I read with both interest and dismay the article, “Consistently inconsistent, the posterior vaginal wall,” in which Drs Hale and Fenner describe symptoms of posterior vaginal wall prolapse, describing dyssynergic defecation, constipation, splinting, tenesmus, etc and rightfully bemoan that “… patient expectations are not met by standardized surgical procedures.” Although I laud the authors for memorializing the lack of global success of these site specific repairs, I posit that one of the reasons for failure is a disconnect between patient and provider in history taking and focus of repair when no attention is paid to sexual complaints and when no effort is made during the surgical repair to address sexual concerns.

We may say we do not hear sexual complaints from our patients, but none will come our way if we fail to ask. A “don’t ask/don’t tell” philosophy appears to be routine in many if not most patient/physician interactions. We must expand our horizons to incorporate sexual concerns and address these in our repairs to include a multilayered closure to minimize vaginal diameter and approximate the levator musculature, well support the pelvic floor, strengthen and elevate the perineal body, and moderate the size and appearance of the introitus with an aesthetically mindful repair.

To ensure a greater success rate, in addition to personalizing the repair technique, I submit that addressing and incorporating our patients’ sexual concerns into repair planning and execution, in addition to incorporation of pre- and postoperative pelvic floor physical therapy, will significantly improve the overall success rates.

The authors state, “… As the levator drops, a more vertical vagina axis is produced …” without taking the important next step and discussing the sexual effects of this descent and relaxation. This produces effects relating to orgasm and sexual enjoyment, which are ignored in the review. Also ignored is the fact that a woman’s sexual enjoyment is mediated by her genital self-image.

An idealized patient is presented in the article, her symptoms discussed and analyzed. No one asked her about sexual or body image issues, and nowhere in her therapy are these important aspects taken into account. In the discussion of surgical therapy, there is no mention of incorporating sexual and aesthetic awareness.

I applaud the authors for questioning the one-size-fits-all traditional site-specific posterior colporrhaphy approach to pelvic floor repair, but the review unfortunately appears to be characterized more by what is missing than what is presented. No wonder “… What appears to be a straightforward condition to diagnose and treat surgically … has proven to be frustratingly unpredictable with regard to symptom relief for patients” when the entire focus is on the bulge. I await a time when clinicians add concern about rehabilitation of sexual function, aesthetics, and muscular strength when approaching the issue of pelvic floor repair.