By Jacqueline N. Murrell, MD, Jennifer R. Berman, MD Robert Weiss, MD, Laura Berman, PhD, Sheila R. Keane, MA, Mary Christina Zierack MA, Trudy Van Hooten, PhD, Irwin Goldstien, MD, and Phillip Stubblefield, MD: Sexuality is a crucial component of the general health and well being of women. It is a central part of their body image, self-esteem, relationship satisfaction and success. Female sexual dysfunction is a significant problem that affects the quality of life of many women.
According to The National Health and Social Life Survey, one third of American women report lack of sexual interest, and almost one fourth have difficulty achieving orgasm (Laumann et al., 1994). Sexual dysfunction can have a tremendous negative impact on a woman’s perception of herself as well as her relational and social functioning.
The incidence of sexual dysfunction and sexual complaints in women increases with age. (Goldstein & Berman, 1998; Segraves & Segraves, 1991; Spector & Carey, 1990). Aging, menopause, and declining estrogen levels positively correlate with sexual complaints (Sarrel, 1990,1998). Estrogen and testosterone have been found to be instrumental in regulating female sexual function, impacting on arousal, libido, as well as orgasm. Furthermore, estrogens have vasoprotective and vasodilatory roles, resulting in increased vaginal and clitoral arterial flow, aiding in the prevention of vaginal atrophy and vaginal smooth muscle fibrosis (Berman, Berman, & Goldstein, 1998).
Similar to the impact of menopause on sexual function, surgical menopause brought on by hysterectomy with or without oophorectomy has been a subject of significant interest and debate (Carlson, 1997, Northrup, 1998, Virtanen, Makinen, et. al., 1993). Common postoperative sexual complaints include loss of desire, decreased frequency of sexual activity, painful intercourse, diminished sexual responsiveness, difficulty achieving orgasm and decreased genital sensation. While many studies have shown a decrease in sexual function and desire after hysterectomy; others suggest that sexual function may actually improve. One prospective study examined the impact of supracervical versus abdominal hysterectomy and found that women undergoing abdominal hysterectomy had a significant decline in orgasmic ability one year after surgery, while women with supracervical hysterectomy had no significant changes in sexual function. (Kikku, et al 1983). In contrast, a recent paper in the Journal of the American Medical Association (JAMA) concluded that the frequency of sexual activity increased and problems with sexual dysfunction decreased after hysterectomy (Rhodes, et al 1999).
At present, we have a limited understanding of female pelvic anatomy, in particular the precise location of neurovascular structures vital to normal sexual arousal and function. This paper provides a detailed neuroanatomical review, with particular attention to the autonomic innervation, and describes a potential “nerve sparing” approach to hysterectomy. Similar to the impact of radical prostatectomy on male erectile function, we believe that pelvic surgical procedures in women, as they currently are described, can also negatively impact on sexual function. By preserving pelvic autonomic fibers, post-operative sexual arousal and orgasm may be consistently maintained. In circumstances involving genitourinary or gynecologic malignancies, such approaches may not be possible; however, for benign disease and well-localized tumors, “nerve-sparing” techniques may be possible. Detailed anatomic dissections and nerve tracing studies to delineate the precise location of the neurovascular bundles, as well as prospective studies on patient symptoms will key in to the definite etiology of post-operative sexual dysfunction.
For the purpose of this paper, we will focus on the neuroanatomy of the uterus, cervix, and vagina, as these structures have nerves that can be directly injured in the hysterectomy procedure. We propose that these injuries may be related to post- hysterectomy sexual dysfunction.
