Importance Sexual dysfunction can occur after midurethral sling (MUS) and transvaginal prolapse surgery. It remains unclear whether these procedures impact the clitoris, despite its role in sexual function and proximity to the MUS and vagina.

Objectives To compare postoperative sexual function and clitoral features by MUS and vaginal surgery approach after transvaginal prolapse repair with/without concomitant MUS.

Design Cross-sectional ancillary study of magnetic resonance imaging (MRI) and sexual function data from the Defining Mechanisms of Anterior Vaginal Wall Descent study.

Setting Eight clinical sites in the US Pelvic Floor Disorders Network.

Participants: 88 women with uterovaginal prolapse who underwent vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension with/without MUS between 2013-2015. Data were analyzed between September 2021-June 2023.

Exposures Between June 2014-May 2018, participants underwent pelvic MRI 30-42 months after surgery, or earlier if reoperation was desired. Sexual activity and function at baseline and 24-48-month follow-up were evaluated using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Clitoral features were obtained from postoperative MRI-based 3-dimensional models.

Main Outcomes and Measures PISQ-IR scores and clitoral features (size, position).

Results Eighty-two women (median [range] age, 65 [47-79] years) were analyzed: 45 MUS (22 hysteropexy, 23 hysterectomy) and 37 No-MUS (19 hysteropexy, 18 hysterectomy).

Postoperatively, 25 MUS, 12 No-MUS, 20 hysteropexy, and 17 hysterectomy patients were sexually active (SA). Overall, within the MUS and vaginal surgery groups, sexual function remained unchanged or improved (most PISQ-IR change from baseline scores were ≥0) among SA and NSA women. Among SA women after surgery, the MUS group (vs No-MUS) had a poorer PISQ-IR arousal/orgasm (SA-AO) score (median, 3.5 vs 4.3; P=.02). The hysteropexy group (vs hysterectomy) had less improvement in PISQ-IR SA-AO score (median, 0.0 vs 0.3; P=.01). Women with MUS (vs without) had a smaller clitoral glans thickness (median, 9.0 mm vs 10.0 mm; P=.008) and clitoral body volume (median, 2783.5 mm3 vs 3587.4 mm3; P=.01).

Conclusions and Relevance SA women with MUS (vs without) or hysteropexy (vs hysterectomy) experienced poorer postoperative sexual function. MUS was linked to a smaller clitoris. Future studies should explore surgery-induced changes in clitoral anatomy and sexual function.

Question How do sexual function and clitoral anatomy differ by midurethral sling placement and vaginal surgery approach?

Findings This cross-sectional study compared patient-reported sexual function outcomes and 30-42-month postoperative magnetic resonance imaging-based 3-dimensional clitoral models of 82 women after vaginal prolapse surgery with or without concomitant midurethral sling. Midurethral sling (vs no sling) and vaginal mesh hysteropexy (vs vaginal hysterectomy) were associated with poorer postoperative sexual function outcomes. Additionally, midurethral sling was associated with a smaller clitoral glans and body.

Meaning Midurethral sling and vaginal mesh hysteropexy were associated with, and may adversely alter, postoperative sexual function and/or clitoral anatomy.

All authors reported funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Institutes of Health Office of Research on Womens Health, and that Boston Scientific Corporation provided partial support for the SUPeR trial through a research grant to the Pelvic Floor Disorders Network (PFDN) Data Coordinating Center, RTI International. - Dr. Moalli reported receiving funding from NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (R01HD083383, R01HD097187, R01HD108666) and the Richard King Mellon Foundation; has a patent for Elastomeric Auxetic Membrane for Urogynecological and Abdominal Implantations. - Dr. Rogers reported receiving royalties from UpToDate and travel and stipend from AUGS for Editor in Chief services for Urogynecology - Dr. Rardin reported receiving research support from the NICHD, Reia LLC, and Foundation for Female Health Awareness. - Dr. Hahn reported receiving research support from General Electric and serving as a consultant to HealthLytix. - Dr. Weidner reported receiving grants from the NIH and Ethicon; served as a consultant for Urocure and Inspire Medical outside the submitted work. - No other disclosures were reported.

NCT01802281

https://pmc.ncbi.nlm.nih.gov/articles/PMC7917148/

This study was conducted by the Eunice Kennedy Shriver NICHD-sponsored PFDN (grant numbers U10 HD054214, U10 HD041267, U10 HD041261, U10 HD069013, U10 HD069025, U10 HD069010, U10 HD069006, U10 HD054215, U01 HD069031) and the National Institutes of Health (NIH) Office of Research on Womens Health (ORWH). Partial support for the SUPeR trial was provided by Boston Scientific Corporation through a research grant to the PFDN Data Coordinating Center, RTI International. Research training support was provided by the National Academies of Sciences, Engineering, and Medicine Ford Foundation Predoctoral Fellowship, the Massachusetts Institute of Technology (MIT) School of Engineering Postdoctoral Fellowship Program for Engineering Excellence, and the Icahn School of Medicine at Mount Sinai (ISMMS) Blavatnik Family Womens Health Research Institute. The content is solely the responsibility of the authors and does not necessarily reflect the official views of these funding sources.

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Ethics committee/IRB of University of California San Diego gave ethical approval for this work. Ethics committee/IRB of Duke University gave ethical approval for this work. Ethics committee/IRB of University of Alabama at Birmingham gave ethical approval for this work. Ethics committee/IRB of Brown University gave ethical approval for this work. Ethics committee/IRB of University of New Mexico gave ethical approval for this work. Ethics committee/IRB of University of Pennsylvania gave ethical approval for this work. Ethics committee/IRB of University of Pittsburgh gave ethical approval for this work. Ethics committee/IRB of Cleveland Clinic gave ethical approval for this work.

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↵* co-first authors

SOCIAL MEDIA POST: Among sexually active women after vaginal surgery with or without concomitant midurethral sling, midurethral sling (vs no sling) and vaginal mesh hysteropexy (vs vaginal hysterectomy) were associated with poorer sexual function and/or a smaller clitoris.

Twitter/X Handle: @ShanielBowen

Data - Data available: Yes - Data types: Deidentified participant data - How to access data: Data from the DEMAND study will be available from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Data and Specimen Hub (DASH) https://dash.nichd.nih.gov/ after completion of planned DEMAND analyses. - When available: 12-31-2026 Supporting Documents - Document types: None Additional Information - Who can access the data: researchers whose proposed use of the data has been approved by DASH - Types of analyses: secondary analysis - Mechanisms of data availability: Through DASH - Any additional restrictions: The following disclaimer should be added to all abstracts and manuscripts using the PFDN public use datasets: "Data in this report was collected by the Pelvic Floor Disorders Network. This study was supported by grant funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. The content of this report is solely the responsibility of the authors and does not necessarily represent the views of the Pelvic Floor Disorders Network investigators or the NIH."

https://pmc.ncbi.nlm.nih.gov/articles/instance/11822609/bin/jamasurg-e246922-s001.pdf