Pelvic organ prolapse (POP) is a frequently occurring pelvic floor disorder characterized by the descent of the anterior vaginal wall, posterior vaginal wall, uterus/cervix, and/or vaginal apex, which can cause symptoms from a bulging vagina to urinary, bowel and sexual difficulties. It becomes more of a problem as you get older, as you have more children, as you reach the menopause, as you become obese, and with any other factor that weakens your pelvic support. Recent evidence highlights that POP is not just an anatomic disorder, as symptoms have been shown to impact body image, self-confidence, sexual relationships and quality of life. In light of this population-based evidence and current reviews, therefore, a patient-centred approach is indicated in which decisions are made based on the anatomical correction as well as the functional outcomes. Sexual health is important as not all women with symptomatic PLFDs have sexual dysfunction and may not be identified due to embarrassment, cultural or language barriers, or the assumption that sexual health is not a priority for a PLFD. [3,4]

POP can affect sexual function in women in many different ways, including sexual desire, arousal, lubrication, orgasm, satisfaction, genital or pelvic pain, and comfort in sexual activity. The mechanical and psychological effects of prolapse can impact these domains. A bulge in the vagina could cause discomfort or when it is hard to pass urine, a feeling of blockage, vaginal dryness, pelvic pain, or fear of worsening the prolapse can decrease sexual confidence, and the frequency of sex. Distorted body image can also exacerbate a lack of interest in and avoidance of intimacy. Recent studies have associated POP with sexual dysfunction and psychological health and recommend evaluation of sexual health as a component of routine POP care. Changes in these patients can be systematically measured and compared pre- and postoperatively using validated patient questionnaires like the

Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) and the Female Sexual Function Index (FSFI). [3,6]

Surgical repair is typically recommended if the symptoms caused by prolapse are a problem, if conservative treatment fails or is not appropriate, or if the patient wishes to have the condition corrected. Anterior colporrhaphy, posterior colporrhaphy, apical suspension, uterosacral/ sacrospinous fixation, sacrocolpopexy, hysteropexy, or any combination of the above may be performed. Current data suggests that choice of procedure should take into consideration the prolapse compartment, degree of prolapse, prior surgery, comorbidities, patient preference, and sexual function goals. Importantly, it is not necessarily true that restoring the anatomy of the vagina correlates to the outcome of sexual experience following surgery. [7,8] Improvement can happen because the correction eliminates mechanical obstruction, pressures, urinary or bowel symptoms or embarrassment. On the other hand, sexual function can be negatively impacted by postoperative pain, scarring, change in the size of the vagina, dysfunction of the pelvic floor, a recurrence of the tumor, or complications. These conflicting mechanisms account for the historical complexity of the impact POP surgery has on sexuality, and sometimes inconsistencies. [5,9]

There is growing recent positive evidence. Evidence on specific procedures is also applicable: Recent studies have shown that anterior repair using native tissue does not impact sexual function and that patient-reported outcomes can be improved following the correction of prolapse in the anterior compartment by native-tissue surgery. [11]

One of the major clinical factors associated with surgery that is of significant importance is dyspareunia. Preoperative dyspareunia can be caused by mechanical discomfort, pelvic-floor dysfunction, vaginal dryness, and/or other pain disorders in women with POP. As a result, a successful repair may alleviate painful sexual intercourse in a significant number of patients. The findings of this large-scale prospective, longitudinal study with 5-year follow-up are relevant to counseling, as sexual activity was found to increase after POP surgery, and de novo dyspareunia occurred very rarely, but preoperative surgery, pain, prolapse characteristics, and posterior repair were associated with postoperative symptoms; more than half of women who experienced dyspareunia preoperatively had remission of symptoms within six months. The repair of the posterior compartment should be discussed in detail, as constriction or narrowing of the posterior vagina wall could have a different impact on sexual function from anterior or apical repair. [9,12]

Long-term evidence of quality of life also backs the general advantages of prolapse surgery. Patient-reported sexual function, symptom relief, quality of life and satisfaction are important outcome measures that should be considered when assessing the effectiveness of pelvic reconstructive surgery in addition to the anatomic results, and current literature highlights that anatomic success is not the only measure of success when evaluating the effectiveness of this surgery to treat prolapse. [7,15]

Although there is increasing evidence, there are important gaps. Definitions of sexual activity, length of follow-up, surgical technique, concomitant procedures, and instruments used to evaluate sexual function vary, among studies. Some exclude sexually inactive women, although inactivity could be due to prolapse symptoms or social factors. Postoperative outcomes also may be related to cultural expectations, relationship status, menopause, age, hormonal status, partner factors and anatomic repair, independently. Thus, the clinical value of validated questionnaires evaluating sexual function prior to and following POP repair is clinically useful. This assessment can measure shifts in desire, sexual arousal, lubrication, orgasm, satisfaction, pain, and sexual function, and can determine women who could benefit from counseling or pelvic-floor rehabilitation. In this study, therefore, a comparison of the sexual function both before and after POP repair was made, with special emphasis on sexual function and dyspareunia. Collecting local data on these results can enhance the preoperative counseling process, aid patient-centered surgical planning, and enable the surgeon to differentiate successful anatomic repair from meaningful functional recovery.

Study Design and Setting This prospective observational pre–post study was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital, Abbottabad, Pakistan. The study included 80 sexually active women aged ≥18 years with symptomatic pelvic organ prolapse (POP) who were planned for surgical repair. Participants Women with clinically diagnosed symptomatic POP who were sexually active and willing to undergo preoperative and postoperative sexual-function assessment were included. Women with active pelvic infection, pelvic malignancy, severe psychiatric or cognitive disorders affecting questionnaire completion, or inability to complete the postoperative assessment were excluded. Written informed consent was obtained from all participants. Clinical Assessment Baseline demographic and clinical characteristics were recorded using a structured proforma, including age, parity, body mass index, menopausal status, previous pelvic surgery, duration of prolapse symptoms, and associated urinary or bowel symptoms. Pelvic organ prolapse was assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system. Of the 80 participants, 32 (40.0%) had stage II, 36 (45.0%) had stage III, and 12 (15.0%) had stage IV prolapse. Regarding prolapse compartment, 30 (37.5%) had anterior vaginal wall prolapse, 26 (32.5%) had uterine/apical prolapse, and 24 (30.0%) had posterior or combined prolapse. Surgical Management The surgical procedure was selected according to the type and severity of prolapse, associated symptoms, previous surgical history, and standard departmental practice. Procedures included anterior colporrhaphy in 22 (27.5%), posterior colporrhaphy/perineorrhaphy in 12 (15.0%), vaginal hysterectomy with anterior repair in 18 (22.5%), vaginal hysterectomy with combined anterior and posterior repair in 16 (20.0%), apical suspension/hysteropexy in 8 (10.0%), and other reconstructive procedures in 4 (5.0%). The operative procedure and perioperative complications were documented for each participant. Assessment of Sexual Function Sexual function was assessed using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). The PISQ-12 is a 12-item condition-specific instrument assessing sexual function in women with pelvic-floor disorders, including behavioral-emotive, physical, and partner-related aspects. The total score ranges from 0 to 48, with higher scores indicating better sexual function. The same questionnaire and assessment procedure were used at baseline and follow-up. Participants completed the questionnaire privately to promote confidentiality and accurate reporting. Outcome Measures and Follow-up The primary outcome was the change in total PISQ-12 score between the preoperative assessment and the 6-month postoperative assessment. Secondary outcomes included changes in dyspareunia and sexual activity. Dyspareunia was defined as self-reported pain during vaginal intercourse. The previously used categories of “satisfactory sexual function” and “overall improvement” were not used as independent outcomes because no predefined clinical thresholds had been established. Statistical Analysis Data were analyzed using SPSS. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Normality was assessed before selection of statistical tests. Preoperative and postoperative PISQ-12 scores were compared using the paired-samples t-test or Wilcoxon signed-rank test, as appropriate. Changes in paired categorical outcomes, including dyspareunia and sexual activity, were assessed using the McNemar test. Exploratory subgroup analyses were performed according to menopausal status, age, POP-Q stage, prolapse compartment, and surgical procedure. These analyses were considered exploratory and unadjusted, and no independent predictive or causal relationship was inferred. A two-sided p<0.05 was considered statistically significant. Ethical Considerations Ethical approval was obtained from the relevant institutional ethics committee before commencement of the study. Written informed consent was obtained from all participants. Because sexual function is a sensitive subject, all assessments were conducted privately and confidentiality was maintained. Participants were identified by study codes rather than names, and study information was accessible only to the research team. Participation was voluntary, and participants were informed of their right to withdraw without affecting their medical care. The study was conducted in accordance with the principles of the Declaration of Helsinki

A total of 80 women undergoing surgical repair for symptomatic pelvic organ prolapse were included in the analysis. The mean age was 48.6 ± 8.7 years. Most participants were multiparous, with 58 (72.5%) having parity ≥3, while 56 (70.0%) were postmenopausal. Regarding POP-Q staging, stage III prolapse was most common (36, 45.0%), followed by stage II (32, 40.0%) and stage IV (12, 15.0%). Anterior vaginal wall prolapse was observed in 30 (37.5%), uterine/apical prolapse in 26 (32.5%), and posterior/combined prolapse in 24 (30.0%) women.

Table 1. Baseline Characteristics of Participants

Anterior colporrhaphy was the most frequently performed procedure (22, 27.5%), followed by vaginal hysterectomy with anterior repair (18, 22.5%) and vaginal hysterectomy with combined anterior and posterior repair (16, 20.0%).

Table 2. Surgical Procedures Performed

At 6 months, sexual function showed a significant improvement following POP repair. The mean PISQ-12 score increased from 29.4 ± 5.8 preoperatively to 34.7 ± 4.9 postoperatively (p<0.001). Dyspareunia decreased significantly from 28 (35.0%) to 13 (16.3%) (p=0.006). Sexual activity at postoperative assessment was reported by 71 (88.8%) women.

Table 3. Sexual Function Before and 6 Months After POP Repair

An exploratory subgroup analysis showed that improvement in sexual function was more frequent among premenopausal women than postmenopausal women (87.5% vs. 66.1%, p=0.04). The association between age and improvement was not statistically significant (p=0.08), and no significant association was observed according to prolapse compartment (p=0.32). These subgroup findings were considered exploratory and unadjusted.

The present study demonstrated a significant improvement in sexual function following surgical repair of pelvic organ prolapse. The mean PISQ-12 score increased from 29.4 ± 5.8 before surgery to 34.7 ± 4.9 at 6 months after surgery (p<0.001). In parallel, the prevalence of dyspareunia decreased from 35.0% to 16.3% (p=0.006). These findings suggest that restoration of pelvic support may be accompanied by meaningful improvement in sexual-function outcomes among women undergoing POP repair. The improvement in PISQ-12 scores is consistent with previous evidence indicating that prolapse surgery generally improves sexual function or does not adversely affect it. Antosh et al. reported in a systematic review that sexual-function outcomes generally improved after POP surgery across different reconstructive approaches, although the magnitude of improvement varied between procedures and studies. [16] Similarly, pooled evidence has demonstrated improvement in validated sexual-function scores following surgical management of POP, supporting the findings observed in our cohort. [17] The reduction in dyspareunia is another clinically important finding. Before surgery, more than one-third of women reported pain during intercourse, whereas this proportion declined to 16.3% at 6 months. POP can interfere with sexual intercourse through vaginal bulging, pelvic pressure, discomfort, altered vaginal anatomy, and psychological concerns regarding intercourse. Correction of these anatomical and symptomatic problems may consequently facilitate more comfortable sexual activity. A nationwide longitudinal study by Wihersaari et al. demonstrated that sexual activity and dyspareunia can improve after POP surgery, with many women experiencing resolution of preoperative intercourse-related pain. [18] In the present study, 71 (88.8%) women reported sexual activity at postoperative assessment. This finding is clinically relevant because prolapse symptoms may lead some women to avoid or reduce intercourse because of discomfort, embarrassment, fear of worsening the prolapse, or concerns regarding body image. Surgical correction may therefore improve not only anatomical support but also confidence and willingness to resume sexual activity. Recent clinical evidence has similarly suggested that successful treatment of POP can improve sexual function and quality of life. [19] The exploratory subgroup analysis showed a higher proportion of improvement among premenopausal women than postmenopausal women (87.5% vs. 66.1%, p=0.04). This difference should be interpreted cautiously because the analysis was unadjusted and the sample size was relatively small. Menopausal status may influence sexual function through factors such as vaginal dryness, reduced estrogen exposure, changes in genital tissues, and differences in sexual desire. These factors may persist despite successful anatomical correction of prolapse. Studies of uterus-preserving prolapse surgery in premenopausal women have also reported favorable postoperative sexual outcomes, highlighting the importance of considering sexual and reproductive concerns when planning prolapse surgery. [20] The present study included women with different prolapse compartments and different reconstructive procedures. Improvement in sexual function was not significantly associated with prolapse compartment. This finding is compatible with evidence suggesting that postoperative sexual outcomes are not determined solely by the anatomical compartment repaired. Different reconstructive procedures may provide comparable improvements when appropriately selected according to the patients prolapse characteristics. Evidence from systematic reviews and Cochrane analyses also emphasizes that surgical choice should be individualized according to prolapse location, patient characteristics, treatment goals, and surgeon expertise. [16,21] The effect of individual reconstructive procedures on sexual function remains an important consideration. Concerns regarding vaginal narrowing, postoperative scarring, or new-onset dyspareunia may influence both patients and clinicians when selecting a surgical approach. Evidence evaluating anterior repair has not demonstrated a consistent detrimental effect on sexual function, and some studies have reported improvement following correction of anterior vaginal wall prolapse. [22] Nevertheless, surgical counseling should acknowledge that a proportion of women may continue to experience sexual dysfunction or develop new symptoms despite successful anatomical repair. Sexual function is multifactorial and cannot be attributed to anatomical correction alone. Partner-related factors, pre-existing sexual dysfunction, menopausal status, vaginal dryness, psychological wellbeing, pelvic-floor muscle function, postoperative pain, and relationship factors may all influence sexual outcomes. Therefore, the improvement observed in this observational study should be interpreted as an association with POP repair rather than proof of a causal effect. The absence of a non-surgical control group also prevents determination of whether some improvement could have occurred through factors unrelated to surgery. This study has several limitations. It was conducted at a single tertiary-care center and included a relatively small sample of 80 women, which may limit generalizability. The cohort included different prolapse stages and surgical procedures, introducing clinical heterogeneity. Sexual function was assessed using self-reported responses and may have been influenced by cultural sensitivity surrounding discussion of sexual health. Potential confounders such as partner sexual function, vaginal estrogen use, baseline sexual dysfunction, and psychological factors were not comprehensively assessed. In addition, subgroup analyses were unadjusted and should therefore be considered exploratory. Finally, the 6-month follow-up provides information on short-term postoperative outcomes but cannot establish long-term durability of sexual-function improvement. Despite these limitations, the study provides clinically relevant evidence that sexual function can improve following POP repair and that dyspareunia may decrease after restoration of pelvic support. Assessment of sexual health should therefore form part of routine preoperative counseling and postoperative follow-up. Future multicenter prospective studies with larger samples, standardized surgical techniques, validated sexual-function instruments, longer follow-up, and multivariable adjustment for important confounders are needed to clarify the long-term effects of different POP repair techniques on sexual function.

Surgical repair of pelvic organ prolapse was associated with a significant improvement in sexual function at 6 months, demonstrated by a higher mean PISQ-12 score and a significant reduction in dyspareunia. These findings suggest that correction of prolapse may provide benefits beyond anatomical restoration, including improved sexual health and patient-reported outcomes. However, because this was a single-center observational study without a control group, the findings should be interpreted as an association rather than a causal effect.

RECOMMENDATIONS

Sexual function should be routinely assessed before and after POP repair using a validated instrument such as the PISQ-12, and women should receive appropriate preoperative counseling regarding expected sexual outcomes and the possibility of persistent or new sexual symptoms. Particular attention should be given to postmenopausal women and patients with pre-existing dyspareunia. Larger multicenter prospective studies with standardized surgical techniques, longer follow-up, and adjustment for important confounding factors are recommended to establish the long-term effect of different POP repair procedures on sexual function.

DISCLAIMER:

Nothing to declare.

ACKNOWLEDGEMENT:

The author thank the department medical staffs for their help and support. They keep patient record properly and managed the data carefully which helped in completing this research.

AUTHORS’ CONTRIBUTIONS

Anaheeta Israr: Write up, literature review. Ayesha Ismail: Study design, write up, proofreading. Hadia Javed: Literature review, data analysis. Zunaira Farzeen: Data analysis, proofreading. Syeda Seher Iqbal: Literature review, proofreading. Sabiha Khatoon: Literature review, data analysis.

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