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Multicenter Study
. 2025 Apr 1;160(4):396-406.
doi: 10.1001/jamasurg.2024.6922.

Postoperative Sexual Function After Vaginal Surgery and Clitoral Size, Position, and Shape

Shaniel T Bowen  1   2 , Pamela A Moalli  2   3   4 , Rebecca G Rogers  5 , Marlene M Corton  6 , Uduak U Andy  7 , Charles R Rardin  8 , Michael E Hahn  9 , Alison C Weidner  10 , David R Ellington  11 , Donna Mazloomdoost  12 , Amaanti Sridhar  13 , Marie G Gantz  13 ; NICHD Pelvic Floor Disorders Network
Collaborators, Affiliations
Multicenter Study

Postoperative Sexual Function After Vaginal Surgery and Clitoral Size, Position, and Shape

Shaniel T Bowen et al. JAMA Surg. .

Abstract

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Moalli reported receiving grants from the National Institutes of Health (NIH) and the Mellon Foundation outside the submitted work. Dr Rogers reported receiving grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) during the conduct of the study; personal fees from American Urogynecologic Society Editor in Chief of Urogynecology, royalties from UpToDate, and nonfinancial support as executive board member of Society of Gynecologic Surgeons outside the submitted work. Dr Andy reported receiving grants from NICHD during the conduct of the study. Dr Rardin reported receiving grants from NICHD, the Foundation for Female Health Awareness, and Reia outside the submitted work. Dr Hahn reported receiving grants from the NIH during the conduct of the study. Dr Weidner reported receiving grants from NICHD during the conduct of the study. Ms Sridhar reported receiving grants from NICHD during the conduct of the study. Dr Gantz reported receiving grants from NICHD and Boston Scientific during the conduct of the study. No other disclosures were reported.

Comment on

References

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