To investigate the predictors of vaginal laxity (VL) and female sexual dysfunction (FSD) in a multi-ethnic population.

A cross-sectional study conducted at tertiary hospital, from July to December 2022, with design and reporting following STROBE guidance. The hospital audit department granted approval for the study. All women referred to the Urogynecology Clinic were included. Data collected included sociodemographic variables, clinical presentation, Pelvic Organ Prolapse Quantification system (POP-Q), sexual function (Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised - PISQ-IR), VL (Vaginal Laxity Questionnaire - VLQ), sexual attitudes (Brief Sexual Attitudes Scale - BSAS), sexual distress (Female Sexual Distress Scale-Revised - FSDS-R), sexual quality of life (Sexual Quality of Life-Female - SQOL-F), vaginal symptoms (International Consultation on Incontinence Questionnaire Vaginal Symptoms - ICIQ-VS), and pelvic floor disorders. The chi-square or Fisher's exact tests were used to compare the categorical variables between the groups. The Mann-Whitney test and the Kruskal-Wallis test were used for numerical variables between groups. Unadjusted and adjusted regression analyses were used to identify predictors of VL and FSD.

The mean age was 41.6 years, and four major ethnic groups were identified. Among participants (n=200) vaginal delivery, multiparity, perineal laceration and menopause were significantly more frequent (all p<0.05) in those reporting VL. No differences were found in ethnicity (P=0.698). Participants with a loose vagina and those with genital prolapse scored significantly worse across all domains on the ICIQ-VS (P<0.001), on SQoL-Female (P<0.001), and FSDS-R (P<0.001) scores. Compared to nulliparity, primiparity and multiparity increased by approximately five and twelve times the odds of VL, respectively (unadjusted OR 5.00, 95% CI 2.05–12.19; OR 12.75, 95% CI 5.77–28.14). Menopause and perineal laceration increased by five times the odds of VL, respectively (unadjusted OR 5.23, 95% CI 2.71–10.09; OR 5.89, 95% CI 3.05–11.39). Type of birth and POP-Q staging was highly associated with VL. In multivariate analysis, menopause, multiparity, and POP-Q staging 1 and 2 remained associated with VL, increasing the odds of VL by four, three and ten times, respectively (adjusted OR 4.72, 95% CI 1.49–14.97; adjusted OR 4.07, 95% CI 1.40–11.81; adjusted OR 3.11, 95% CI 1.09–9.58; adjusted OR 10.04, 95% CI 1.62–62.15).

Around 33% of the investigated women had symptoms of VL in our population, consistent with previous secondary care estimates[1]. Sexual function, vaginal symptoms, quality of sexual life and sexual distress were significantly impacted in our participants with VL. This highlights the need to assess laxity alongside sexual function in patients attending urogynecology clinics. POP grade I and II staging were predictors of VL in the multivariate analysis. Previous reports have suggested that women with VL may be representative of the early stages of POP, although most studies investigating VL have excluded participants with prolapse symptoms greater than grade II. Contrasting with our findings, VL was not correlated with POP in one earlier study[2]. Complaints of VL can be reported after the first delivery and worsen in subsequent deliveries[3]. According to our findings, parity, perineal lacerations and types of delivery were predictors of VL. In the present study, not only was vaginal delivery a predictor of VL, but also caesarean delivery. Participants who underwent both types of delivery had an even greater chance of developing VL. The protective effect of caesarean section on the pelvic floor remains under debate.

Vaginal symptoms, sexual quality of life and sexual distress were significantly affected in participants with VL. Menopause, multiparity and POP were all associated with greater VL complaints. No differences were found in ethnicity.

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