Unwanted Sexual Arousal after Pelvic Surgery

Abstract

In pelvic surgery there is a risk of damage to the pelvic autonomic nerves with consequent urinary dysfunction, impotence and orgasmic failure. An increase in sexual arousal is a side-effect not previously reported. CASE HISTORYA woman in her mid-30s underwent a Ripstein repair 1 for a 10 cm full-thickness rectal prolapse. The rectum was elevated and fixed with a sling of mesh placed around the anterior surface and secured with two stitches to each side of the mid-portion of the sacrum. There were no technical difficulties and she recovered rapidly. Four weeks later she reported continued, distressing, sexual arousal and a frequent urgent need to pass urine. She felt constantly agitated and anxious. During the next few weeks she found that the state of arousal could not be satisfied by intercourse or by masturbation as many as eight times a day. Lifting or bending down tended to cause spontaneous orgasm. She was unable to return to work and the only relief was obtained by lying still in bed.Hormone profiles, pelvic ultrasound scan and barium enema were all normal. Neither benzodiazepines nor cyproterone acetate relieved her symptoms. Pelvic autonomic function was assessed by urodynamic studies and by anorectal physiology, the results of which were normal except for a lax external anal sphincter. She underwent laparoscopy, and injection of local anaesthetic agent around the pelvic nerves gave complete but temporary relief. Eventually she underwent revisional surgery. The mesh was removed and the rectum was fixed to the sacral promontory with sutures well away from the pelvic nerves. Three months later she was well, with only the occasional unwanted sensation. COMMENTPelvic surgery can cause failure of sexual function in both sexes if the nerve supply to the sexual organs is interrupted. The anatomy of the dissection danger-zones is well understood. 2 The sensory component of sexual arousal is transmitted from the pelvic organs and perineum by the pudendal nerve (S2,3,4) which crosses the mid sacral area in the region where the mesh was attached. Engorgement of the erectile tissues is mediated by the parasympathetic pelvic splanchnic nerves (S2,3) which pass across the same area, through the inferior hypogastric plexuses. Orgasm is triggered by spinal reflexes discharging via the lower ganglia of the sympathetic chain, nerves from which cross the same presacral area. Stimulation of any part of this system could have caused the patient's symptoms.Ripstein's repair has a low rate of complications, 3,4 the commonest being recurrence of the prolapse and constipation. Increased sexual arousal must be a very infrequent sequel. Reports on sexual dysfunction are dominated by male disorders, and the few that deal with women focus on reduced vaginal lubrication, reduced sensitivity and orgasm failure. 5