It's a fact of life, like death and taxes, and it's guaranteed to bring a groan from everybody in the delivery room. The baby is in the warmer being checked by the nurses and the mother remains in the indecorous delivery position while I repair the episiotomy or perineal laceration, if there is one. Sooner or later the dad is bound to say to me, "Hey doc, throw in an extra stitch for me, will you?" This universal demonstration of the insensitivity of men always embarrasses me as a male obstetrician. I usually adopt a really sarcastic tone and say "Oh boy, I've never heard that before." and the nurses usually say, "I wish I had a dollar for every time I heard somebody say that." Occasionally, it is not the male who raises this concern regarding post partum sexual functioning, but it is the woman herself. I have had women make similar remarks on a number of occasions right after delivery. And I am reminded of something that a friend said to my wife shortly before she had our first baby. The friend and her husband were eating dinner with us at a nice, rather quiet restaurant, and she leaned across the table to my wife and said "It's never the same after you've had a baby, you know." She gave her a knowing look to make it clear just exactly what "it" was that she was talking about.
I am not aware of any scientific study that has undertaken to answer this question as to whether childbirth is detrimental to men's and women's perception of sexual satisfaction. The universality of people's interest in throwing in an extra stitch at the time of episiotomy repair strongly suggests that it is widely believed that vaginal delivery is, in fact, detrimental to one's future sexual enjoyment. Further circumstantial evidence to support this hypothesis derives from the often quoted fact that in certain areas of Brazil the cesarean section rate is as high as 90%! In reference to this statistic, it is generally intimated that Brazilian women prefer cesarean section to avoid injury to the birth canal (or should I say, conception canal?). I do not suggest that this is scientific evidence. When it comes to sexuality, however, I do have tremendous respect for the Brazilians. Their land is, after all, home of Ipanema Beach, Carnival and the Bosanova.
Actually, it stands to reason that the vaginal tone, which depends on the muscles of the pelvic floor, would be significantly damaged by the passage of a baby which weighs between six and ten pounds and has a head diameter of ten centimeters or greater. These pelvic floor muscles or levator sling, as they are sometimes called, are a complex arrangement of muscles which cross the pelvic opening from the pubic bone to the sacrum and coccygeus bones at the bottom of the spine. They are responsible for making sure that the internal organs of the abdomen and pelvis do not fall out when a woman stands up, especially when straining. These muscles also contribute to a complex arrangement of sphincters which help to maintain fecal continence, urinary continence, and as I have previously mentioned, vaginal tone. The evaluation of sexual function following vaginal delivery is clearly a highly subjective matter which is dependent on multifactoral issues, not the least of which are psychosocial considerations resulting from changes in family dynamics that occur as the result of the new addition. Regardless of mode of delivery, family life and relationships are invariably changed as a result of having children.
By contrast, however, the continence functions of the pelvic floor musculature can be evaluated in a highly objective manner. Up to 60% of women who have undergone vaginal delivery report an ongoing problem with stress urinary incontinence indicating a permanent change in the anatomy of the pelvic floor. For many of these women the involuntary loss of urine with coughing, sneezing, laughing, running, or engaging in any strenuous, physical activity represents a social problem of significant proportions causing them to severely limit their activities for fear of embarrassment.
A lesser, but still significant number of women report problems with fecal incontinence following vaginal delivery. This may either be transient or permanent. Often, this will occur as a result of direct traumatic injury to the anal sphincter muscle caused by a laceration occurring at childbirth or by extension of the episiotomy incision through the anal sphincter muscle. Nerve conduction studies have shown, however, that even in cases where the external and internal anal sphincter muscles remain intact, the trauma of childbirth may cause irreparable damage to the nerves which control the musculature of the pelvic floor. This neurologic damage contributes to problems with continence and to the general laxity of the pelvic floor. Most gynecologists believe that the problem of urinary incontinence and, especially, the problem of fecal incontinence is severely under-reported by women, largely due to their embarrassment in discussing these issues.
In addition to the problems of urinary and fecal incontinence, an extremely common gynecologic problem seen primarily in women who have had multiple vaginal deliveries is the problem of uterine prolapse. In this condition, the uterus literally begins to fall down into the vagina. Different degrees of uterine prolapse are described in the gynecologic literature. First degree prolapse involves the uterus falling into the vaginal area but not all the way to the vaginal opening. In second degree prolapse, the cervix is visible at the level of the vaginal opening and in third degree prolapse, the uterus protrudes entirely through the vagina and hangs externally. Usually, uterine prolapse is accompanied by prolapse of other pelvic structures. Most commonly the front wall of the vagina which overlies the bladder bulges down into the vaginal opening. This condition is called a cystocele and is very often, although not always, associated with urinary incontinence. The back wall of the vagina overlies the rectum and this also forms a prominent bulge into the vaginal opening. This is called a rectocele. The term pelvic prolapse generally refers to a combination of these defects which include cystocele, rectocele, and uterine prolapse. Pelvic prolapse will often cause severe symptoms which bring the patient to see her gynecologist. Indeed, a wide range of symptoms are attributable to this process of pelvic prolapse. Among them, the most common are the sensation of constant pressure in the vagina and constant backache which worsens after standing for long periods of time. Pelvic pain and abdominal pain during and following intercourse (dyspareunia) is also a frequent result of uterine prolapse. Urinary symptoms are also common. These can include the sensation of incomplete emptying of the bladder. Often a woman will find it necessary to push up on the bladder in order to be able to void. In the most extreme cases a woman may be unable to void altogether because of kinking of the urethra (the tube that empties the bladder) and she may experience painful urinary retention when the bladder becomes over-distended with a large volume of urine and must be emptied with a catheter.
A severe rectocele can cause similar problems with defecation and it is not uncommon to find an older woman with this problem who must push against the back wall of her vagina with her fingers in order to empty the rectum.
Later, when we consider hysterectomy, we will find that approximately 20% of all hysterectomies performed in the United States are performed for just these problems of pelvic prolapse. Usually, uterine prolapse accompanied by cystocele and rectocele are repaired by performing vaginal hysterectomy with simultaneous repair to the vaginal walls by a procedure known as anterior and posterior repair or colporrhaphy. During these procedures, especially posterior repair, the surgeon typically performs a procedure called perineoplasty whereby the anatomy of the area between the vagina and rectum is reconstructed to more closely resemble its pre-childbirth condition. The second half of this book will discuss some alternative approaches to this problem of prolapse, but this treatment, vaginal hysterectomy with anterior and posterior colporrhaphy is by far the most common approach for definitive resolution of these symptoms. The procedure takes approximately two hours and is usually done under general anesthesia. Women undergoing this procedure are typically between 40 and 70 years old. It is quite ironic to note here that the final part of the posterior colporrhaphy, the perineoplasty, is essentially equivalent to throwing in the extra stitch that all of those insensitive husbands were asking for in the immediate post partum period.
As far as alternative treatments are concerned, I suspect that many readers will be familiar with the famous Kegel exercises. But, how many of you have heard of a pessary? This is a roughly doughnut shaped rubberized device which is placed inside the vagina of older ladies and kept there on a more or less permanent basis to prevent their insides from falling out.
In Brazil they speak Portuguese. I have always wondered how to say "Kegel exercises" and "pessary" in Portuguese.