuspend kidneys (nephropexy) rectums (rectopexy), uteri (aka uterus’ plural) (sacrohysteropexy), prolapsed vaginas after hysterectomy (sacrocolpopexy), chin augmentations (mentoplasty), chest wall repair in certain thoracic surgeries, (abdominal hernias (inguinal, umbilcal, ventral) and both male and female urethral sling operations for stress urinary incontinence, to name a few.

Over the last 8-10 years, the use of prolene mesh for vaginal prolapse surgery has expanded to include cystocele and rectoceele repair, In an effort to standardize application and, arguably, make it easier for gynecology, urogynecology and urology surgeons to use the mesh, and, definitely, to market the new pelvic organ prolapse mesh kits effectively, Prolene mesh companies have tweaked mesh pore size (degree of laciness), thickness, and density; they’ve mixed it with other graft materials, impregnated it with various materials, each in an effort to reduce horrific complications and claim clinical superiority. The industry cannot advertise or market superiority without data, so they sponsor scientific clinical trials hoping for favorable data that will legally permit them to claim product  superiority in marketing activities, via studies paid for in part or in full by the companies manfacturing the mesh, often but not always recruiting surgeons who work as paid advisors and consultants, much the same way pharmaceutical companies use paid advisors to participate in clinical drug trials. I know, I’ve been, at various points in my career, one of those advisor/consultants. It is a very fine ethical tightrope clinicians walk when participating at that level. The perks are large. The rewards many. It’s an elite group of clinical industry insiders that trumpet the merits of these meshes. Those surgeons publishing outside of the advisory board arena compete for journal space along side industry funded trials.

A few times a year, I and a few colleagues comb the literature for the Journal of Sexual Medicine, fashioning reviews of research with a sexual function implication. This month, I found three that “turn me on” – 2 of which focus on Prolene mesh for vaginal implantation in pelvic organ prolapse surgery for cystoceles (dropped bladders) and rectoceles (back wall vaginal hernias).

Here are the two trials on 2 different Prolene mesh kits: AMS Perigee and Gynecare Prolift.

The first study, using Prolift, found that young sexually active women were more likely to suffer vaginal erosion of mesh, literally mesh showing where the vaginal skin over it has eroded away. A bit of a problem, if your young, like sex, have prolapse, and use Prolene mesh, at least with this particular kit, to have it fixed. Prolene mesh in the vagina creates a mechanical risk of sexual dysfunction; your sex life could, quite literally, hit the skids. Forget carpet burns, we’re talking penis-meets-sand paper. Woops.

The second study, using a different brand of Prolene mesh vaginal prolapse kit for dropped bladder (cystocele) repair called Perigee, claims a close-to-zero mesh erosion rate, each erosion “minimal and easily remedied” with a bit of tinkering in the office. The investigators report some interesting ongoing changes in the sonographic appearance of the mesh once implanted in the vagina. In this study, Prolene mesh demonstrated folding in a few, and continued to shrink or shorten and thicken more and more at each of three sonograms done in the first year after implantation. Makes you wonder how it’s behaving after, say, 5  or 10 years.

I’ve said before and I’ll say again here, Prolene mesh ribbons for uterine suspension, vaginal cuff suspension after hysterectomy and female urethral sling operations for urinary incontinence have been around a long time and really do seem, in my experience and in my opinion, to work very well with low rates of minimally bothersome, easy to fix complications. BUT I’ve seen nightmares with Prolene mesh kits used for cystocele and rectocele repair – full recurrence of the prolapse, sometimes worse that before surgery, along with horrific, painful, bleeding mesh  vaginal or bladder erosions, kinking of ureters (the tubes that drain urine from your kidney to your bladder) glued to the mesh requiring ureteral re-implantation into a diffierent part of the bladder (this is big surgery, not a quickie), in addition to mesh bundles eroding into the vagina creating bleeding vaginal wounds that make sex impossible. Explanting (removing it in full) Prolene mesh from the anterior and posterior walls of the vagina is no easy task.  Not to mention, who wants a vagina literally lined on all’round with plastic mesh? Pore size, shmore size – it’s a Franken-vagina. How can that be good?

To date, I use this paper by Dr. Donald Ostergard as the yardstick by which all Prolene mesh graft products are to be measured, including the uses I consider acceptable and continue to employ. I don’t see any similar works coming from other surgical specialties about Prolene mesh as a surgical graft material. Urogynecology seems to be the lightning rod specialty for Prolene mesh graft considerations.

In 2008 the  FDA issued an official warning about Prolene mesh implantation in the vagina, and continue to express concern, as we see here in this Feb 2009  FDA newsletter posting:

Serious Complications with Surgical Mesh for Gynecologic Surgery

The FDA is alerting healthcare professionals about rare but serious complications associated with the surgical mesh used to treat pelvic organ prolapse and stress urinary incontinence. The mesh is usually placed transvaginally using minimally invasive techniques.

Over the past three years, FDA has received over a thousand reports of complications. The most frequent included erosion of the mesh through the vaginal epithelium, infection, pain, urinary problems, and recurrence of the prolapse or the incontinence. There were also reports of bowel, bladder, and blood vessel perforation during insertion. In some cases, vaginal scarring and mesh erosion led to a significant decrease in quality of life due to discomfort and pain, including dyspareunia.

Treatment of the complications included IV therapy, blood transfusions, drainage of hematomas or abscesses, and additional surgical procedures, in some cases to remove the mesh.

Clinicians using mesh for treatment of pelvic organ prolapse and stress urinary incontinence should:

• Obtain specialized training for each mesh placement technique, and be aware of its risks.

• Be vigilant for potential adverse events from the mesh, especially erosion and infection, and also from the tools used in transvaginal placement, especially bowel, bladder and blood vessel perforations.

• Inform patients about the potential for serious complications and their effect on quality of life, including scarring and pain during sexual intercourse. Patients should also be informed that implantation of surgical mesh is permanent, and that some complications associated with the mesh may require additional surgery that may or may not correct the problem.

• Provide patients with a written copy of the patient labeling from the surgical mesh manufacturer, if it is available.

So here’s some of the latest research data on both sides of the Prolene mesh fence – 1st up – if you’re young and like sex and need cystocele/rectocele prolapse repair, beware Prolene mesh. Second up – a study showing that kit- Prolene for bladder lift/cystocele repair is great stuff, no major problems, the authors reporting great results and almost no complications! However, sonographic evaluation of Prolene mesh over the first year showed that folding might occur early on, and mesh shrinkage and thickening increased steadily at each sonogram evaluation. These papers were back-to-back in a recent issue of a major urogynecology journal. Kudos to the editorial board of the International Urogynecology Journal.

Sorry for the confusion – this is the world we live in:

Prolene mesh kits for cystocele and rectocele repair: erosion correlates to young age and sexual activity

Kaufman Y, Singh SS, Alturki H, Lam A.

Age and sexual activity are risk factors for mesh exposure following transvaginal mesh repair.

Int Urogynecol J (2011)22:307-13.

A prospective, observational study evaluates safety and complication risk factors of the Prolene mesh prolapse surgery product, GYNECARE PROLIFT.  Polypropylene mesh kits are available for cystocele, rectocele and global (total vaginal lift) prolapse repair, each marketed as a more reliable method of prolapse repair with lower recurrence rates. This study evaluated 114 consecutive Gynecare Prolift patients for graft exposure (erosion of prolene mesh through the vaginal wall). Women were excluded if they were unwilling to undergo risks of polypropylene mesh vaginal grafting, or had severe vaginal scarring from prior operations. Exposure was further divided into early (< 6 weeks post-op) and late > 6 weeks post-op) categories, comparing each to demographic factors to determine what patient characteristics are associated with Prolift prolene mesh vaginal erosion.  Standardized pelvic floor/sexual function quality of life questionnaires were used in addition to pre-and post operation examination. Age, parity and demographic factors were collected.

114 women met criteria for inclusion, average age 61, BMI 26, parity 3. Follow-up ranged from 6.3-7.4 months, average 7.4.  19 underwent cystocele Prolift, 14 rectocele Prolift, and 81 Total (cystocele and rectocele) Prolift.  Only 58 (51%) of participants were sexually active before surgery, 18 (31%) of whom reported dyspareunia before surgery. 52 women were sexually active after surgery, 14 (27%) reporting de novo dyspareunia and 9 (17%) with persistent dyspareunia.  Four (3.5%) demonstrated early mesh exposure and 10 (8.8%) late mesh exposure with 6 (5.3%) repair procedure failures, all of which carries implications for sexual function.  Mesh exposure was higher in overweight women and women of higher parity. Early mesh exposure correlated to greater degree of pre-surgery prolapse and higher parity. Younger age and sexual activity were risk factors for late mesh exposure, most commonly on the anterior vaginal wall.  The authors found no correlation between mesh exposure and dyspareunia, postulating that painful sex may reduce mesh exposure by paradoxically deterring sexual activity, the erosion-risk behavior. The authors further caution that sexually active, especially younger, patients must be cautioned as to the potential for Prolift polypropylene mesh exposure, a complication with severe negative implications for sexual quality of life.

Prolene mesh kits for cystocele repair: mesh erosions and prolapse recurrence minimal, mesh shrinkage and thickening seen on sonogram.

Lo TS, Ashok K.

Combined anterior transo-obturator mesh and sacrospinous ligament fixation in women with severe prolapse-a case series of 30 months follow-up.

Int Urogynecol J (2011)22:299-306.

A prospective, observational study evaluates efficacy and safety risk factors of the anterior Prolene mesh prolapse surgery product, PERIGEE. In women with severe pelvic organ prolapse.  Polypropylene mesh kits are available for cystocele, rectocele and global (total vaginal lift) prolapse repair, each marketed as a more reliable method of prolapse repair with lower recurrence rates. This study evaluated 128 Perigee patients for recurrence of prolapse, mesh erosion, mesh folding and mesh shortening, shrinkage and thickening. No exclusion criteria are reported.   Standardized pelvic floor/sexual function quality of life questionnaires were used in addition to pre-and post operation examination, urodynamics evaluation of bladder function,  and post-operation introital sonography to evaluate in situ mesh characteristics. Age, parity and demographic factors were collected.

120 women met criteria for inclusion, average age 63, BMI 25, parity 4. Follow-up ranged from 12-47 months, average 30 months. Post-operation evaluation included  prolapse examinations for recurrence, and introital sonograph measurement of distance from edge of mesh to bladder neck, length and thickness of mesh, plus thickness of vaginal wall at 1, 3 and 12 months and urodynamics evaluation before and 12 months after Perigee implantation.

Recurrence of prolapse was minimal with only 2 recurrences to severe prolapse and an overall 93.3% success rate at 30 months median follow-up. Urodynamics data showed significant changes consistent with relief of prolapse-related bladder outlet obstruction. Graft evaluation showed only 5 (4.1%) cases of mesh erosion, all occurring between 3 weeks and 3 months, each small, and all responded to trimming and outpatient wound management with no further cases of Prolene mesh exposure noted over the course of the study. With regard to sonographic evaluation of  in-situ mesh, 5 (4.1%) demonstrated frank mesh folding beneath the vaginal skin, one with mesh erosion into the vaginal space. Mesh both thickened and shortened significantly and increasingly over the one year of post-surgery sonographic monitoring, average 20%, shortening consistent with other reports of ongoing changes in Prolene mesh morphology after vaginal implantation.

This careful and detailed report did not include specific evaluation of sexual function.  Prolene mesh erosion rates were low, consistent with prior reports for this Perigee Prolene mesh product. Prolene mesh vaginal grafting for pelvic organ prolapse continues to be a force in the clinical marketplace. The vast difference in reported safety and complication outcomes between permanent Prolene mesh products warrants careful scrutiny by clinicians and surgeons when counseling patients, particularly with regard to vaginal sexual function. This study, showing steady ongoing changes in implanted mesh morphology (folding, thickening, shortening), highlights the bio-active dynamics of in situ vaginal Prolene graft.

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

(c) L. Romanzi, 2011

Sexy = no pull-up Huggies in the ocean

Apr 2011 Journal of Sexual Medicine Literature Review

Handa VL, Whitcomb E, Weidner AC, et al. Sexual Function Before and After Nonsurgical Treatment of Stress Urinary Incontinence. Female Pelvic Med Reconstr Surg 2011;17:30-35.

A secondary analysis of the larger “Non-surgical management of stress urinary incontinence: ambulatory treatments for leakage associated with stress (ATLAS) incontinence” published in 2010, this study of 445 sexually active and inactive women described sexual function in women seeking stress incontinence therapy, compared the impact on sexual function of incontinence pessary alone, Kegel exercise and behavior modification alone, and combined pessary/Kegel/behavior modification, in addition to determining whether or not these non-surgical management therapies for stress urinary incontinence (SUI) improve sexual function.

Women who were sexually active answered 2 validated questionnaires before and 3 months after therapy, both the Pelvic Organ Prolapse – Urinary Incontinence Sexual Function Questionnaire (PISQ-12) that has been validated only in sexually active women in heterosexual relationships, and the generic short form Personal Experiences Questionnaire (SPEQ) that is validated among peri-menopausal women both sexually active and inactive.  The SPEQ total score and individual domain scores of libido, arousal and dyspareunia were included for all women while the sexually active women also underwent PISQ data analysis included total score and questions directly evaluating impact of incontinence on sex; “Are you incontinent of urine with sexual activity?” and “Does fear of incontinence (urine or stool) restrict your sexual activity?”

Women in all three treatment arms were about 49 years of age, mostly white, and evenly divided between pre- and post-menopausal women of normal BMI.  Analysis included women with only SUI and women with mixed stress and urge urinary incontinence.  PISQ scores were lower, indicating lesser sexual satisfaction, the mixed compared to pure stress urinary incontinence group.  Women successfully treated for pure SUI had greater improvement in overall PISQ score, greater reduction of leakage with sexual activity and greater reduction in restriction of sexual activity due to incontinence-related anxiety than did the women not successfully treated, such that improved sexual scores correlated most strongly to whether or not treatment of incontinence was successful.  The improvement in incontinence during sexual activity was greatest for the combined therapy group than for the pessary only group and similarly for the behavior/exercise only group compared to the pessary only group. While pelvic muscle score (Brinks model) was associated with successful SUI therapy, it did not, in turn, correlate to improvement in either the PISQ or SPEQ score. SPEQ scoring did not differ between stress only or mixed incontinence groups except for dyspareunia that was higher in the mixed incontinence group, nor were changes in SPEQ score different in successful and unsuccessful treatment.  The results suggest that consideration ought to be given to Kegel exercises and behavioral incontinence strategies for non-surgical treatment of women suffering incontinence during sex and who restrict sexual activity due to coital incontinence anxiety.

Surviving the Big C sometimes ain’t so sexy, except of course that you’re alive, which is the sexiest of all. But sometimes, often times, it lets all the air out of your tires when it comes to feeling sexy, being sexy, getting your heart and soul around that Marvin-style Sexual Healing.  A recent study in the American Journal of Obstetrics and Gynecology reports on a need for greater attention paid to the sexual and pelvic floor function of women fortunate enough to survive gynecologic cancers.  If you or someone you love sounds like the women in this study, chances are she’ll find help and hope in the consultation services of a specialist in female sexual dysfunction.

Life ain't for sissies.

Apr 2011 Journal of Sexual Medicine Literature Review

Rutledge TL, Heckman SR, Qualls C, Muller CY, Rogers RG.

Pelvic floor disorders and sexual function in gynecologic cancer survivors: a cohort study.  Am J Obstet Gynecol 2010;203;514E1-7.

This questionnaire survey study used the Pelvic Organ Prolapse/Urinary Incotinenence sexual Questnnaire (PISQ-12) along with validated urinary and fecal incontinence and pelvic organ prolapse questionnaires to determine the prevalence of sexual and pelvic floor disorders in a group of women over age 30 with histories of uterine, cervical, ovarian or vulvar cancer, all disease and treatment free for at least one year.

A control cohort of 108 women without cancer histories also completed the questionnaires after chart review matched them to the study group of cancer survivors. Because the study group was far more likely to have undergone hysterectomy (87% vs 26%) and removal of ovaries (82% vs 14%) than the control group, both of which may independently affect sexual function, data analysis was multivariate.

45% of study participants had history endometrial cancer, 29% ovarian cancer, and 22% cervical cancer. 87% had undergone surgical therapy, 35% radiation, and 35% chemotherapies.  Both groups had rates of urinary incontinence and pelvic organ prolapse that were not statistically significantly different. Women with cancer histories did report higher rates of fecal incontinence and also reported greater fecal incontinence bother than cancer-free controls, despite only 40% of cancer survivors reporting being asked by their oncologists about urinary or incontinence symptoms.

Cancer survivors reported lower libido, higher rates of anorgasmia, lower orgasm intensity, less sexual excitement, lower rates of sexual satisfaction and higher rates of negative emotional response to sexual activity with 5 point lower average PISQ scores and lower rates of sexual activity (45% vs 70%) than the cancer-free cohort. The authors speculate that severe changes in body image and hormone function due as a result of radical pelvic surgery, early withdrawal of natural hormones, hormone suppressive therapies, and radiation effects may all play a role in the extra margin of sexual dysfunction reported by the cancer survivors. The authors state that greater attention to pelvic floor and female sexual dysfunction (FSD) conditions is warranted among clinical oncologists working with female cancer survivors to optimize holistic quality of life issues for these women.