Blackwell Science, LtdOxford, UKIJUInternational Journal of Urology0919-81722004 Blackwell Publishing Asia Pty LtdJanuary 20041213538Original Article Sexual function

and mesh repair of inguinal herniaJ Zieren

et al.

International Journal of Urology (2005) 12, 3538

Original Article

Sexual function before and after mesh repair of inguinal hernia

JRGEN ZIEREN, CHARALAMBOS MENENAKOS, MARCO PAUL AND JOCHEN M. MLLER Department of General, Visceral, Vascular and Thoracic Surgery, Charit, Campus Mitte, Humboldt University of Berlin, Schumannstrae, Berlin, Germany
Abstract Aim: Several factors having an inuence on the quality of life after an inguinal hernia repair have been studied, yet little has been reported on sexual function before and after this operation. Methods: In a prospective follow-up study from January 1999 to July 2002, 210 men and 14 women were asked to answer an anonymous questionnaire of 40 questions before elective inguinal hernia repair to assess pre- and postoperative sexual function (preoperatively, 3 months postoperatively and every 6 months afterwards). Inguinal hernia repair was performed using a standardized Plug and Patch mesh technique. Results: Fifty-two (23.2%) patients mentioned preoperative sexual dysfunction related to the groin hernia. Postoperatively, the surgical repair had a positive inuence on the sexual function in these patients. Thirty-six (16%) patients complained of postoperative sexual dysfunctions, which improved or disappeared over the next few months. All patients suffered surgical complications, which were surgically treated in six cases. Symptoms specically associated with inguinal hernias can cause certain limitations in the sexual life. Conclusions: In most cases, and in the absence of postoperative complications, the operative repair can lead to a recovery of the sexual life in patients with preoperative sexual dysfunction, while, in most cases, it does not affect patients with a preoperative normal sexual life. inguinal hernia, plug and patch, sexual function.

Key words

Introduction
Quality of life has increasingly been a matter of consideration in the assessment of medical and, above all, surgical procedures. In inguinal hernia repair, one of the most common surgical procedures, several factors of postoperative quality of life, such as pain and recovery, have recently been assessed.1,2 However, little has been reported on another aspect of quality of life: postoperative sexual function. This is even more impressing because the operation is performed in the inguinal region close to testicular structures and nerves, which
Correspondence: Jrgen Zieren, PhD, Department of General-, Visceral-, Vascular and Thoracic Surgery, Charit, Campus Mitte, Humboldt University of Berlin, Schumannstrae 20/21, D-10117 Berlin, Germany. Email: juergen.zieren@charite.de Received 10 November 2003; accepted 28 June 2004.

are important for sexual function. Furthermore, modern, so-called tension free techniques, of hernia repair are based on the implantation of a mesh to reinforce the inguinal oor. The rst results of a prospective study of the Department of General Surgery Charit, Campus Mitte, showed no signicant inuence of the hernia repair with mesh on sexual function for at least 3 months postoperatively.3 Meanwhile, the implanted mesh can cause long-term tissue induration or even shrink4 as part of a chronic foreign tissue reaction and affect sexual function in this way. The long-term results concerning sexual function should be assessed in the current study.

Materials and methods

The present study was set up as a prospective follow-up study and was ratied by the local Ethics Committee.

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From January 1999 to July 2002, 210 men and 14 women before elective inguinal hernia repair in the Department of General Surgery Charit, Campus Mitte, were included after giving their written consent. Exclusion criteria were those aged under 18 years old, recurrent or incarcerated inguinal hernias and diseases of the testicles (orchitis or tumors).
Operative technique

In all cases, a standardized Plug and Patch technique was used for hernia repair.5 With the exception of seven patients who desired general anesthesia, the operation was routinely performed under local anesthesia (1 : 1 mixture of 0.5% Carbostesin and 1% Xylocithin; Fa. Astra, Wedel, Germany). Using a 45 cm skin incision, the external oblique fascia was opened and the hernia sac carefully dissected from the adjacent cord structures. It was cleared to the level of the internal inguinal ring or indirect defect, respectively, and was pushed gently into the abdominal cavity. In all cases, a plug was formed out of a 10 10 cm Prolene mesh (Ethicon, Norderstedt, Germany) and its length was adapted to the individual anatomical situation. The plug was inserted behind the defect and xed to its margin with sutures. The internal inguinal ring was then narrowed with sutures so that only the ngertip could pass through. Additionally, an onlay Prolene mesh (5 10 cm) was implanted and sutured onto the inguinal oor. The spermatic cord structures passed through a slit in the mesh, which was closed by suture. The external oblique fascia was closed with a running suture and skin with an intracutaneus suture. The patients were prompted to direct mobilization. If the immediate postoperative course was uneventful and the local ndings were normal, they were discharged on the day of the operation. Postoperative sexual and physical activities were not limited and patients were let free to decide upon their continuation.
Study protocol-tests

disorders, orgasm disorders, pain or discomfort during sexual intercourse). The patients were also asked to mention whether they were pleased with their sexual and partner life. The questionnaire was specially adapted for the current study, so that the inuence of specic parameters related to the operation, such as wound healing abnormalities or wound pain on sexual life, could be also assessed. In order to preserve anonymity, the patients were asked to use and maintain a personal codeword for the period of the study, so that they could answer with the same codeword both preand postoperative questionnaires. Furthermore, the patients should mention any eventual problems related to wound healing and their general wellbeing. The test was carried out preoperative, 3 months postoperatively and every 6 months afterwards during the observation period. Sonography of the groin region was carried out only in case the patient mentioned local complaints or when a hernia recurrence was suspected. The statistical analysis of the data was performed using the Mann Whitney U-test for continuous, not parametrical, data. The signicance level was dened as P < 0.05.

Results
Two hundred and twenty-four patients (210 men and 14 women) with an average age of 53 17 years were nally included in the study and were re-examined on the predened dates as shown in Figure 1. During the study, 13 patients (5.8%) died, 27 (12%) moved away and were lost to follow-up and 28 (12.2%) with a normal preoperative sexual history found no motivation in continuing the study. As far as local ndings are concerned, 137 cases (61.1%) were indirect inguinal hernias, 36 (16.1%) direct and 51 (22.8%) combined direct and indirect inguinal hernias. The average hernia defect was 2.5 1.9 cm (0.65.7). There were no intraoperative complications. Postoperative complications con-

The main criterion of this study was sexual function, which was examined with an anonymous questionnaire. This questionnaire was specially organized and developed by the Institute of Sexual Medicine of the Charite University Hospital. It had been checked for its re-test reliability and had been already been used in several studies dealing with the inuence of chronic diseases on sexuality and sexual partnership6,7 and has been validated in order to be equivalent for both male and female patients. The questionnaire consists of 40 questions about sexual life, experiences and behaviour, paying attention to the detection of sexual disorders (potency

200 150

Patients (n)

100 50

0 0 6 12 18 24 30 36 42 48 Months post operative

Fig. 1 Follow-up rate of patients.

Sexual function and mesh repair of inguinal hernia

37

sisted mainly in wound healing problems (seroma, n = 40, 17.8%; hematomas, n = 21, 9.3%; wound infection, n = 7, 3.1%) and neuralgia (ilioinguinal neuritis; n = 15, 6.7%). The wound healing complications receded spontaneously without any further problems within the rst 3 postoperative months, while the neuritis persisted partially in three (1.3%) patients. Fiftytwo patients (23.2%) mentioned preoperative sexual dysfunction related to symptoms of the groin hernia. All of these patients suffered from pain in the groin region; 31 also mentioned local pressure or tension feelings. These complaints had a negative inuence on potency (n = 21), erection (n = 15) and orgasm (n = 16). The surgical repair had a positive inuence on the sexual function, since most of the patients preoperative complaints receded and only a few new complaints appeared. As shown in Table 1, 36 patients complained postoperatively about sexual dysfunctions, which seemed to get better or completely disappeared over the next few months (mean period of 8 months). Within this group, 13 (5.8%) of these patients referred no preoperative sexual dysfunctions, while the other 23 patients had both pre- and postoperative sexual dysfunction. There is no difference in both of these groups concerning the kind or course of sexual dysfunction. Postoperative dysfunction consisted mainly of potency disorders in 63% and in orgasms disorders in 37% of patients. Almost all the patients with postoperative sexual dysfunction had suffered surgical complications (wound healing complications, n = 21) or postoperative problems (neuritis, n = 15). In 28 patients, local ndings in the inguinal
Table 1 Patients characteristics n Men Women Complications Seroma Hematoma Wound infection Neuralgia Sexual function Pre op disorder Post op disorder Post op disorder Total Potency disorders Orgasms disorders Correlated surgical problems Wound healing Neuralgia Spontaneous normalization Surgical revision + normalization Persistant disorder 210 14 40 21 7 15 52 36 36 22 14 21 15 28 6 2 % 93.8 6.2 17.8 9.3 3.1 6.7 23.2 16 100 63 37 58.3 41.6 77.7 16.6 5.5

region and sexual function came to normal without surgical revision in an average period of 8 months. Three patients with persistent neuritis, one patient with a hernia recurrence and two patients with a subjective feeling of local induration in the inguinal region were submitted to surgical revision (6, 11 and 13 months postoperatively) and their symptoms clearly receded after a median duration of 6 months after revision. Only two patients (0.9%) with normal clinical and sonographic ndings suffered from a subjective feeling of induration in the inguinal area, which appeared within 712 months postoperatively and affected their sexual life. They had not decided on surgical revision 12 16 months postoperatively. No male patient reported any disorders related to penis erection or ejaculation. Over the whole period of the present study, no other new sexual dysfunctions were reported.

Discussion
In adult patients, complications rates from open inguinal herniorrhaphy vary from 1 to 26%, with most reports ranging from 7 to 12%.8 Inguinal hernia operations can seriously affect sexual functions. A direct injury of the spermatic cord or its components (ductus deferens or pampiniform plexus of veins) can cause reversible (hematoma, seroma or orchitis) or irreversible testicular damage (atrophy or oligospermia). Operative trauma can lead to tissue or nerve injury (ilioinguinal, iliohypogastric nerves or ramus genitalis of genitofemoral nerve) leading to hypaesthesia or other neurological symptoms. While in previous years the hernia orice was simply closed with sutures, the current surgical options rely on the use of mostly non-absorbable implanted meshes to reinforce the inguinal oor. The consecutive foreign body tissue reaction can cause the mesh to shrink or lead to local tissue induration and affect nerves and other anatomical structures of importance (ductus deferens). Experimental studies on animals have shown that direct tissue contact with the mesh leads to a reactive induration of the ductus deferens, although the quality and quantity of the semen does not seem to be affected.9 Only a small number of studies to date have essentially dealt with quality of life after inguinal hernia surgical repair,10,11 but we found no other study reporting on sexual quality of life under these settings. The sexual needs of patients with groin hernias are rarely discussed openly, but they still seem to be of great importance, as our anonymous inquiry has shown (unpublished data). We have to emphasize the fact that studies referring to patients sexual life and feelings are

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difcult to set up and organize. Although our questionnaire was checked in other patients groups concerning its re-test ability, we should mention the following possible bias problems: (i) voluntary participation could promote patient selection; (ii) mistrust of disbelief as far as the anonymity was concerned could affect the sincerity of the answers; (iii) factors of co-morbidity; and (iv) the relationship state with the sexual partner was not taken into account. The above-mentioned problems can explain the relatively low incidence of preoperative sexual dysfunctions of 19% in the present study. The reported causes of these dysfunctions were symptoms associated with the inguinal hernia (pain, bulge in the groin region or fear), which lead with almost the same frequency to several sexual disorders related to orgasm, libido and penis erection. Lauman12 found sexual problems in 31% of the male patients in a representative study of nonhospitalized patients. In the present study, the operation had a positive inuence on the sexual function of patients with previous sexual disorders; an improving of these preoperative symptoms was reported in all patients in an average time of 8 months after the surgical procedure. Postoperative resolution of symptoms related to the hernia caused a complete improvement of the sexual disorders. Thirtysix patients complained postoperatively about a limitation of sexual function, which could be attributed to postoperative complications. After spontaneous or surgical improvement of these complications, nearly all patients reported normal sexual function. In conclusion, symptoms specically associated with inguinal hernias, such as groin bulge or pain, can lead to limitations of a patients sexual life. The operative procedure, performed with the implantation of a mesh in the present study, can lead to, besides the resolution of the preoperative symptoms, a recovery of the sexual life. The majority of patients with no preoperative complaints were not negatively inuenced by the surgery as far as their sexual life was concerned. Only patients with local problems (wound healing complications or neuralgias) experienced partially impaired sexual function postoperative. According to the present study, the implantation of the mesh for groin hernia repair did not

affect sexual function. However, other studies taking into account the role of the partner in a balanced sexual life, as well as the different surgical approaches of surgical inguinal hernia repair, have to be conducted in order to gain more complete information on the several aspects of this subject.

References
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