Comparison of Sexual Functions in Transobturator Tape Surgeries Performed with Inside-Out Technique and Outside-In Technique

Abstract

Objectives:

To compare the postoperative sexual function results of inside-out transobturator tape (TOT) and outside-in TOT in the treatment of stress urinary incontinence.

Materials and Methods:

The study included 54 women with stress incontinence between 2020 and 2022. Group 1 patients underwent the inside-out transobturator tape (TOT) procedure, while Group 2 patients underwent the outside-in TOT procedure. Female Sexual Function Index (FSFI), Female Sexual Distress Scale-R (FSDS-R), Golombok-Rust Sexual Satisfaction Scale, Quality of Sexual Experience Scale (QSES), and Patient Global Impression of Improvement (PGI-I) were applied to the patients preoperatively and 18 months postoperatively to compare the results of the 2 surgical procedures on sexual functions.

Results:

Postoperative results were statistically significantly higher in both groups. Group 1 was found to be more effective for FSDS, FSFI sexual desire, FSFI sexual arousal, FSFI lubrication, FSFI orgasm, FSFI pain, and FSFI total variables. When the p values of Golombok levels in Groups 1 and 2 were examined, it was concluded that there was a significant difference between the groups because the p values of communication, avoidance, satisfaction, and vaginusmus scales were <0.05.

Conclusion:

When the methods were compared with each other, it was observed that the increase in sexual functions was more significant in the group with inside-out TOT procedure.

Introduction

Urinary incontinence is defined by the International Continence Society as social and hygienic problems caused by involuntary urinary incontinence, which adversely affects the quality of life.¹ Urinary incontinence has become an increasingly common health problem with the increase in life expectancy in recent years.²

In a meta-analysis, it was found that urinary incontinence was seen in one-third of women aged 30–60 years³ and it causes sexual dysfunction by causing problems such as loss of self-confidence, embarrassment, sexual reluctance, and depression that affect the daily lives of these women.⁴

Stress urinary incontinence (SUI) is most common in middle-aged women, while mixed urinary incontinence (MUI) is most common in older aged women.⁵ The aim of the treatment of SUI is to ensure urethral stability and to restore the function of the tissues supporting the urethra by strengthening them.⁶ Pelvic floor muscle exercises, electrostimulation techniques, behavioral changes, and pessaries are among conservative treatments. Midurethral slings, burch operations, and urethral bulking are among surgical treatments.^7–9

Among the surgical methods applied, midurethral sling operations are accepted as the gold standard method.¹⁰ Transobturatuar tape (TOT), one of the most commonly used methods, was described by Delorme. In this technique, after a midurethral incision is made 2–3 cm below the urethra, the mesh is advanced from outside to inside and passes through the obturator membrane and then exits through the midurethral incision. In the modified technique described by Leval, after the midurethral incision, the mesh is advanced from inside to outside and passes through the obturator membrane and exits.

Women with urinary incontinence have complaints such as decreased libido, dyspareunia, sexual reluctance, and vaginal dryness, which negatively affect their sexual life.¹¹ These negative effects are thought to be present in one-fourth of women with SUI.¹² In approximately half of the women with these complaints, abstinence from sexual intercourse was observed in parallel with the severity of incontinence.^13,14 However, there is no clear consensus about the effect of incontinence surgery on sexual functions. In some studies, improvement in sexual functions was found in patients in the long term,^15,16 in some studies, improvement in sexual functions of patients was not statistically significant,¹⁷ and in some studies, it was reported that sexual functions may be impaired after SUI surgery.¹⁸

While the efficacy of TOT on sexual functions is being investigated, there is a gap in the literature on the possibility that the surgical difference between inside-out and outside-in may affect sexual functions. In this study, the effect of TOT surgical application techniques on sexual functions was investigated.

Materials and Methods

Between 2020 and 2022, 54 patients who presented with urinary incontinence and were diagnosed with stress-type urinary incontinence were included in the study. This study was approved by the Ethics Committee of Istanbul Esenyurt University. (Approval No.: 2023/08-2). The technical procedure to be conducted initially was determined by tossing a coin and the groups were separated. Group 1 was designated as “inside-out TOT” and Group 2 as “outside-in TOT.” Then, patients with surgical indications were distributed one by one according to the order of arrival. Patients were given detailed information about the operation they would undergo. Demographic data of the patients were recorded and written informed consent was obtained. Group 1 (n = 27) patients underwent inside-out TOT. Group 2 (n = 27) patients underwent TOT from outside to inside. All operations were performed by a single experienced surgeon who had previously performed at least 100 operations in both procedures.

Patients who were pregnant or breastfeeding, who had neurological diseases that would impair bladder function, who had undergone previous incontinence surgery, who did not benefit from the operation, who had pelvic organ prolapse in the form of cystocele, rectocele, enterocele, sigmoidocele, apical prolapse, etc., who had received any treatment for sexual dysfunction, who had a history of malignancy, who had a history of radiotherapy, and who had no partner were not included in the study.

Group 1 (n = 27) patients underwent the modified technique in the reverse route as described by Leval.¹⁹ Group 2 (n = 27) patients underwent the original method described by Delorme.²⁰

Patients were called for follow-up visits at 2 weeks, 6 months, and 18 months after discharge. Patients who were at least 18 months postoperatively were called back to the clinic. Female Sexual Function Index (FSFI) Scale, Female Sexual Distress Scale-R (FSDS-R), Golombok-Rust Sexual Satisfaction Scale, Quality of Sexual Experience scale (QSES), and Patient Global Impression of Improvement (PGI-I) questionnaires, which were validated in Turkish, were applied to the patients in a quiet environment to evaluate their postoperative sexual life.

Incontinence complaints of the patients were questioned. Operative complications were categorized according to the International Urogynecological Association (IUGA) mesh classification validated in Turkish by Yassa et al.²¹

The FSFI questionnaire (Supplementary Appendix 1), which evaluates women’s sexual dysfunction in the past 4 weeks, has 6 categories: sexual desire (Items 1 and 2), arousal (Items 3–6), lubrication (Items 7–10), orgasm (Items 11–13), sexual satisfaction (Items 14–16), and pain (Items 17–19). In total, a minimum score of 2 and a maximum score of 36 can be obtained and higher scores mean a better sexual function.²²

FSDS-R (Supplementary Appendix 2): In this 5-point Likert-type scale, each item is asked to be scored between 0 and 4 points. It requires a response graded as 0 never and 4 always. Possible scores are between 0 and 52. Women who score 11 and/or above are considered to have impaired sexual functioning. Lower scores indicate more favorable sexual functioning.²³

Golombok-Rust Sexual Satisfaction Scale (Supplementary Data 1) consists of 28 questions and evaluates the dimensions of sexual problems such as frequency of intercourse, communication, avoidance, touching, satisfaction, vaginismus, anorgasmia, and quality of sexual intercourse. In the scoring of frequency and communication categories, a score of 4 and above suggests that there is a problem in this area. A score of 9 points or more in the scoring of the categories of avoidance, touch, satisfaction, vaginismus, anorgasmia, and quality of sexual intercourse suggests that there is a problem in these areas.²⁴

The QSES,²⁵ (Supplementary Data 3) which measures satisfaction with their last sexual experience, and PGI-I,²⁶ which measures the status of their complaints, were applied to the patients.

PGI-I (Supplementary Data 2) Patients are asked to compare and score the complaints in the urinary tract compared to before the operation. They are asked to give a score from 1 (much better) to 7 (much worse). In the QSES questionnaire, patients are asked to rate their last sexual experience. They are asked to score the questions from 1 to 7. The total score ranges from a minimum of 7 to a maximum of 49. Higher scores indicate higher quality sexual experience.

Statistical analysis

IBM SPSS Statistics 22 program was used for statistical analyses while evaluating the findings obtained in the study. The suitability of the parameters for normal distribution was evaluated by Kolmogorov–Smirnov test. In addition to descriptive statistical methods (mean, standard deviation, median, frequency), paired-samples t-test and Wilcoxon signed-rank test were used for preop-postop comparisons of parameters in the comparison of quantitative data. Significance was evaluated at p < 0.05 level.

Results

Demographic data of the patients are given in Table 1. When Table 1 is analyzed, it is observed that the mean age of the patients in the study was 45.04 ± 7.61 years in Group 1 and 51.68 ± 11.08 years in Group 2. It is seen that the educational status was mostly primary school and high school in both groups. No one in both groups had psychiatric illness. There were no patients with sexual diseases in both groups. The average number of children born by caesarean section was close in both groups. In total, 94% of the total patients were married and this resulted in a close number of married patients in both groups. The average years of marriage is longer in Group 2.

Table 1.

Descriptive Data of the Patients

	Group 1(n = 25)	Group 2(n = 25)
Age (years) (mean ± SD)	45.04 ± 7.61	51.68 ± 11.08
• Level of education (n, %)
Primary school	10 (40%)	10 (%40)
High school	10 (40%)	11 (44%)
University	3 (12%)	1 (4%)
Postgraduate	2 (8%)	3 (12%)
• Systemic diseases (n, %)
None	22 (88%)	22 (88%)
Yes
Hypertension	2 (8%)	2 (8%)
Diabetes mellitus	1 (4%)	1 (4%)
• Psychiatric disorders (n, %)
None	25 (100%)	25 (100%)
Yes
• Sexual disorders (n, %)
None	25 (100%)	25 (100%)
Yes
• Previous gynecological surgery (n, %)
None	22 (88%)	23 (92%)
Yes
Hysteroscopy	1 (4%)
Hysterectomy	2 (8%)	1 (4%)
Bilateral tubal ligation		1 (4%)
• Parite [Median (min-max)]	2 (1–4)	2 (0–6)
Number of children born with NVD [Median (min-max)]	2 (0–4)	2 (0–6)
Number of children born with CS [Median (min-max)]	0 (0–2)	0 (0–3)
(Mean ± SD)	0.28 ± 0.61	0.20 ± 0.64
Number of abortions [Median (min-max)]	0 (0–1)	0 (0–2)
(Mean ± SD)	0.08 ± 0.27	0.20 ± 0.50
Number of living children [Median (min-max)]	2 (0–4)	2 (0–6)
Menopause (n, %)
None	23 (92%)	22 (88%)
Yes	2 (8%)	3 (12%)
Marriage (n, %)
Married	23 (92%)	24 (96%)
Single/Divorced	2 (8%)	1 (4%)
Years of marriage (Mean ± SD)	20.44 ± 9.27	25.10 ± 12.35

CS, Cesarean Section; NVD, Normal Vaginal Delivery; SD, standard deviation.

When the menopausal status of the patients is analyzed according to the groups, it is seen that only 2 patients in the first group entered menopause. In Group 2, it is seen that 3 patients entered menopause.

After the operation, 1 patient in each group did not benefit from the treatment and mesh erosion was observed in 1 patient from each group. These patients were excluded from the study. In total, 50 patients were included in the study.

When total FSDS values were analyzed, a statistically significant decrease was observed in postoperative FSDS values in both groups compared to preoperative FSDS values.

When the groups were evaluated among themselves, it was observed that the procedure applied to Group 1 patients was statistically more effective than Group 2 (Table 2).

Table 2.

Comparison of Pre- and Postoperative FSDS Levels According to Surgical Procedure

FSDS Score
Procedure	Group 1 (mean ± SD)	Group 1 p-value	Group 2 (mean ± SD)	Group 2 p-value
Preoperative FSDS score	8.24 ± 4.36	0.000^b	6.52 ± 6.55	0.000^b
Postoperative FSDS score	6.32 ± 4.60	0.000^b	4.92 ± 6.12	0.000^b
p value	0.000^a		0.000^a

Paired-samples t-test.

Wilcoxon signed-rank test.

FSDS, Female Sexual Distress Scale; SD, standard deviation.

When the results of the FSFI questionnaire were evaluated, it was concluded that the surgical procedure applied to patients in Group 1 was statistically more effective for FSFI Sexual desire, FSFI sexual arousal, FSFI lubrication, FSFI orgasm, FSFI pain, and FSFI total variables. Only for FSFI satisfaction, the comparison between procedures showed that the procedure in Group 2 was statistically more effective (Table 3).

Table 3.

Comparison of FSFI Sublevels between Two Groups

FSFI Score	Group 1(Mean ± SD)	Group 1p value	Group 2(Mean ± SD)	Group 2p value
Procedure	Group 1(Mean ± SD)	Group 1p value	Group 2(Mean ± SD)	Group 2p value
Preoperative FSFI Sexual Desire	4.15 ± 1.14	0.006^b	4.10 ± 1.04	0.053^b
Postoperative FSFI Sexual Desire	4.51 ± 0.79	0.006^b	4.27 ± 1.08	0.053^b
p value	0.006^a		0.050^a
Preoperative FSFI Sexual Stimulation	4.39 ± 1.40	0.000^b	4.33 ± 1.17	0.000^b
Postoperative FSFI Sexual Stimulation	5.11 ± 1.02	0.000^b	4.86 ± 1.38	0.000^b
p value	0.000^a		0.000^a
Preoperative FSFI Lubrication	3.86 ± 0.80	0.000^b	3.72 ± 1.11	0.001^b
Postoperative FSFI Lubrication	5.24 ± 1.09	0.000^b	4.75 ± 1.61	0.001^b
p value	0.000^a		0.000^a
Preoperative FSFI Orgasm	4.03 ± 1.19	0.000^b	3.74 ± 1.19	0.000^b
Postoperative FSFI Orgasm	4.96 ± 1.33	0.000^b	4.51 ± 1.59	0.000^b
p value	0.000^a		0.000^a
Preoperative FSFI Satisfaction	4.12 ± 0.83	0.023^b	3.88 ± 1.02	0.009^b
Postoperative FSFI Satisfaction	4.38 ± 1.07	0.023^b	4.16 ± 1.16	0.009^b
p value	0.527^a		0.005^a
Preoperative FSFI Pain	2.92 ± 1.45	0.002	2.33 ± 0.92	0.000
Postoperative FSFI Pain	4.91 ± 1.74	0.002	4.28 ± 2.02	0.000
p value	0.001^a		0.000^a
Preoperative FSFI Total	23.49 ± 4.85	0.000^b	22.12 ± 5.90	0.000^b
Postoperative FSFI Total	29.12 ± 6.63	0.000^b	26.84 ± 8.45	0.000^b
p value	0.000^a		0.000^a

Paired-samples t-test.

Wilcoxon signed-rank test.

FSFI, Female Sexual Function Index; SD, standard deviation.

When the results of the QSES questionnaire scale were evaluated, it was found that the quality of sexual intercourse was higher in Group 2 patients (Table 4).

Table 4.

Mean and Percentage Comparison of QSES Subcategories between Groups

QSES TotalScore	Group 1 (n = 25)mean = 4.24	Group 2 (n = 25)mean = 4.48
Procedure	Group 1 (n = 25)mean = 4.24	Group 2 (n = 25)mean = 4.48
QSES (n, %)
7		1 (4%)
14	1 (4%)	2 (8%)
21	4 (16%)	4 (16%)
28	9 (36%)	2 (8%)
35	10 (40%)	10 (40%)
42	1 (4%)	5 (20%)
49		1 (4%)

QSES, Quality of Sexual Experience Scale.

When the p values of Golombok levels in Groups 1 and 2 are analyzed in Table 5, it was concluded that there was a significant difference between the groups because the p values of communication, avoidance, satisfaction, and vaginusmus scales were <0.05 (0.041, 0.026, 0.001, and 0.010, respectively). As the p values of the other 4 levels analyzed were greater than 0.05, there was no difference between the two groups (Table 5).

Table 5.

Comparison of Golombok-Rust Satisfaction Scale Levels of Two Surgical Procedures

	Group 1 [Median (min-max)]	Group 2 [Median (min-max)]	p
	Group 1 [Median (min-max)]	Group 2 [Median (min-max)]	p	Golombok-Frequency	3 (2–6)	2 (1–6)	<0.001*
Golombok-Contact	2 (1–5)	2 (1–4)	<0.001*
Golombok-Avoidance	2 (2–4)	3 (0–5)	0.193*
Golombok-Touch	1 (1–6)	3 (0–4)	<0.001*
Golombok-Satisfaction	4 (2–7)	3 (0–4)	<0.001*
Golombk-Vajinusmus	0 (0–4)	2 (0–6)	<0.001*
Golombok-Anorgasm	2 (2–8)	3 (0–8)	<0.001*
Golombok-Nature of sexual intercourse	1 (1–6)	3 (1–6)	<0.001*

Chi-square test.

Discussion

In this study, sexual functions were evaluated with FSFI, FSDS, Golombok-Rust Sexual Satisfaction Scale, and QSES questionnaires in patients who underwent inside-out TOT procedure and outside-in TOT procedure and a statistically more significant increase in sexual functions was found in the patient group who underwent inside-out TOT procedure.

There are many studies examining the effects of SUI surgery on sexual functions. Fattah et al. found an improvement in sexual functions in patients who underwent inside-out TOT surgery and outside-in TOT surgery in their study, but they did not detect a significant difference in terms of the superiority of these 2 procedures.²⁷ Arıcı et al. found that there was a statistical increase in emotional, behavioral, and physical parameters in the SQoL-F questionnaire in the group undergoing inside-out TOT.²⁸ In another study, an improvement was found in sexual arousal, orgasm, and satisfaction, but this improvement was not statistically significant.²⁹

Similarly, Dursun et al. applied TOT to 96 women in their study and found no significant difference in FSFI total scores and subgroups.³⁰ The anterior vaginal wall possesses significant and erogenous structures relevant to sexual functions.³¹ The incision made beneath the urethra in both groups affects the sensitivity of this area. It is believed that the small incision and minimal invasive approach of the inside-out TOT procedure cause minimal damage to the anterior vaginal region. Although the midurethral incision might seem to have a negative impact on erogenous areas in terms of sexual functions, an increase in sexual functions owing to the treatment of urinary incontinence has been statistically significant in patients. Thus, improvement in sexual functions in Group 1 patients, where more minimal dissection is performed in the midurethral and paraurethral areas, was found to be more significant compared with Group 2. FSFI, FSDS, and Golombok-Rust questionnaire were applied to both the groups and it was determined that the positive effect of the surgical procedure applied to Group 1 patients on sexual functions was statistically more significant.

In this study, dyspareunia complaint was found to be higher in Group 1 patients. It is thought that this pain may be caused by a foreign body reaction to the bladder placed close to the adductor muscle or peripheral obturator nerve in Group 1 patients and may also be owing to trauma to the muscles.^32,33 In a study by Elzevier et al., an increase in postoperative dyspareunia complaint was observed, but it was not statistically significant.³⁴ Doğan et al found that dyspareunia complaint was higher in inside-out TOT procedure in their study.³⁵

PGI-I questionnaire was applied to the patients at postoperative 18th month to evaluate incontinence complaints. In Group 1, 22 patients stated that their complaints were much better, while 16 patients in Group 2 gave the same answer. Postoperative satisfaction was statistically more significant in the Group 1.

Strength and limitations

The limitation of the study is the limited number of native language-validated questionnaires related to sexual dysfunction and urinary incontinence. The strengths of the study are that all surgeries were performed by the same surgeon, and thus, complications that may occur owing to surgical technique and material were prevented. In addition, there are few studies examining sexual dysfunction after sling operations.

Conclusion

It was found that the inside-out and outside-in procedures improved the incontinence complaints of the patients and had a positive effect on their sexual life. When the superiority of the methods was compared, it was determined that there was no difference in terms of incontinence, but the improvement in the sexual function of the patients after the operation was statistically more significant in the inside-out TOT procedure applied to the Group 1 patients.

Institutional Review Board Statement

This study was approved by the Ethics Committee of Istanbul Esenyurt University (Approval No.: 2023/08-2).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Footnotes

Data Availability Statement

If required, our data can be submitted.

Authors’ Contributions

U.E.: Study conception and design, ethics approval, acquisition of data, article writing, and critical revision. D.O.: Editing of article, acquisition of data, analysis and interpretation of data, and critical revision.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research received no external funding.

Supplementary Material

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Supplementary Material

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