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Sexuality and surgery of the uterus

sexuality surgery

Functional and psychosexual consequences of a hysteroscopy

 

J-P Estrade, G. Andre, A-L Sutter and D Dallay

 

Complications resulting from hysteroscopy can be related to the organic modifications induced by the surgery. They usually are functional (pain and sexual problems), generally predating the operation and under evaluated in the preoperative assessment.  They can, therefore, be difficult to treat.  Sexuality, after a hysteroscopy, should not be altered.  If sexual problems do occur, the patient’s psychological state prior to the operation and their expectations after surgery must be taken into consideration.   The existence of hemorrhagic incidents, an invalidating dysmenorrhea not cured with medical treatments and a conservative surgery (myomectomy, endometrectomy, thermotherapy… ) are all factors indicating a good prognostic on the quality of sexual acts after the operation.

 

Introduction

Functional and particularly sexual consequences of a hysterectomy are the subject of many gynecological, psychological, and psychiatric medical publications.  Additionally, internet forums on the web, where women’s questions are openly expressed and discussed, are useful information and a psychological preparation for those about to go through the operation.  The complications of the hysterectomy can be the direct consequence of the postoperative anatomical or organic modifications, in which case the surgeon has a high level of competence.  The situation is different if these symptoms, particularly pain and sexual problems, have been under evaluated in the preoperative process, and still persist after the operation.  These are the postoperative consequences that will be discussed in this chapter, aiming at exposing the risk factors and psychological fragility that justify the preoperative care.

 

Anatomical correlations

It is necessary to emphasize that the hysterectomy, by interrupting the local nerve substitutes, modifies the anatomical relationship between the pelvic organs and their functions. It seems to be involved in the development of many symptoms including some alterations in the intestinal urinary and sexual functions (1).   The idea that sexual well-being could be modified, depending on the type of hysterectomy, is based on the assumption that the techniques more or less disturb the innervations and supporting tissues of the pelvic floor.  During the hysterectomy, the pelvic innervations, whether somatic or vegetative, may be injured in different ways.

 

  • Vegetative alteration: the surgical lesion of the vegetative innervations takes place at various levels:

                        - The uterovaginal plexus composed of lymphatic nodes and terminal nerves. The uterine nerves, running along the uterine artery and anamostosized with the lateral homo ovarian plexus, innervate the womb and the medial part of the fallopian tube, the cervico-isthmic nerves that penetrate the posterior surface of the isthmus.  The vaginal nerves run along the vaginal arteries, they innervate the vagina, the urethra, the glands and vestibular bulbs, and end up as cavernous nerves of the clitoris, the vesical plexus, for the bladder and urethra.

                        -The average rectal plexus accompanying the average rectal artery: these three main plexus stem from the same inferior hypo gastric plexus.  It consists of a reticulated blade running through the lateral part of the uterosacral ligament, S2-S3 stretched, along the side edge of the rectum, cervix and posterior vaginal fornix: it spreads in the lateral vaginal walls, cardinals ligaments (parameter and paracervix) and the base of the broad ligaments.

                        -From a theoretical point of view, surgical removal of the uterosacral ligaments of the cervix will result in the loss of a large part of the inferior hypo gastric plexus and cause dysfunctions in the organs that it innervates (2).  Butler (3) has studied the content of the nerve fibers and the uterosacral and cardinal ligaments, in women undergoing either radical or simple hysterectomy: studies confirm that the radical hysterectomy causes more injuries to the nerves than the simple hysterectomy, but suggest that the damages limited to the uterosacral tissue located near the cervix would probably neither be lateral or deep enough to cause damages done by a radical hysterectomy.

 

  • Somatic alteration: the somatic innervations come from the lumbar, sacred and pudendal plexus.   The lumbar plexus consists of :

                        -The iliohypogastric and ilioinguinal nerves.  They run a curvilinear path inside the abdominal wall.  The nerve endings can be slightly damaged during incisions like the suture or incision of the aponeurosis of the transversal muscle, resulting in hypoesthesia or neuralgia (4-6)

                        - The genito-femoral nerve is placed down below and inside of the psoas, perforates the anterior inner layer of the muscle and travels under the iliac fascia.  Lesions affecting this nerve are rare, usually secondary to a psoas hematoma and lead to hypoesthesia or neuralgia.

                        - The lateral femoral cutaneous nerve runs down until the lateral edge of the psoas at the level of the crista iliaca, then runs on the iliac muscle.  It branches out, innervating the fascia tata and the antero-lateral area of ​​the thigh as well as the peritoneal branches of the iliac fossa. Its effect is manifested by paresthesias at the level of the seams of trousers, sometimes aggravated by walking. It can be injured during a hysterectomy if the spacers are too lateral (7, 8). 

                        - The femoral nerve is located laterally between the two psoas and runs forward under the iliac fascia, then going through the muscular gap, under the inguinal ligament, outside the iliopectineal strip and ends in the femoral triangle under the sieve fascia. It innervates the flexors of the thigh, the anterior side of the thigh and the upper-medial leg. The femoral nerve can be injured during a vaginal (9, 10) or abdominal hysterectomy (11-13) causing hypoesthesia in the innervated areas, and leading to a limitation in flexing the thigh or extending the leg onto the thigh. 

                        - The obturator nerve runs down through the iliac-lumbar fossa and forward on the internal obturator muscle, opposite the ovarian recess before getting to the foramen and splitting into two terminal branches. It is responsible for the sensitivity of the internal superior side and adduction of the thigh. Touching it during an intervention causes hypoesthesia and / or neuralgia associated (or not) with physical mobility disorders (14, 15).  The sacral plexus gives the gluteal nerves, the nerves of the piriformis muscles, the quadratus femoris, and the internal obturator and the posterior cutaneous nerve of the thigh.  Much of the ventral nerves at SI-S2-S3 merge with the lumbo-sacral trunk to form the sciatic nerve.

                        - The posterior cutaneous nerve of the thigh is a collateral of the sacral plexus, giving three collateral branches participating to the innervation of the labia, sacral and inferior-lateral quadrant of the buttocks (16, 17).

                        - The sciatic nerve exits the pelvis through the infrapiriform foramen outside the pudendal nerve. Touching this nerve can happen during an hysterectomy (16, 17), if the patient lies in the wrong position, and it will generate pain throughout the nerve, a hypoesthesia and physical mobility disorders affecting the areas innervated by the two terminal branches.  The pudendal plexus is formed by spinal nerves at S2-S3-S4. It includes the nerves "lifting" the anus, the coccygeal muscle, the superior rectal, and the visceral nerves providing the sympathetic nerve to the hypogastric ganglion, ending in the pudendal nerve.  The pudendal nerve is the terminal branch of the pudendal plexus.  It is a mixed nerve studied by Shafik (18-20) and consists of three roots detached from the second, third and fourth sacral roots. In regards to the physical mobility, this nerve is responsible for the tonicity of the puborectal strap and the urethral and anal sphincters, as well as for the activity of the transversal muscles, ischiocavernosus, bulbocavernosus and constrictors of the vulva. On the sensory level, it conveys sensitivity to the posterior two thirds of the labia majora, labia minora, clitoris, bulb and vaginal orifice, as well as to the perineal and perianal sensitivity. At all levels, this nerve can be damaged by stretching, compression or inflammation, provoking neuralgia aggravated by touching the nerve trajectory, and often by sitting. These sensory disorders may be associated with dysfunctions of the sphincter.  The role of  hysterectomy as the generator of pudendal neuralgia is difficult to establish.  Some authors (21) noted electro physiological alterations that regress after a radical hysterectomy; however the assumption that it would decompensate preexisting problems cannot be ruled out (22).

 

Sexuality after hysterectomy

 

The majority of studies concentrates on the effect of hysterectomy on the patients’ sexual life, and relevant literary reviews lead us to believe that its effect is nil, or even positive. However we can observe that there are real differences depending on the mode of operation, mainly surgical, the patient’s preoperative psychological state and expectations.

 

  • Routes used in surgeries: It is difficult to evaluate the importance of the different routes used to perform hysterectomies and their impact on the postoperative sexual activity especially after a major surgical act like the ablation of the uterus.  Some studies show no difference between hysterectomies whether done via upper channels (total and subtotal), vaginal (23), and laparoscopy (24). However Ayoubi and al. (25) noted a delayed resumption of intercourse when hysterectomy was performed via upper channels. The decreased dyspareunia is significant in vaginal and laparoscopic approaches. There seems to be a better relationship between the couple and higher self-esteem after a surgical laparoscopy. Sexual deterioration seems more important for hysterectomies performed via the upper channels. Cosson and al. (26) evaluated the long-term aftereffects of a vaginal inter adnexal hysterectomy, by retrospectively comparing a group of women operated by laparoscopic cholecystectomy. On the sexual point of view, no significant difference whether qualitative or quantitative was noted between the two groups, except for the higher partner’s satisfaction in the hysterectomy group. Generally speaking, according to the scholars, age determines the postoperative functional signs. Apart from exceptional cases, indications of which route to use are not based on the patient’s sexual activity, but rather on an organic indication introducing a confounding but significant factor between the type of routes and the postoperative sexual function.

 

  • Types of hysterectomies: the real question is whether a subtotal hysterectomy should be performed.  Only Kilku and al. (27) found a significant difference in the postoperative orgasm, hence favoring a cervical conservation. The author suggests several reasons, absence of a vaginal scar, therefore respecting the anatomy, and moreover the vegetative cervical innervation by the Franckenhausen plexus would then be respected.  However, the author admits that the sub conscious psychological reaction may play a role. Even when conserving the cervix, Helstrom (28) states that the prevailing factor remains the quality of the relationship with the partner, demonstrating that the results concerning the sexual activity fall from 61% to 17%, depending on the quality of the relationship.

 

Completion of bilateral ovariectomy in the same operative time, is responsible for a drop in the estrogen and androgen levels, however, the published results are contradictory on the effects on the postoperative sexuality (29). Khastgir and Studd (30) suggest that the bilateral annexectomy would damage the patients’ sexual prognosis with respect to their ages, the hormonal supplementation being a routine approach in their study.  Kilku and al. (31) noticed a risk of decreased libido (RR = 1,9 ; CI = 1,3-2,8) and reduced frequency of orgasms (RR = 2,0 ; CI = 1,4 to 2,8) associated with ovariectomy. These results are balanced out by the known effects of the hormonal deficiency in postmenopausal women.

 

  • The psychological state : the absence of a uterus can be sexually experienced organically and / or symbolically. The organic function is described in the research of Masters and Johnson, showing the presence of uterine contractions felt during orgasm, that can also be perceived by women having undergone hysterectomy, (phantom organ).  On the opposite, the effects of the ablation of the uterus may be beneficial to patients forced to rare intercourse, to abstinence due to difficult contraception, to major bleeding disorders or debilitating pain; in those situations where the surgical indication is consensual, changes due to the operation have been assessed in a prospective study of Rhodes and al (32): 1,101 patients aged between thirty-five and forty-nine, have been interviewed before the intervention, and one year later.  The author found an increase in sexual activity from 70.5% to 76.6% at one year, and improvements in the quality of sexuality with a decrease in dyspareunia (18.6% to 3.6 %), a decrease in anorgasmia (7.6% to 4.9%) and also a decrease in the number of women suffering from a decreased libido (10.4 to 6.2%). Consequences of the hysterectomy are quite different in a context of functional pathology. The most common situation is that of a hysterectomy performed for pelvic pains, badly assessed and that show risks of aggravating the initial state (33).   Chronic pelvic pain,  often linked to psychosomatic pain and disorders called functional, cannot be explained by an anatomical or physiological abnormality in which the choice of the organ and symptom would have a symbolic meaning.  According to international classifications (DSMIV and CIM-10), these pains are within the scope of somatoform pain disorders (Table 1), and should not be mistaken with somatic and dissociative disorders (conversion hysteria). During the patients’ interview, experiencing  chronic pelvic pain, we should systematically  look for two frequently associated parameters, cited by Dellenbach (34):

           - A history of sexual trauma

           - Domestic problems or violence

These may represent vulnerability factors, triggering or lingering factors, depending on circumstances, that are necessary to take into account in the patient’s treatment. Whatever the clinical state, the patient operates under guilt, leading to avoidance behavior that may contribute to the development of a real anxiety disorder: all these mechanisms participate in the maintenance of chronic pelvic pain. Few studies have focused on the therapeutic management of these patients, but they show that a significant improvement in the patients is possible when a multi-dimensional approach is proposed (35, 36).

 

  • Foretelling factors: the presence of dysmenorrhea and the frequency of preoperative intercourse, are the foretell signs of good quality postoperative sexual relations (37-39).  The indication for surgery for an organic lesion seems to be predominant among the good prognosis factors, and has been confirmed in an essay by Alexander and al. (40), in which he did not find any significant difference in the postoperative sexual activity when comparing the hysterectomy and endometrial resection, in case of functional hemorrhages. This finding was confirmed by Hurs Kainen (41) when he compared the hysterectomy to the intrauterine device in cases of severe menorrhagia.  On the psychological side, the work of Donoghue and al. (42) shows that in a group of 60 hysterectomised patients, 34% suffered from depression and 29% from anxiety disorder prior to the operation.  The prevalence of depression fell to 8% after the intervention, and the level of anxiety disorders remained stable (22%).  The main highlighted risk factors for negative emotions in the postoperative period, are an intense preoperative depression and deep concerns about the intervention itself. The rest of the literature on this subject raises the same type of results (40, 43, 44). Graesslin (45) confirms that the consequences of hysterectomies are limited, but insists on the management of pre and postoperative patients.  A healthy preoperative sexual activity seems to be the most important factor, as the sexual partner, with his emotional integration, adaptation to the consequences of the hysterectomy, and his physical and mental abilities play a key role.  

 

Conclusion

 

If a hysterectomy is performed in a context of indisputable organic disorders, symptoms will disappear and the quality of life will be improved.  On the contrary, a wrong indication, in particular for pelvic pain associated with anxiety disorders, or a history of depression expose the patient to the risks of postoperative decompensation.  These are the situations that require a complete organic and psychological preoperative assessment.  The preoperative information is turned towards the forensic risk, with its exhaustive and multiple complications list,  but nevertheless sufficient enough to aggravate the anguish.  The anatomical and physiological data must be adapted to each patient.  While most women can easily conceptualize the abdominal hysterectomy, through a painful imagination of the act but still standard in terms of surgery, the situation is different for vaginal or laparoscopic surgeries.  The postoperative recoveries are a priori better, but for some patients the organ disappears too quickly or too easily for them to mourn. A certain phantasm about the body’s permeability and organ instability can still remain.  Quite often, a few words associated with an explicit sketch are enough, but are necessary before and not after the surgery.   The imaginary physical integrity goes sometimes through the conservation of the cervix. In regards to the operative technique, the patient must be listened to, prior to making a decision with her and not for her.  The postoperative follow up must be provided by the surgeon himself to complete the information, reassure and accompany the patient. This simple advice can definitely minimize the risks for a postoperative psychological decompensation.

 

 

 

 

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