KHALED I. ABDULLAH, M.D.*; HAITHAM A. SABAA, M.D.* and MONA A.I. GABER, M.Sc.**

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1 Med. J. Cairo Univ., Vol. 82, No. 2, September: , Evaluation of the Effect of Tension Free Vaginal Tape (TVT) and Trans-Obturator Suburetheral Tape (TOT) for Treatment of Stress Urinary Incontinence on Female Sexual Function KHALED I. ABDULLAH, M.D.*; HAITHAM A. SABAA, M.D.* and MONA A.I. GABER, M.Sc.** The Department of Obstetrics & Gynecology, Faculty of Medicine, Ain Shams University* and Ministry of Health**, Cairo, Egypt Abstract Objectives: To evaluate the impact of correction of stress urinary incontinence (SUI) using either Transobturator tape (TOT) or Tension-free vaginal tape (TVT) procedure on females sexual function. Patients and Methods: The study included 80 women with SUI; 40 underwent TVT and 40 underwent TOT and completed preoperative Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) for evaluation of sexual function in compared to before getting incontinent. All women were subjected for re-evaluation of sexual function at 6-month postoperative in comparison to preoperative scoring. The study also included 40 women free of SUI and completed the PISQ-12 questionnaire as control group. Results: Preoperative PISQ-12 scorings for both groups were significantly lower compared to scoring of control women, with non-significantly higher preoperative scores of women had TOT compared to those had TVT. Postoperative PISQ-12 scorings for both groups were significantly lower compared to scoring of control women, but were significantly higher compared to their respective preoperative scoring. Mean postoperative scoring for patients who had TVT was non-significantly higher compared to those who had TOT. Conclusion: SUI had a deleterious effect on female sexual function and quality of life; however, surgical correction could ameliorate such effect, irrespective of the approach applied which could be chosen according to surgeon s experience and preference. Key Words: Stress urinary incontinence Female sexual function TOT TVT. Introduction URINARY incontinence as defined by the International Continence Society is the complaint of any involuntary leakage of urine. Incontinence can be a sign, a symptom or a condition diagnosed by Correspondence to: Dr. Haitham Abdel Mohsin Sabaa profhaithamsabaa@gmail.com an examiner [1]. Urinary incontinence is a common health problem among women; it has a considerable impact on their quality of life [2]. Female sexual dysfunction is one of the intimate sequlae of urinary incontinence and such relationship could be attributed to dyspareunia, consequence of recurrent dermatitis, decreased libido, and depression reducing sexual interest for embarrassment and fear of occurrence of leakage during intercourse; coital incontinence account for a frequency of 55% of complaints of incontinent women [3,4]. Many different surgical procedures have been described for treatment of urodynamic stress incontinence and there was no general agreement as to the most effective. However, since the description of the suburethral technique for genuine stress incontinence all the others have been abandoned. The surgical indications have not changed and are related to the poor quality of life of the patient induced by stress incontinence. A careful clinical examination and a preoperative urodynamic investigation should prevent from the failures due to a wrong indication [5,6]. Tension-free vaginal tape (TVT) procedure for treatment of female urinary stress incontinence (USI) has become a widely used new minimally invasive operation probably due to the fact that it has high rate of cure in primary cases of USI. The newest variation of the midurethral sling is the trans-obturator approach where the sling is passed through the obturator foramen laterally instead of retropubic passage; this creates a more lateral point of fixation. The purported advantage is reduction in bladder, bowel or major vascular injury. Women affected by SUI had an improved sexual function 195

2 196 Evaluation of the Effect of Tension Free Vaginal Tape (TVT) after surgery, particularly in relation to the urinary leakage during intercourse, reacquiring a major self confidence [7,8]. The current comparative study aimed to evaluate the impact of correction of stress urinary incontinence (SUI) using mid-urethral tape (MUT) procedure, either Transobturator tape (TOT) or Tension-free vaginal tape (TVT), on females sexual function. Patients and Methods The current study was conducted at Obstetrics and Gynecology Department, Faculty of Medicine, Ain Shams University since Jan 2011 till June After approval of the study protocol by the Local Ethical Committee and obtaining written fully informed patients consent, all women with SUI and underwent MUT application procedure were enrolled in the study after fulfillment of the following inclusion criteria: Age range of 25 to 45 years, all patients must be sexually active and had SUI as diagnosed urodynamically and this is their primary surgical interference with no past history of previous surgery for SUI. Enrolled patients must be cured or improved after surgery as regards their SUI and completed preoperative Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Patients had sexual dysfunction prior to developing SUI, had other anti- incontinence surgery, did not improve after MUT, had concomitant hysterectomy or did not complete preoperative PISQ-12 questionnaire were excluded from the study. The study also included 40 agematched control women chosen from those admitted to General Surgery Department for other Surgical procedure and were free of urological problems. The study design depends on extraction of preoperative data out of files of the enrolled females and interviewing them during their follow-up visit at 6 months after surgery. Thus the study design was retro-prospective design. The data extracted out of patients files included demographic data, preoperative clinical examination data. Control women and patients at their 6-month postoperative visit were asked to complete the PISQ-12 questionnaire. The PISQ-12 is composed of 12 questions divided into three sections: Emotional and Behavioral (Questions 1-4); Physical (Questions 5-9) and Partner relationships (Questions 10-12). Answers are graded according to the Likert scale which ranges from Always, Usually, Sometimes, Seldom. Never. Overall PISQ-12 scores range from 0-48, with each response scoring a value of 0-4, as follows: Always=0, Usually=1, Sometimes=2, Seldom=3 and Never=4. Questions 1, 2, 3 and 4 inverse scoring was used and higher scores indicate better sexual function [9]. Questions of PISQ-12 questionnaire and score for each answer [9]. Score question 1- How frequently do you feel sexual desire? 2- Do you have an orgasm when having sexual intercourse with your partner? 3- Do you feel excited when having sexual activity with your partner? 4- Are you satisfied with the varieties of sexual activities in your current sex life? 5- Do you feel pain during sexual intercourse? 6- Do you still have urine leak with sexual activity? 7- Do you still have fear of urine leak with sexual activity?

3 Khaled I. Abdullah, et al. 197 Cont. Score question 8- Do you still avoid sexual intercourse because of fear of urine leak during sexual activity? 9- Do you have negative emotions as fear, shame, guilt during sexual activity? 10- Does your partner have problems with erection that affects sexual activity? 11- Does your partner have problems with ejaculation that affects sexual activity? 12- Compared to the prior to have SUI, how intense are the orgasm you had during the past 6 months? Much more intense More intense Same intensity Less intense Much less intense Results The study included 80 women design; 40 had TVT and 40 had TOT. There was non-significant (p>0.05) difference between both groups as regards demographic data as shown in (Table 1). All enrolled women were multipara and 57 had vaginal delivery, while 23 had cesarean section. There was non-significant (p>0.05) difference between studied groups as regards obstetric history as shown in (Table 2). Preoperative PISQ-12 scorings for both groups were significantly (p<0.05) lower compared to scoring of control women, with non-significantly (p>0.05) higher preoperative scores of women had TOT compared to preoperative scores of women had TVT. Postoperative PISQ-12 scorings for both groups were significantly ( p<0.05) lower compared to scoring of control women, but were significantly (p<0.05) higher compared to their respective preoperative scoring. Mean postoperative scoring for patients had TVT was nonsignificantly (p>0.05) higher compared to those had TOT, (Table 3, Fig. 1). Table (1): Patients demographic data. Control TVT TOT p-value Age (years) Strata <30 6 (15%) 11 (27.5%) (47.5%) 14 (35%) > (12.5%) 4 (10%) >40 10 (25%) 11 (27.5%) =0.145 Total 35.6± ±6.3 =0.542 Weight (kg) 86.4± ± 10.9 =0.696 Height (cm) 170.3± ±3.6 =0.406 BMI (kg/m 2 ) Strata <25 7 (17.6%) 6 (15%) (37.5%) 17 (42.5%) =0.167 >30 18 (45%) 17 (42.5%) Total 29.8± ±3.3 =0.653 Data are shown as Mean±SD & numbers, Percentages are in parenthesis, p-value >0.05=Non-significant difference.

4 198 Evaluation of the Effect of Tension Free Vaginal Tape (TVT) Table (2): Patients obstetric data. Control TVT TOT p-value Number of pregnancies Strata (45%) 20 (50%) (50%) 20 (50%) =0.095 >6 2 (5%) 0 Total 4.6± ± 1 Number of living offspring Strata <3 7 (17.5%) 6 (15%) (77.5%) 33 (82.5%) >5 2 (5%) 1 (2.5%) =0.674 Total 3.53± ± 1 Number of abortions Strata No 9 (22.5%) 12 (30%) 1 19 (47.5%) 18 (45%) = (30%) 10 (25%) Total 1.08± ±0.7 Mode of delivery Vaginal 30 (75%) 27 (67.5%) = CS 10 (25%) 13 (32.5%) Data are shown as Mean±SD & numbers, Percentages are in parenthesis, p-value >0.05= Non-significant difference. Table (3): PISQ-12 scoring of studied patients determined before and 6-months after surgery in comparison to scoring of control women. Control TVT TOT Preoperative Postoperative Preoperative Postoperative Mean±SD P 1 P2 P 3 P ± ±2.56 = ±3.81 = =0.019 P1: Significance versus control score. P2: Significance of difference between preoperative scores of study groups. P3: Significance of difference between preoperative & postoperative scores of each study group. P4: Significance of difference between postoperative scores of study groups ±2.63 = = ±3.62 = =0.031 = Discussion PISQ-12 score Control TVT/Pre TVT/PO TOT/Pre TOT/PO Fig. (1): Mean PISQ-12 score determined before and 6-month after surgery in both study groups compared control level. The current study showed an impact of SUI on females sexual function manifested as significantly lower preoperative PISQ- 12 score of patients compared to controls. However, such impact was ameliorated by surgical correction of SUI using MUT, irrespective of the approach used, as manifested by the significantly higher postoperative PISQ- 12 score determined 6-months after surgery compared to preoperative score, despite being still significantly lower than control scores. These data implies that deteriorated sexual function secondary to the presence of SUI is an important entity that must be evaluated in SUI

5 Khaled I. Abdullah, et al. 199 patients side-by-side with the urodynamic evaluation and must be respected especially in this young age group who is still sexually active and in the childbearing period. Moreover, patients must be notified about the benefits gained of surgical correction concerned sexual function, especial in the Eastern communities which may be shaming to deal with this problem. In line with the impact of treatment of SUI on female sexual function, irrespective of method of treatment; Filocamo et al., [10] showed that after a mid-urethral sling procedure, female sexual function improves and a very relevant percentage of non-sexually active women reported renewed sexual activity. Leone Roberti Maggiore et al., [11] found periurethral injections of polyacrylamide hydrogel to treat SUI are clinically effective and safe, and cause significant improvements in sexual function and sexual satisfaction of patients. Zyczynski et al., [12] reported that midurethral sling surgery for SUI significantly improves sexual function manifested as significant improvement of dyspareunia, incontinence during sex, and fear of incontinence during sex with concomitant significant increase of PISQ-12 score. Naumann et al., [13] documented that singleincision sling (SIS) treatment for SUI led to improvements in continence, quality of life scores related to global bladder feeling and significantly higher scores on the Female Sexual Function Index (FSFI) at 6 months of postoperative follow-up. Naumann et al., [14] reported that SIS procedure appears to be as effective in improving incontinencerelated quality of life and sexual function as the TVT through 6 months of post-operative follow-up with no differences in complications and sexual function were demonstrated between the groups. Concerning the applied approach for MUT application, both TOT and TVT significantly improved PISQ-12 scores determined at 6 months after surgery compared to preoperative scores with non-significantly higher postoperative PISQ-12 scores determined in patients had TVT compared to those had TOT. This difference could be attributed to the reported decreased scores of climax and emotional response, in line with increased pain sensation scores with TOT but not with TVT; a finding indicating the possibility of detrimental effect of MUT on certain parameters of the questionnaire, despite of the improved collective score. These data go in hand with Elzevier et al., [15] found TOT gave rise to more sexual dysfunction than TVT-obturate (TVT-O), but because of the successful outcome on incontinence, both proce- dures had, overall, a positive effect on sexual function. Wang et al., [16] found both TVT and TVT-O appear to lower the peri- and post-operative complication rates and have an equal efficacy in the surgical treatment of SUI during a 3-year follow-up, but TVT-O has a higher rate of groin and thigh pain. Liang et al., [17] reported that TOT procedures for correcting USI had favorable clinical outcomes and did not alter overall sexual function; however, climax during sexual intercourse and emotional response were worsened postoperatively. De Souza et al., [18] compared the effect of TVT to the Monarc sling on sexual function in women with SUI and found a significant increase in PISQ-12 score especially, coital incontinence and fear of leakage following both procedures, but the score was greater in the TVT group at 6 months. Dursun et al., [19] investigated the effect of the TOT procedure on sexual function in women and reported that SUI causes some problems affecting quality of life, including sexual dysfunction and after the TOT procedure, significant improvement was determined in sexual function affected by SUI. Narin et al., (2013) reported that in patients with SUI and underwent TOT, two parameters of the libido scoring system, orgasm and frequency of women who start renewed sexual activity, increased at a statistically significant rate and concluded that sexual satisfaction and desire have partially improved after the TOT procedure. Schettino et al., (2013) assessed the effect of TVT, TVT-obturate (TVT-O) and SIS on sexual function and reported that at month 12 follow-up, patients underwent TVT, TVT-O or SIS showed comparable significant improvement of sexual function as evaluated by FSFI compared to preoperative scoring. These findings indicated a minimal effect of the approach on the improvement of sexual function and assured the effect of surgical correction irrespective of approach. So the choice of approach to be used can be determined by the surgeon s experience with certain approach. Thus, it could be concluded that SUI had a deleterious effect on female sexual function and quality of life; however, surgical correction could ameliorate such effect, irrespective of the approach applied which could be chosen according to surgeon s experience and preference. References 1- ABRAMS P.: The standardization of terminology of lower urinary tract function: Report from the standardization sub-committee of the international continence society; Urology, 61: 37, 2003.

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