Obstetric Anal Sphincter Injury & Female Sexual Dysfunction: A Systematic Review

Objectives: To characterize and report on rates of postpartum female sexual dysfunction (FSD) following obstetric anal sphincter injury (OASI).

Methods: For this IRB-exempt study, we conducted a MEDLINE and PubMed search from May 2006 to April 2023 using PRISMA guidelines for studies that explored outcomes of sexual dysfunction in postpartum patients who sustained OASI tears. Studies that reported on rates of dyspareunia and/or used a questionnaire that measures female sexual function were included. Articles were evaluated by 3 independent reviewers and screened for outcomes and quality indicators according to GRADE guidelines.

Results: Of the 14 studies that met criteria for inclusion, 11 were prospective and 3 were retrospective. Ten out of 14 studies reported on FSD rates in the first year postpartum, while the remaining 4 studies assessed FSD at longer intervals after OASI (at 3, 5, 5.5, and 18 years). Rates of dyspareunia in the first year after OASI ranged from 27-35% with only 40%-57% of women having resumed sexual activity at 3 months postpartum. The Female Sexual Function Index (FSFI) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) were each utilized in 5 studies, among other questionnaires (Table 1). Using a cutoff score of 26.55 (out of 36) on the FSFI, with lower scores indicating greater degree of dysfunction, the range of FSD was 47-81% among patients with OASI (Table 2). FSD was reported in 21-41% among patients without OASI. Among studies that longitudinally followed OASI patients, FSFI scores improved with time; one study reported a mean score of 11.0 at 2 months vs 20.6 at 4 months (p 0.02). The FSFI subdomain scores (maximum 6) for Desire and Arousal were reported to have the less improvement with time, with scores ranging from 1.3-2.1 at 2 months and then to 3-3.1 at 4 months. Pain, Lubrication, and Orgasm domains showed greater improvement with time, with scores ranging from 1.4-1.6 at 2 months and up to 3.5-3.8 at 4 months. Among the studies that used the PISQ-12, with higher scores indicating better sexual function (range 0-48), the range of mean scores seen was 34.1-39. Of the 5 studies that used the PISQ-12, 3 found no difference between OASI and control patients. Only one study evaluated a potential intervention for FSD after OASI and found that pelvic floor physical therapy did not significantly impact sexual function in OASI patients at 6 and 12 months postpartum.

Conclusions: There is sparse literature on FSD in postpartum patients who sustained OASI tears at the time of delivery. Existing studies report high rates of FSD, dyspareunia, and non-resumption of sexual intercourse in the postpartum period. Additional research using validated questionnaires with longitudinal follow-up regarding FSD following OASI, and more data about potential interventions is needed.