Editorial Comment: Effects of mesh surgery on sexual function in pelvic prolapse and urinary incontinence

Abstract

In this issue of the Int Braz J Urol, Sukgen and colleagues (1) presented the evolution of the Female Sexual function Index (FSFI) in a prospective series of 72 women who underwent correction of pelvic organ prolapse (POP), eventually associated to stress urinary incontinence (SUI), using a four-arm anterior mesh implant (Betamix POP4®, Betatech Medical, Turkey) with a transobturator fixation. The study only included patients with POP stage 3 or 4 according to the Pelvic Organ Prolapse Quantification system (POP-Q). Procedures varied based on the vaginal compartments involved and SUI concomitance. This study concluded that POP surgery using mesh implants was associated with a significant improvement in patient sexual function over one year follow-up. The human sexual response, and women's in particular, is a multidimensional phenomenon (2, 3). In patients with POP, association with urinary incontinence, the impairment of self-image and the sensation of vaginal enlargement and laxity makes the assessment of the impact of any treatment in sexual function quite complex. Although FSFI has been culturally adapted to several languages and represent an alternative for a comprehensive evaluation of sexual function (4), it does not specifically assess vaginal symptoms (5), which is very relevant after POP surgery. In Sukgen and colleagues study, a prosthesis with dual function was used, since, in patients with associated urinary incontinence, it was adjusted in anterior vaginal wall in order to reach the proximal aspect of the urethra. However, nowadays we are experiencing a trend for the use synthetic transvaginal implants only for repositioning the vaginal apex rather than more extensive prostheses, such as the one used by Sukgen and colleagues, and combine it with a midurehral sling implanted through another suburethral incision in case of concomitant SUI. The possible impact of this trend in sexual function is still to be stablished (1). The relevance of urinary incontinence in female sexual function has already been extensively investigated (6, 7), thus, greater influence is given to urge urinary incontinence rather than stress urinary incontinence. As POP can be associated with both incontinence types, treatment can thereby improve sexual function. As the anterior arms of the prosthesis used by the authors act as a midurethral sling, it is relevant to comment about the influence of synthetic sling implant on sexual function. This issue was recently assessed in a meta-analysis (8), which concluded that although overall sexual function remained the same or improved for most women, improvements in orgasmic function were only observed in one third of cases after a midurethral sling procedure. The possible deterioration of orgasm in patients who underwent midurethral slings could be due to a denervation of the periurethral area resulting from the local dissection. In this sense, in 2017, Arslan and colleagues proposed a modifica