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Rectocele-related sexual problems.

I was glad to see the informative article on "Managing Posterior Vaginal Wall Prolapse" by Dr. Dee E. Fenner (April 2010, p. 26) acknowledging the bowel problems many women have. However, I was disappointed to see only a glossing over of the sexual function problems women have related to their rectoceles before surgery, and more of an emphasis on the postoperative problems of dyspareunia and vaginal opening constriction from the overtightening of the bulbocavernosus muscles.

Postpartum anatomic changes impact bladder, bowel, and sexual function in women, and can affect the sexual function of men as well. The lateral stretch of the muscles at the vaginal opening resulting in the shortened perineum and gaping introitus can cause the penis to fall out in the middle of intercourse. The stretched back vaginal wall can cause reduced sensation for one or both partners. Some of my patients have told me they can't even tell when their partners are inside of them. Air moves in and out of a wider vagina causing gaslike noises, that if rare or occasional one could live with, but if they happen often or every time, take away from the intimacy of the moment. Rarely, a woman can defecate with penetration as the penis hits the stool-filled rectum. These women are appalled by this. Some couples prefer not to engage in intercourse at all, and that can affect their marriages. Treating these problems has never been up front in the field of ob.gyn. or any field; they're only treated silently. However the benefit of enhanced sexual gratification is well known and documented with the posterior repair for bowel function problems.

Patients who have come to me have said when they complained to their ob.gyns. about sensation or fall-out problems, they were told these are normal consequences of childbirth and to do Kegel exercises, but no one told them that if they had too much stretched tissue in the canal, their muscles wouldn't contract effectively. No one counseled them that after 3 months of trying without improvement, that surgery is probably a good option. What surgery, you ask? Posterior repair and perineorrhaphy.

In "Gynecologic and Obstetric Surgery" (St. Louis: Mosby--Year Book, 1993), edited by Dr. David H. Nichols, he states that if all else is good in the martial relationship, the posterior repair can help improve coitus. So why is it that we don't have discussions with our patients and their partners before these women get pregnant, or right after delivery, or a year after childbirth to assess sensation changes, fall-out issues, gaslike noises, or the passage of stool with penetration, along with the assessment of the various bowel function and tampon problems? We as a group are not asking the right questions regarding sexual function to gather the information from our patients that would enable us to realize the extent of these problems, nor are we addressing the problems effectively.

In January 2009, at the American Academy of Cosmetic Surgeons' meeting, I presented my first 4 1/2 years of data on sexual function problems related to anatomy and their treatment with the YAG (yttrium aluminium garnet) laser, instead of electrocautery, for posterior colporrhaphy and perineorrhaphy. Most significant is the fact that of the 520 women who presented with decreased sensation with intercourse, 100% had identifiable rectoceles on physical exam.

In addition to the shortened perineal body, the rectocele is an anatomic defect that is affecting sexual function. Our patients deserve not only recognition of the anatomic changes childbirth causes, but also discussion of how those changes may impact their lives. And they need to be treated when quality of life is impacted (that means in terms of comfort, function, and possible appearance issues such as pigmented or stretched skin). Quality of life is important for everyone, and going to the bathroom "like a normal person" and having fulfilling sexual intercourse are important parts of being human, and we, as physicians, should do what we can to appropriately address these issues directly.

Sexual function problems have no CPT or diagnostic codes, and insurance won't cover a posterior repair and perineorrhaphy for those reasons alone. Not all of the women who undergo childbirth have bladder and bowel function issues. Some have only sexual function concerns and are unable to get them adequately addressed and treated. It is time for the field to wake up and recognize this group of women who are in as much need of our education, compassion, and understanding of their sexual function problems as of the bladder and bowel problems with which they present.

In my practice, I primarily treat two groups of women whose health needs are not being addressed by the majority of ob.gyns.: those with sexual function problems related to childbirth and those with labial issues. In my poster presented at the American College of Obstetricians and Gynecologists' annual meeting in May 2009, I revealed outcome data for my first 488 labiaplasty patients, identifying 13 reasons female patients requested labia reduction, only 3 of which are related to appearance. Indeed, 83% of the patients came in for comfort and function reasons, so only 17% came in for appearance only.

There is a huge misperception about labial issues, as well as their impact--both physical and emotional--on sexual function. Again, we as a group are not asking our patients questions about their labia, so we don't realize the extent to which these issues concern them. We are not even trained to ask, "Does this tissue bother you?" when a speculum is inserted. I believe educating both residents and physicians about the sexual function problems women have related to their anatomy is paramount to helping these two neglected groups of women--those with sexual function problems related to childbirth and those with labial issues--who need our services.

Currently, I am collaborating with the center for sexual health promotion at Indiana University, Bloomington, to collect data on 1,000 women and why they are choosing vulvovaginal surgery. More research needs to be done to scientifically document sexual function changes related to delivery and their impact on women.

Troy Robbin Hailparn, M.D.

San Antonio

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Title Annotation:LETTERS
Author:Hailparn, Troy Robbin
Publication:OB GYN News
Article Type:Letter to the editor
Geographic Code:1USA
Date:Jun 1, 2010
Words:1076
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