The Somatic and Autonomic Innervation of the Clitoris; Preliminary Evidence of Sexual Dysfunction After Minimally Invasive Slings

Abstract

Introduction Vaginal sling procedures may have a negative effect on sexual function due to damage to vascular and/or neural genital structures. Even though autonomic innervation of the clitoris plays an important role in female sexual function, most studies on the neuroanatomy of the clitoris focus on the sensory function of the dorsal nerve of the clitoris (DNC). The autonomic and somatic pathways in relationship to sling surgery have up to the present not been described in detail. Aim The aim of this study is to reinvestigate and describe the neuroanatomy of the clitoris, both somatic and autonomic, in relation to vaginal sling procedures for stress urinary incontinence. Method Serially sectioned and histochemically stained pelves from 11 female fetuses (10–27 weeks of gestation) were studied, and three-dimensional reconstructions of the neuroanatomy of the clitoris were prepared. Fourteen adult female hemipelves were dissected, after a tension-free vaginal tape (TVT) (7) or tension-free vaginal tape-obturator (TVT-O) (7) procedure had been performed. Main Outcome Measures Three-dimensional (3-D) reconstruction and measured distance between the clitoral nerve systems and TVT/TVT-O. Results The DNC originates from the pudendal nerve in the Alcock’s canal and ascends to the clitoral bodies. In the dissected adult pelves, the distance of the TVT-O to the DNC had a mean of 9 mm. The cavernous nerves originate from the vaginal nervous plexus and travel the 5 and 7 o’clock positions along the urethra. There, the autonomic nerves were found to be pierced by the TVT needle. At the hilum of the clitoral bodies, the branches of the cavernous nerves medially pass/cross the DNC and travel further alongside it. Just before hooking over the glans of the clitoris, they merge with DNC. Conclusions The DNC is located inferior of the pubic ramus and was not disturbed during the placement of the TVT-O. However, the autonomic innervation of the vaginal wall was disrupted by the TVT procedure, which could lead to altered lubrication-swelling response.

Effects of Transobturator Midurethral Sling Surgery on Sexual Functions: One-Year Follow-Up

“…In a systematic review evaluating 21 articles assess- ing sexual functions and/or coital incontinence following continence surgery in the absence of prolapse in 1,271 women, there was significant reduction in coital incontinence postoperatively [2]. Similar results were observed in other studies [4,8,18,30]. Although some studies have shown significant improvement in sexual functions after the decrease or disappearance of coital incontinence in the postoperative period, other studies have not supported this finding [2,31].…”

“…The mean age of menopause was 46.7 ± 5.2 (31-53); the mean number of years since menopause was 7.5 ± 5.6 (0. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. The mean number of deliveries were 2.9 ± 1.4 (0-9).…”

“…Sexual function is an important aspect of well-being and some women undergoing surgery for stress incontinence do so in the hope that it will improve their sexual function [2]. Bekker et al [4] suggested that autonomic innervation of the clitoris and the vaginal wall may be affected during retropubic and transobturator midurethral sling surgeries, which may have an adverse effect on clitoris functions, vaginal lubrications, and therefore on sexual functions. Transobturator tape surgery (TOT) is a midurethral sling operation defined in 2001 for the treatment of SUI and it has become one of the most commonly performed anti-incontinence surgeries due to its minimal invasive nature, high success rate, and acceptable complication rates [5,6].…”

Stress urinary incontinence and LUTS in women—effects on sexual function

“…After TVT, the vascularization of clitoral erectile tissues might be altered, as shown by colour Doppler ultrasonography. 99 By contrast, TOT procedures are not associated with orgasmic dysfunction, as confirmed by Bekker et al 100 They showed that the dorsal nerve of the clitoris was not disturbed during placement of a TVT-O, whereas autonomic innervation of the vaginal wall and clitoris was disrupted by the TVT procedure. Elzevier et al 101 reported deterioration in clitoral sensitivity and tumescence after TOT and TVT-O in 11.5% and 10% of cases, respectively.…”

A Meta-Analysis Detailing Overall Sexual Function and Orgasmic Function in Women Undergoing Midurethral Sling Surgery for Stress Incontinence

“…We believe that a subgroup of women who derive their primary orgasmic function from vaginally elicited orgasms, that is, through penetration or stimulation of the anterior vaginal wall and periurethral female prostate region, could lose this response postoperatively after placement of the midurethral sling. The dissection for, and placement of, the midurethral sling clearly is likely to compromise the neural integrity of the anterior vaginal wall and periurethral female prostatic tissue 4, 5, 10, 13, 39…”