Impact of High Tone Pelvic Floor Dysfunction on Change in Sexual Function Following Hysterectomy

INTRODUCTION: Existing literature on the potential impact of hysterectomy on female sexual function indicates that most patients report fairly stable sexual function postoperatively. However, most studies indicate subsets of patients who report meaningful improvement or decline in sexual function. Yet there is little clarity as to which factors predispose patients to direction or likelihood of change. High tone pelvic floor dysfunction, or pelvic myofascial pain, has been strongly associated with dyspareunia, sexual dysfunction, and restriction of sexual activity in existing literature. However, the potential impact of high tone pelvic floor dysfunction in patients undergoing hysterectomy has not been explored. OBJECTIVE: To evaluate the relationship between pelvic floor muscle tone and tenderness on change in sexual function following hysterectomy. METHODS: Observation cohort study of patients undergoing hysterectomy for benign indications evaluating presurgical predictors of pain, sexual function, and quality of life. Patients were prospectively recruited and completed multiple validated measures including the Female Sexual Function Index preoperatively and at 6 months postoperatively. A smaller subset of patients underwent a standardized pelvic exam prior to surgery, which included detailed assessment of pelvic floor muscles. Examiner assessed muscle tone on palpation at three sites (4, 6, and 8 o’clock), which ranged from +3 (very hypertonic) to −3 (very hypotonic). Tenderness to palpation was also assessed at six pelvic floor muscle sites (bilateral pubcoccygeus, iliococcygeus, obturator), which was reported by the patient as tenderness from 0–10 at each site (all six sites summed, range 0–60). This is a secondary analysis of the full cohort focusing on the association between baseline high tone pelvic floor dysfunction and change in sexual function at 6-month follow-up. RESULTS: There were 59 patients with preoperative pelvic exam and 6-month follow-up data. Mean age of the cohort was 40.41+5.84 and 19 (32%) of patients reported history of endometriosis. Mean baseline FSFI score was 20.51+8.76. Mean 6-month FSFI score was 19.78+8.17. Eleven (18.6%) patients reported improved sexual function postoperatively, defined as 30% improvement from baseline, whereas 48 (81.4%) reported stable to worsened sexual function. Binary logistic regression was performed to assess independent effect of preoperative factors on probability of reporting improved sexual function. Pelvic floor muscle tone on baseline exam was negatively associated with likelihood of improved sexual function postoperatively (OR 0.34, 95% CI 0.14 – 0.83, P=.018), adjusting for age and baseline FSFI score. History of endometriosis and overall pelvic myofascial tenderness score were not significantly associated with likelihood of improvement (Figure 1). CONCLUSIONS: High tone pelvic floor muscles prior to hysterectomy is associated with decreased probability of improved sexual function postoperatively. Each one point increase in pelvic floor muscle tone is associated with a 64% lower likelihood of improvement in sexual function at 6 months following hysterectomy (Table 1).