Postoperative Sexual Function After Vaginal Surgery and Clitoral Size, Position, and Shape
Authors: Bowen Shaniel T. , Moalli Pamela A. , Rogers Rebecca G. , Corton Marlene M. , Andy Uduak U. , Rardin Charles R. , Hahn Michael E. , Weidner Alison C. , Ellington David R. , Mazloomdoost Donna , Sridhar Amaanti , Gantz Marie G. ,   NICHD Pelvic Floor Disorders Network, Ferrante Kimberly , Johnson Sherella , Lukacz Emily S. , Nager Charles W. , Diwadkar Gouri B. , Dyer Keisha Y. , Mackinnon Linda M. , Tan-Kim Jasmine , Zazueta-Damian Gisselle , Amundsen Cindy , Bruton Yasmeen , Coleman-Taylor Notorious , Kawasaki Amie , Longoria Nicole , McLean Shantae , Siddiqui Nazema , Carter Kathy , Lockhart Mark E. , Patel Sunita , Richter Holly E. , Saxon Nancy , Willis Velria B. , Carberry Cassandra , Hampton Brittany S. , Korbly Nicole , Meers Ann S. , Myers Deborah L. , Sung Vivian W. , Wohlrab Kyle , Dunivan Gena , Komesu Yuko , Jeppson Peter , Arya Lily , Flick Lorraine , Harvie Heidi , Kinglee Michelle , Smith Ariana , Abramowitch Steven D. , Bonidie Michael , Gruss Judy , Shepherd Jonathan , Sutkin Gary , Zyczynski Halina M. , Barber Matthew , Graham Annette , Paraiso Marie Fidela R. , Ferrando Cecile , Burdekin Kate , Ham Michael , Shaffer Amanda , Wallace Dennis , Whitworth Ryan , Swankie Taylor 
Published: February 2025

Importance

Transvaginal surgery is commonly performed to treat pelvic organ prolapse. Little research focuses on how sexual function relates to clitoral anatomy after vaginal surgery despite the clitoris’ role in the sexual response.

Objective

To determine how postoperative sexual function after vaginal surgery is associated with clitoral features (size, position, shape).

Design, Setting, and Participants

This was a cross-sectional ancillary study of magnetic resonance imaging (MRI) data from the Defining Mechanisms of Anterior Vaginal Wall Descent (DEMAND) study. The setting comprised 8 clinical sites in the US Pelvic Floor Disorders Network and included the MRI data of 88 women with uterovaginal prolapse previously randomized to either vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension between 2013 and 2015. Data were analyzed between September 2021 and June 2023.

Exposures

Participants underwent postoperative pelvic MRI at 30 to 42 months (or earlier if reoperation was desired) between June 2014 and May 2018. Sexual activity and function at baseline (preoperatively) and 24- to 48-month follow-up (postoperatively) were assessed using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, International Urogynecological Association Revised (PISQ-IR). Clitoral features were derived from postoperative MRI-based 3-dimensional models.

Main Outcomes and Measures

Correlations between (1) PISQ-IR mean, subscale, and item scores and (2) clitoral size, position, and shape (principal component scores).

Results

A total of 82 women (median [range] age, 65 [47-79] years) were analyzed (41 received hysteropexy and 41 received hysterectomy). Postoperatively, 37 were sexually active (SA), and 45 were not SA (NSA). Among SA women, better overall postoperative sexual function (higher PISQ-IR summary score) correlated with a larger clitoral glans width (Spearman ρ = 0.37; 95% CI, 0.05-0.62; P = .03) and thickness (Spearman ρ = 0.38; 95% CI, 0.06-0.63; P = .02). Among NSA women, sexual inactivity related to postoperative dyspareunia correlated with a more lateral clitoral position (Spearman ρ = 0.45; 95% CI, 0.18-0.66; P = .002), and sexual inactivity related to incontinence/prolapse correlated with a more posterior clitoral position (Spearman ρ = −0.36; 95% CI, −0.60 to −0.07; P = .02) (farther from the pubic symphysis). Shape analysis demonstrated that poorer postoperative sexual function outcomes in SA women and sexual inactivity in NSA women correlated with a more posteriorly positioned glans, anteriorly oriented clitoral body, medially positioned crura, and lateral vestibular bulbs.

Conclusions and Relevance

Results of this cross-sectional study suggest that postoperative sexual function after vaginal surgery was associated with clitoral glans size, position, and shape. Results warrant prospective studies on surgery-induced changes in clitoral anatomy and sexual function.