Sexual Health, Pain

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).

{mosbanner:id=1:right:0}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.

The Uterus and Cervix
The autonomic nerves of the pelvic viscera are divided into a sympathetic (thoracolumbar) and a parasympathetic (craniosacral) system. The sympathetic nerves are called the adrenergic while the parasympathetic is the cholinergic system. The superior hypogastric plexus overlies the aorta and splits into two trunks, the hypogastric nerves, which connects to a plexus of nerves lateral to the pelvic viscera, the inferior hypogastric plexus.
The nerves of the uterus arise from the inferior hypogastric plexus (pelvic plexus), which is a large dense plexus formed by the commingling of the hypogastric and pelvic splanchnic nerves. It can be divided into three portions: anteriorly, the vesical plexus, the uterovaginal plexus (Frankenhauser's ganglion) and the middle rectal plexus. The inferior hypogastric plexus consists primarily of sympathetic and sensory fibers that originate in T11-l2. The parasympathetic innervation is derived from spinal segments S2, S3, and S4. They reach the inferior hypogastric plexus via the pelvic splanchnic nerves. The uterovaginal plexus (Frankenhauser's ganglion) lies in the base of the broad ligament dorsal to the uterine vessels and lies laterally to the uterosacral and cardinal ligament's insertion into the uterus. These nerves have fibers that continue superiorly along the uterus and inferiorly along the cervix and vagina. The vaginal fibers innervate the vestibular bulbs, urethra and the clitoris. The autonomic fibers are usually vasomotor and most of the afferent fibers ascend through the inferior hypogastric plexus and enter the spinal cord via T10 to T12 and L1 spinal nerves. At the level of the cervix, these sympathetic and parasympathetic nerves form a plexus, which is referred to as the paracervical ganglia. One of these paracervical ganglia is often larger than the other and is called the uterine cervical ganglion. It is at this level that injury to the autonomic fibers of the vagina, labia and cervix can occur because these nerves lie in the tissue just lateral to the area where the pedicles for the uterine arteries, the cardinal and the uterosacral ligaments are made during a hysterectomy.

The Vagina
The inferior hypogastric plexus is a dense network of nerve fibers and some small ganglia. Each plexus lies against the posterolateral pelvic wall, internal to the corresponding internal iliac artery and lateral to the rectum, the vagina, and the base of the bladder. Each plexus contains autonomic fibers from the sympathetic and parasympathetic system, as well as visceral afferent fibers carrying impulses from the viscera to the central nervous system. As noted, the middle rectal plexus, the vesical plexus and the uterovaginal plexus innervate their respective organs. The vagina receives its autonomic innervation from the uterovaginal plexus (Frankenhauser's ganglion). The sympathetic and parasympathetic nerve fibers from this plexus supply the cervix and the superior part of the vagina as well as the urethra, vestibule bulbs and the clitoris via the cardinal and uterosacral ligaments. Presumably, most of the pain fibers from the vagina travel with the sacral parasympathetic fibers, and therefore enter the spinal cord through S2, S3, and S4 nerves. The lower part of the vagina receives its innervation primarily through branches of the pudendal nerve. Although originating from the same sacral segments, the pudendal nerves are somatic rather than visceral nerves, and convey somatic rather than visceral information.

The pelvic viscera are supplied by these autonomic plexuses, which convey sympathetic and parasympathetic motor and visceral sensory nerves to these organs.

Sympathetic innervation causes muscular contraction and vasoconstriction whereas parasympathetic innervation is responsible for vascular and non-vascular smooth muscle relaxation resulting in an increase in genital blood flow, clitoral, labial and vaginal wall engorgement and vaginal lubrication. These parasympathetic nerves arise from pelvic splanchnic nerves (nervi erigentes).

This paper will suggest a modified operative technique for hysterectomy in which identifying female pelvic neural anatomy may help to preserve structures essential to normal female sexual function and physiology. As they have successfully accomplished for men, performing "nerve-sparing" radical prostatectomy, they may also do the same for pelvic surgeries in women.

Preparation for Surgery
In preparing the patient for the operative procedure, it is important to place the lower extremities in Allen universal stirrups with the thighs flexed approximately 15 degrees in relation to the abdomen and the knees separated 30 degrees. Empty the bladder with a foley catheter that remains in the bladder throughout the surgery. A bimanual and rectovaginal exam performed before the patient is prepped and draped. Without question, a pelvic exam under adequate anesthesia is the best time to evaluate for pelvic pathology. The choice of incision can be made from findings on pelvic exam under anesthesia. Prep and drape the patient in a sterile fashion paying particular attention to clean the umbilicus with cotton applicators. Although it is impossible to sterilize the vagina, it is important to render this area surgically clean before draping the patient. This can be accomplished by using several betadine soaked sponges on long forceps.

Incision and Entering the Peritoneal Cavity
Adequate exposure is mandatory. The choices of skin incision include the Maylard, Pfannenstiel, and vertical. While many OB/GYN's chose the Pfannenstiel incision, larger fibroids or surgery where the upper abdomen may need to be explored may require a vertical skin incision. After the incision is made and carried down to the level of the underlying fascia, knick the fascia in the midline and separate the fascia from the rectus muscles. The peritoneum is then entered and the upper abdomen is explored. Palpate the kidneys, liver, gallbladder, pancreas stomach and par-aortic lymph nodes. A self-retaining retractor is inserted to expose the pelvic contents. Regardless of the type of retractor used, the lateral blades must not be allowed to compress the femoral nerves to avoid injury to these nerves that innervate the thigh muscles. Place the intestines in the upper abdomen with moist, tagged, laporotomy sponges. At this point, the surgeon should pause and assess the extent of pelvic pathology and of anatomical relationships, with reference to the ureters, bladder, and rectum, and to whether this surgery involves preservation of one or both of the ovaries, which has already been decided prior to the procedure.

{mosbanner:id=1:right:0}The operation begins with the round ligaments. Even with distorted anatomy, the round ligaments are usually identifiable laterally and can be followed medially to the uterine corpus. One of the round ligaments is grasped with a curved clamp (usually Kocher, Kelly) cut with a scalpel or scissors and ligated a short distance lateral to the clamp. The anterior leaf of the broad ligament is then incised along the bladder reflection on the uterus. Beneath the uteroovarian ligament, the posterior leaf of the broad ligament is pushed forward with the surgeon's fingers. This gives a window that can be incised with the scissors.

Ovarian Preservation or Oophorectomy
There are two ways to proceed with the procedure depending upon whether the ovaries are to be preserved. In the ovarian preservation procedure, clamp the uteroovarian ligament usually with three clamps to avoid back bleeding and to be prepared in case of slippage of one of the clamps. Thus, the ligament is incised between the clamp closest to the uterus and the two other clamps. A free tie of absorbable suture is then placed on the pedicle followed by a suture ligature to the pedicle. This ligature is placed medial to the first ligature in the center of the pedical placing the free ends of the suture around the tip and heel of the clamp and then the clamp is removed.

In a bilateral oophorectomy, the infundibulopelvic ligament portion of the broad ligament is triply clamped. The surgeon should be cognizant of the location of the ureter prior to placing the clamps. After locating the ureter, the clamp is placed followed by two clamps placed above the first. The ligament is then divided between the medial and middle clamp. A free tie of absorbable suture is then placed over the pedicle, followed by a suture ligature placed in the middle of the pedicle and wrapped around the tip and heel of the clamp. Again, the clamp is removed. This procedure starting with round ligaments followed by the uteroovarian or infundibulopelvic ligament is repeated on the contralateral side. The various steps in the hysterectomy procedure described are the same as the routine procedure.

Ligation of the Uterine Vessels, Uterosacral and Cardinal Ligaments
Attention is now placed on the lower uterine segment where the reflection of the bladder peritoneum on the uterus must be freed by extending the incision in the anterior leaf of the broad ligament medially from the point where both round ligaments are cut. This incision is extended medially and inferiorly until they meet in the midline on the lower uterine segment. The bladder can be gently pushed out of the way with a sponge stick. If the bladder is unusually adherent to the cervix, pushing it away with a sponge stick may cause unnecessary trauma. Thus, using a Metzenbaum scissors to surgically release it may be better. Incising the anterior and posterior broad ligament peritoneum will allow better visualization of the uterine vessels. The uterine vessels are usually skeletonized and then clamped at the level of the internal os to avoid injury to the ureter.

Our modified technique proposes complete dissection of the uterine artery separating it from the uterus so that it can be completely visualized. The vessels should be clamped pushing all other tissue that may include the part of the nerve plexus laterally, to avoid injury. The vessels are then cut with a scalpel and the sutures are placed at the tip of the clamp. This ensures that the ligature secures all of the vessels in the clamp. This modified technique may decrease the amount of damage to the uterovaginal plexus, which lies in the base of the broad ligament at the supravaginal part of the cervix. The suture of 0 -absorbable material is then tied and the clamp is removed. In the routine hysterectomy procedure, following ligation of the uterine vessels a straight clamp can be used between the uterine vessels and the side of the uterus and clamped, incised and ligated with 0 - absorbable suture. This tissue is part of the cardinal ligament.

{mosbanner:id=1:right:0}Furthermore, posterior to the cardinal ligament, the tissue of the uterosacral ligaments is also clamped. We propose a "wedge procedure in which a clamp is placed into the cardinal and uterosacral ligaments at a 45 degree angle, making this a true intra-fascial hysterectomy.

This "wedge" technique spares the nerve fibers of the uterovaginal plexus that lies in the lateral tissue of the ligaments and runs superiorly and inferiorly along the cervix. Although this "wedge" technique may require a few additional steps, we propose that anatomically it may spare the neurovascular bundles and result in preservation of sexual function. Many times this dissection of the uterosacral and cardinal ligaments require more than two series of suture ligations. The uterosacral ligaments are then clamped with a curved clamp, intrafascially, with the clamps placed medially and again that tissue pushed laterally. Again, this intra-fascial placement of the clamps may help to preserve the nerve bundles that run in this tissue. The tissue is incised and ligated as previously described.

Again this procedure is repeated on the contra lateral side. It is important to always ensure that the bladder peritoneum is out of harms way. At this point after, the surgeon determines that the bladder and rectum are adequately dissected off of the anterior and posterior cervix; two clamps are placed across the vagina and clamped so that their tips are facing each other. These clamps are again placed intra-fascially, to avoid injury to that lateral tissue. The cervix is then amputed. The vaginal vault can be left open or closed. If the vault is closed, it is important to not place the sutures too lateral to avoid injury to the fibers of the uterovaginal plexus that run along the superior vagina. Anatomical changes after hysterectomy and scar tissue formation can cause damage to the uterovaginal plexus, independent of whether the vaginal cuff is left open or closed.

In 1973, Masters observed: "Many women certainly describe cervical pressure as a trigger mechanism for coital responsivity. These women can be and occasionally are handicapped sexually when such a trigger mechanism is removed surgically." Such orgasm has often mistakenly been referred to as "vaginal," and its existence has been challenged on the basis that the vaginal walls do not contain nerve endings. It has been postulated however, that women who experience great satisfaction when coitus involves deep vaginal penetrations, depend on some mechanism that lies outside of the vaginal walls themselves. In fact, this internal orgasm is essentially a cervical orgasm caused by stimulation of nerve endings in the uterovaginal and cervical plexus, which intimately surround the cervix and attach to the upper vagina. Since much of the sensory and autonomic information from the pelvic organs, including the uterus, is channeled through the uterovaginal plexus, it is not unreasonable to assume that stimulation of this plexus would be pleasurable. In 1966, Masters and Johnson observed from their laboratory research that during orgasm the muscle contractions in the outer third of the vagina are accompanied by rhythmic contractions of the uterus. These contractions start at the fundus and progress to the lower uterine segment and cervix. Clark and Singer pointed out that the internally induced orgasm occurs when the penis presses hard and repetitively against the cervix, causing movements of the uterus and its broad supporting ligaments. Which stimulates the surrounding peritoneal membrane, which has pleasurable sensitivity.

Thus for some women, the quality and intensity of orgasm (triggered by deep vaginal penetration) is related to the movement of the cervix and uterus. We propose that the loss of a major portion of the uterovaginal plexus through excision of the cervix is bound to have an adverse effect on sexual arousal and orgasm in women who previously experienced internal orgasm. For other women, however, orgasm is achieved mainly by the stimulation of the labia and clitoris alone (clitoral orgasm), which is triggered by the pudendal nerve. Therefore, the loss of the cervix and uterus may not have a comparable effect. Evidence that women experience one or both types of orgasm, sometimes blended, have been reported; however, the percentage of women for whom the cervix and uterus are sexually important is unknown. Furthermore, none of the investigators in the above studies have ascertained whether the cervix and uterus were important to the sexual response of the women being questioned.

We propose that the cervix and uterus are indeed important to sexual function and that there removal can result in sexual dysfunction. Thus, by implementing this modified surgical "nerve sparing technique" we hope that at the very least this will serve as a prelude to further investigations on nerve sparing pelvic surgery. Further anatomic studies including cadaver dissections, retrograde nerve dissections as well as prospective randomized studies are in progress to effectively evaluate this new surgical technique.

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