Comparative Assessment of Female Sexual Function Following Transobturator Midurethral Sling for Stress Urinary Incontinence

Round 1

Reviewer 1 Report

The authors paid special attention to changes of female sex life before and after transobturator tape (TOT) method for stress urinary incontinence. In this study, Female Sexual Function Index (FSFI) questionnaire was evaluated in 50 patients. As results, they found some sexual life-related parameters were improved by the TOT.

I think that their study has important results to discuss the etiology and treatment strategies of loss of female sexual life in patients with stress incontinence. However, I have several questions before publication.

(Major)

1. I think that degree of improvement in incontinence may affect the sexual life in this study population. Please add the information on the improvement of stress incontinence after TOT. In addition, if have the data, I recommend adding the relationship between them.

2. Age is also closely associated with sexual life. I know you showed the mean and range of age of patients in 4. Results section. However, you should show more detailed information, such as median and interquartile range, in same section.

3. More detailed information on method of the questionnaires should be showed in 2.1. Design and Data Collection section; for example, questionnaires were sent by mail, written by herself in private space, doctor/nurse recorded? In addition, do all of patients agree to your survey?

Minor)

1. Please add “transobturator tape (TOT)” in Abstract and 1. Introduction.

Author Response

Dear Reviewer,

Enclosed herein I am submitting the revised manuscript Ref. No.: ijerph-1092931, Maciej Zalewski, Gabriela Kołodyńska *, Agata Zalewska, Waldemar Andrzejewski

The text has been changed according to reviewers’ suggestions. Changes in the manuscript

are marked in red.

With kind regards,

Gabriela Kołodyńska

Reviewer #1

I think that degree of improvement in incontinence may affect the sexual life in this study population. Please add the information on the improvement of stress incontinence after TOT. In addition, if have the data, I recommend adding the relationship between them.

Answer

We added in method section:

All patients underwent a normal TOT operation. After surgery, symptoms of stress urinary incontinence decreased as assessed by interview and physical examination. The TOT method is now considered by many authors as one of the most effective methods of SUI treatment (Delorme, 2001; Hellberg et al. 2007; Rechberger, Wróbel, 2018).

Hellberg D, Holmgren C, Lanner L, Nilsson S. (2007) The very obese woman and the very old woman: tension-free vaginal tape for the treatment of stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. nr 18: 423–429.

Reviewer #1

Age is also closely associated with sexual life. I know you showed the mean and range of age of patients in 4. Results section. However, you should show more detailed information, such as median and interquartile range, in same section.

Answer

We added in results section:

The mean age of women is 57.2 years (median 57.5). The youngest person was 45 and the oldest 65. Only 18% were women under 50. The most numerous group were women aged 51-60 (44%). Patients aged 61-65 accounted for 38% of the entire study group.

Reviewer #1

More detailed information on method of the questionnaires should be showed in 2.1. Design and Data Collection section; for example, questionnaires were sent by mail, written by herself in private space, doctor/nurse recorded? In addition, do all of patients agree to your survey?

Answer

We added in 2.1. Design and Data Collection:

The questionnaires were distributed to the patient on admission to the ward before the TOT procedure and during the follow-up visit, which took place 6 months after the procedure. The questionnaires were written by the patients in private space. The patients gave informed written consent to participate in the study.

(Minor)

Reviewer #1

Answer

Please add “transobturator tape (TOT)” in Abstract and 1. Introduction

We added in abstract and 1. Introduction “transobturator tape (TOT)”

Reviewer 2 Report

Sorry to say, but the English needs help.  It's actually quite difficult to read and really understand what the points are that are being made.  Seems like there's contradictory information throughout the paper, but I think it's just the English issues.

It has long been noted that women with SUI and/or OAB/UUI are negatively impacted with respect to their sexual well-being, due to embarrasment of leakage during sexual activity.  And after correction of that incontinence, that sexual function improves in that patients are less inhibited during the activity since they no longer fear leaking.  In prior studies, that has been seen translated as an increase in sexual desire, arousal, orgasm and satisfaction, and sexual frequency.

Dyspareunia can be multifactorial too.

Vaginal epithelium issue relating to dryness

Vaginal muscle (PFM) issue relating to hypertonicity and/or vaginismus

Other anatomical issues such as prolapse, prior surgery, scarring, radiation.

Slings don't improve any of these factors.

Please explain your findings.

Title should be more focused.  It is misleading the way it is.  This is only evaluating the effect of TOT on sex:  -- not general surgical treatment for stress urinary incontinence.  And I wouldn't use the word life -- sexual life -- in the title.

Suggestion:  Comparative assessment of female sexual function following transobturator midurethral sling for stress urinary incontinence.

Line 18:  TYPO:  embarrasment and embarrasment.

Line 81:  Don't use the term "under-urethra tapes".  They are called midurethral slings.  If you think your audience in this journal is unfamiliar with midurethral slings, then explain them in the intro, but then use the term midurethral sling properly throughout the rest of the paper.

Line 140:  Less pain 6 months after TOT midurethral sling?

Line 140: "after intercourse" -- do you mean WITH or DURING intercourse?

First, I'd like to know the etiology of their pain during intercourse BEFORE the sling.

And how do you account for or explain the decrease IN THAT PAIN perceived 6 months after the TOT sling?

There is a slight 5 point difference in the pain category.

I see it achieved statistical significance, but is it really clinically significant?

There is a much greater difference seen in the category of arousal, but yet not statistically significant?

Similarly, need to comment on WHY you think patients had issues with lubrication after the surgery.  Were they all use estrogen cream vaginally before and after the surgery -- and all were compliant?

Line 273 I don't believe this to be true.  Do you have a reliable citation for this?  "One of the most common causes of sexual dysfunction in women with urinary incontinence is pain."  Do you mean to say "after surgical treatment for urinary incontinence..."?

Conclusions:

1. Stress urinary incontinence CAN significantly affect ....
2. Surgical treatment for STRESS urinary incontinence ....
3. You can't really say this! It was a small difference, and the difference is unexplainable.
4. Same here.  You can't really make a bold statement like this with only 50 patients and borderline results.

As you know, Female Sexual Function/Dysfunction is multifactorial!  When attacking a topic and paper like this, I would suggest pulling out all domains of the FSFI and discussing them separately, to make it more clear: Desire, Arousal, Lubrication, Orgasn, Satisfaction, Pain.

And after revealing your findings, you need to discuss WHY you think it is so.  And if you don't think the data is reliable ... or the conclusions ... then you need to call that out to.  "This is what the data suggested, but clinically ......."

Author Response

Dear Reviewer,

Enclosed herein I am submitting the revised manuscript Ref. No.: ijerph-1092931, Maciej Zalewski, Gabriela Kołodyńska *, Agata Zalewska, Waldemar Andrzejewski

The text has been changed according to reviewers’ suggestions.

With kind regards,

Gabriela Kołodyńska

Rewiewer #2

Line 81:  Don't use the term "under-urethra tapes".  They are called midurethral slings.  If you think your audience in this journal is unfamiliar with midurethral slings, then explain them in the intro, but then use the term midurethral sling properly throughout the rest of the paper.

 Answer

We changed term "under-urethra tapes" to „midurethral slings”. We believe that the audience of this magazine is familiar with this term, so we did not explain it.

Rewiewer #2

Line 140:  Less pain 6 months after TOT midurethral sling?

Answer

 Yes. We corrected it in the text.

Rewiewer  #2

Line 140: "after intercourse" -- do you mean WITH or DURING intercourse?

First, I'd like to know the etiology of their pain during intercourse BEFORE the sling.

And how do you account for or explain the decrease IN THAT PAIN perceived 6 months after the TOT sling?

There is a slight 5 point difference in the pain category.

I see it achieved statistical significance, but is it really clinically significant?

There is a much greater difference seen in the category of arousal, but yet not statistically significant?

Similarly, need to comment on WHY you think patients had issues with lubrication after the surgery.  Were they all use estrogen cream vaginally before and after the surgery -- and all were compliant?

Answer

Research conducted in Denmark on a group of 15,000 women and men aged 40–60 showed that lower urinary tract ailments are an independent risk factor for sexual dysfunction [1]. Moreover, numerous studies emphasize that stress urinary incontinence is accompanied by urine leakage, urgency during intercourse, inability to achieve orgasm or accompanying pain, discomfort associated with urogenital atrophy, as well as anatomical changes that reduce comfort or prevent intercourse. All these factors are the cause of sexual dysfunction in every second patient with urogynecological complaints [2, 3]. As a result of the TOT procedure, the muscle-ligament balance is restored and thus the symptoms of urinary incontinence should disappear. In our opinion, the reduction of pain after TOT is of significant clinical importance. Our experience and the experience of other researchers show that pain during intercourse is a significant problem for patients with urinary incontinence. We described it in the discussion:

„One of the most common causes of sexual dysfunction in women with urinary incontinence is pain. Dyspareunia is a specific type of pain that is associated with sexual activity. It is caused by urological disorders. In this research group, the occurrence of pain during sexual activity was observed. It should be emphasised that during stress urinary incontinence surgery, the number of women experiencing pain decreased statistically significantly. The results of the studies by Lemack et al. [ 25 ] are consistent with ours and indicate that 20% of women operated for SUI reported pain during penetration after one year, and compared to the state before surgery, this is a slightly lower percentage of cases (29% ) .

In this study, after surgery, statistically significantly fewer patients experience pain during sex. The number of patients who never or almost never experience pain has increased by 34%”

1. Hansen BL. Lower urinary tract symptoms and sexual function in both sexes. Eu- ropean Urology. 2004; 46(2): 229–234.
2. Korda JB, Braun M, Engelmann UH. Sexual dysfunction at urinary incontinence. Urologe A. 2007; 46(9): 1058–1065.
3. Salonia A, Zanni G, Briganti A, et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectio- nal study. European Urology. 2004; 45: 642–648.

Rewiewer  #2

Line 273 I don't believe this to be true.  Do you have a reliable citation for this?  "One of the causes of sexual dysfunction in women with urinary incontinence is pain." 

Answer

We changed this sentence: "One of the causes of sexual dysfunction in women with urinary incontinence is pain." 

Rewiewer  #2

Do you mean to say "after surgical treatment for urinary incontinence..."?

Answer

Yes. We meant:  „after surgical treatment for urinary incontinence..."

Rewiewer  #2

Conclusions:

1. Stress urinary incontinence CAN significantly affect ....
2. Surgical treatment for STRESS urinary incontinence ....
3. You can't really say this! It was a small difference, and the difference is unexplainable.
4. Same here.  You can't really make a bold statement like this with only 50 patients and borderline results.

As you know, Female Sexual Function/Dysfunction is multifactorial!  When attacking a topic and paper like this, I would suggest pulling out all domains of the FSFI and discussing them separately, to make it more clear: Desire, Arousal, Lubrication, Orgasn, Satisfaction, Pain.

And after revealing your findings, you need to discuss WHY you think it is so.  And if you don't think the data is reliable ... or the conclusions ... then you need to call that out to.  "This is what the data suggested, but clinically ......."

Answer

We changed conclusion section:

1. Stress urinary incontinence can significantly affects the sexual life of women.
2. Surgical treatment for stress urinary incontinence in the studied patients resulted in more frequent orgasms, fewer patients experienced pain and discomfort during intercourse, lubrication during intercourse also improved.
3. The causes of female sexual dysfunction are complex, they may result not only from urological problems, but also from the quality of women’s relationship with their partner.

Reviewer 3 Report

I have pored over the paper with great interest, and found it to be highly informative and soundly assembled. Urinary incontinence is an all too rife issue, estimated to affect as much as 55% of the population. The assessment of the effect of surgical treatment via the transobturator tape (TOT) procedure represents an element of novelty, although studies have shown that no major differences have been observed based on which surgical procedure was carried out (whether  autologous fascial sling or Burch colposuspension, or a retropubic or transobturator midurethral sling).

Although the authors conclude, among other things, that "surgical treatment for urinary incontinence does not always improve the quality of women's sexual life", a solid trend has in fact been recorded towards an overall improvement of post-operative sex life, so that conclusion ought to be rephrased in order to reflect such findings. The adverb "always", I believe, has an ambiguous acceptation when summing up scientific results on a large scale. 

The references have been suitably selected, but would benefit from further expansion, especially relying on the most recent data available.

I would suggest including findings from the following sources:

Mota RL. Female urinary incontinence and sexuality. Int Braz J Urol. 2017;43(1):20-28. doi:10.1590/S1677-5538.IBJU.2016.0102

Glass Clark SM, Huang Q, Sima AP, Siff LN. Effect of Surgery for Stress Incontinence on Female Sexual Function. Obstet Gynecol. 2020 Feb;135(2):352-360. doi: 10.1097/AOG.0000000000003648. Erratum in: Obstet Gynecol. 2020 May;135(5):1232-1233.

Duralde ER, Rowen TS. Urinary incontinence and associated female sexual dysfunction. Sex Med Rev 2017;5:470–85.

Morgan DM, Dunn RL, Stoffel JT, Fenner DE, DeLancey JO, McGuire EJ, et al. Are persistent or recurrent symptoms of urinary incontinence after surgery associated with adverse effects on sexual activity or function? Int Urogynecol J Pelvic Floor Dysfunct 2008;19:509–15.

The discussion of how sexuality and its perception overall has evolved over the decades is a bit redundant in that position (page 2), whereas the authors ought to dig a bit deeper in factors that are only skimmed through, namely the "psychological and social dimensions" and how "the sexualsphere cannot be separated from emotions, feelings, excitement, interest in one's own body or another person". Those are determining factors in shaping up how an individual lives out her sexuality, and can play a pivotal role in determining satisfaction with outcomes in the post-op phase as well. I would suggest the authors elaborate on that further.

Page 12: why are the first three lines in red? Please rephrase the slightly awkward  "In the present study, the number of women experiencing orgasm increased statistically significantly", Line 297

Overall, the manuscript will be worthy of publication with a few minor changes and more wide-ranging references.

Lastly, make sure you modify the references in adherence with MDPI standards, such as:

Turner, S.W.D.; Ross, M.K.; Ibbetson, R.J. Job satisfaction among dually qualified dental hygienist-therapists in UK primary care: A structural model. Br. Dent. J. 2011, 210, E5, doi:10.1038/sj.bdj.2011.50.

Congratulations on your fine work.

Author Response

Dear Reviewer,

Enclosed herein I am submitting the revised manuscript Ref. No.: ijerph-1092931, Maciej Zalewski, Gabriela Kołodyńska *, Agata Zalewska, Waldemar Andrzejewski

The text has been changed according to reviewers’ suggestions.

With kind regards,

Gabriela Kołodyńska

Rewiewer #3

I have pored over the paper with great interest, and found it to be highly informative and soundly assembled. Urinary incontinence is an all too rife issue, estimated to affect as much as 55% of the population. The assessment of the effect of surgical treatment via the transobturator tape (TOT) procedure represents an element of novelty, although studies have shown that no major differences have been observed based on which surgical procedure was carried out (whether  autologous fascial sling or Burch colposuspension, or a retropubic or transobturator midurethral sling).

Although the authors conclude, among other things, that "surgical treatment for urinary incontinence does not always improve the quality of women's sexual life", a solid trend has in fact been recorded towards an overall improvement of post-operative sex life, so that conclusion ought to be rephrased in order to reflect such findings. The adverb "always", I believe, has an ambiguous acceptation when summing up scientific results on a large scale. 

The references have been suitably selected, but would benefit from further expansion, especially relying on the most recent data available.

I would suggest including findings from the following sources:

Mota RL. Female urinary incontinence and sexuality. Int Braz J Urol. 2017;43(1):20-28. doi:10.1590/S1677-5538.IBJU.2016.0102

Glass Clark SM, Huang Q, Sima AP, Siff LN. Effect of Surgery for Stress Incontinence on Female Sexual Function. Obstet Gynecol. 2020 Feb;135(2):352-360. doi: 10.1097/AOG.0000000000003648. Erratum in: Obstet Gynecol. 2020 May;135(5):1232-1233.

Morgan DM, Dunn RL, Stoffel JT, Fenner DE, DeLancey JO, McGuire EJ, et al. Are persistent or recurrent symptoms of urinary incontinence after surgery associated with adverse effects on sexual activity or function? Int Urogynecol J Pelvic Floor Dysfunct 2008;19:509–15.

Answer

We changed in conclusion section:

1. Stress urinary incontinence can significantly affects the sexual life of women.
2. Surgical treatment for stress urinary incontinence in the studied patients resulted in more frequent orgasms, fewer patients experienced pain and discomfort during intercourse, lubrication during intercourse also improved.
3. The causes of female sexual dysfunction are complex, they may result not only from urological problems, but also from the quality of women’s relationship with their partner.

Thank you for pointing out these literature items. I added them.

Rewiewer #3

The discussion of how sexuality and its perception overall has evolved over the decades is a bit redundant in that position (page 2), whereas the authors ought to dig a bit deeper in factors that are only skimmed through, namely the "psychological and social dimensions" and how "the sexualsphere cannot be separated from emotions, feelings, excitement, interest in one's own body or another person". Those are determining factors in shaping up how an individual lives out her sexuality, and can play a pivotal role in determining satisfaction with outcomes in the post-op phase as well. I would suggest the authors elaborate on that further.

Answer

We added in introduction section

The problem of urinary incontinence affects the patient's daily life, significantly reducing the health-related quality of life, including the quality of sex life. Patients with incontinence often feel discomfort during daily activities such as: physical activity or coughing, have low self-esteem, and depressed mood. The quality of personal, social and professional life is destabilized. Women force themselves to change their lifestyle - they limit social contacts, which causes lower self-esteem and social isolation. Human alienation can lead to depression and anxiety disorders.

In order to cover up their embarrassing ailments, women change their sexual activity. Women are afraid that their partner will discover their intimate problem, so they consciously give up sexual activity. Sexual abstinence can lead to a loosening of the psychological bond of both partners. From the gynecological / sexological interview, women with urinary incontinence are concerned about the involuntary leakage of urine during sex. Patients are upset that their partner smells unpleasant urine or notices stained underwear.

Duralde E.R., Rowen T.S. Urinary Incontinence and Associated Female Sexual Dysfunction. Sex Med. Rev. 2017;5:470–485.

Zyczynski H.M., Rickey L., Dyer K.Y., Wilson T., Stoddard A.M., Gormley E.A., Hsu Y., Kusek J.W., Brubaker L., Network U.I.T. Sexual activity and function in women more than 2 years after midurethral sling placement. Am. J. Obstet. Gynecol. 2012;207:421.e1–421.e6. 

Glavind K., Larsen T., Lindquist A.S.I. Sexual function in women before and after tension-free vaginal tape operation for stress urinary incontinence. Acta Obstet. Gynecol. Scand. 2014;93:986–990.

Fürst M.C.B., Leite P.H.B., Glina F., Baccaglini W., Fürst R.V.D.C., Bezerra C.A., Glina S. Female Sexual Function Following Surgical Treatment of Stress Urinary Incontinence: Systematic Review and Meta-Analysis. Sex Med. Rev. 2018;6:224–233.

Rewiewer #3

Page 12: why are the first three lines in red? Please rephrase the slightly awkward  "In the present study, the number of women experiencing orgasm increased statistically significantly", Line 297

Answer

We have corrected it in the text.

Rewiewer #3

Overall, the manuscript will be worthy of publication with a few minor changes and more wide-ranging references.

Lastly, make sure you modify the references in adherence with MDPI standards, such as:

Turner, S.W.D.; Ross, M.K.; Ibbetson, R.J. Job satisfaction among dually qualified dental hygienist-therapists in UK primary care: A structural model. Br. Dent. J. 2011, 210, E5, doi:10.1038/sj.bdj.2011.50.

Answer

We have corrected it in the text.

Round 2

Reviewer 1 Report

I think that this manuscript is improved by revision. Therefore, I am satisfied with contents and discussion of this revised version of the manuscript. In addition, I believe that many readers will pay attention to the manuscript.

Author Response

Dear Reviewer,

Thank you very much for your thorough evaluation of my manuscript, valuable comments and help in improving.

With kind regards,

Gabriela Kołodyńska

Reviewer 2 Report

1. You mentioned in your response to my comments that this audience is familiar with the midurethral sling, so it does not need to be explained.  In that case, the INTRO is far too long.  You mentioned how prevelent UI is in men and women repeatedly, and then give many examples.  State it once ... State how it can effect one's sexual life, ... that's it.  You lose the reader with such a long, redundant INTRO.
2. INTRO:  Aim statement needs to be more clear:  Suggestion: The study aims to evaluate the effect of surgical treatment on female stress urinary incontinence with the TOT on the sexuality of women.
3. DISCUSSION - Still doesn't postulate as to WHY the result were achieved in this study.  
4. Lemack -- noted more pain after TOT --- but that was due to surgical error with placement of the TOT.
5. CONCLUSION:  Statement 1 - can affect .... not -- can affects
6. CONCLUSION:  Statement 2 - Surgical treat with the TOT (you need to say this, because this is what your study was ... the TOT).  Also the wording of this statement is very cumbersome.  The English needs to be improved on so that your reader knows the positives versus the negatives in this statement.
7. CONCLUSION - Statement 3.  Please include that there are many other medical problems that affect sexual health too, no just urinary and relationship issues.

Author Response

Dear Reviewer,

Enclosed herein I am submitting the revised manuscript Ref. No.: ijerph - 1092931-2. The text has been changed according to reviewers’ suggestions. Changes in the manuscript are marked in red.

Thank you very much for your thorough evaluation of my manuscript, valuable comments and help in improving.

With kind regards,

Gabriela Kołodyńska

Response to the Reviewer #2 comments

Reviewer #2:

1. You mentioned in your response to my comments that this audience is familiar with the midurethral sling, so it does not need to be explained. In that case, the INTRO is far too long.  You mentioned how prevelent UI is in men and women repeatedly, and then give many examples.  State it once ... State how it can effect one's sexual life, ... that's it.  You lose the reader with such a long, redundant INTRO.

Answer

As suggested, the introduction has been shortened.

Reviewer #2:

2. INTRO: Aim statement needs to be more clear:  Suggestion: The study aims to evaluate the effect of surgical treatment on female stress urinary incontinence with the TOT on the sexuality of women.

Answer

As suggested, the aim has been changed.

Reviewer #2:

3. DISCUSSION - Still doesn't postulate as to WHY the result were achieved in this study.  

Answer

As suggested, the discussion section has been expanded to explain why, according to the authors, the changes took place

Reviewer #2:

4. Lemack -- noted more pain after TOT --- but that was due to surgical error with placement of the TOT.

Answer

As suggested, the Lemack studies cited were removed and replaced with more accurate studies by Elzevier et al.

Reviewer #2:

5. CONCLUSION: Statement 1 - can affect .... not -- can affects
6. CONCLUSION: Statement 2 - Surgical treat with the TOT (you need to say this, because this is what your study was ... the TOT).  Also the wording of this statement is very cumbersome.  The English needs to be improved on so that your reader knows the positives versus the negatives in this statement.
7. CONCLUSION - Statement 3. Please include that there are many other medical problems that affect sexual health too, no just urinary and relationship issues.

Answer

As suggested, all three conclusions were corrected.