Strengths and limitations
This is the first systematic review with critical appraisal on sexual dysfunction including dyspareunia, vaginal dryness and body image dissatisfaction as outcomes. We focused on studies which used standardized validated tools and definitions consistent with the IUGA/ICS terminology for the assessment of sexual health in women with pelvic floor dysfunction, with the intention to pool comparable results(1). Nonetheless, we acknowledge some limitations. First, we could include only observational studies in the quantitative analysis. Among those, only 44% were of high quality. As a result, the level of the evidence is low. Second, we could include in the quantitative synthesis, only studies were the outcome measurements were presented as dichotomous. Studies reporting on sexual function as mean score were excluded from quantitative analysis, as the individual data could not been retrieved. A solution may be to conduct a meta-analysis with individual patient data (if available). Moreover, not all eligible studies performed multivariate analysis with logistic regression. Therefore, in our meta-analysis we reported summary ORs from count data and crude ORs, and the possible effect of confounders cannot be excluded. Third, we retrieved few studies that discriminated between elective and emergency cesarean section and among the types of operative delivery, and their association with sexual function after delivery (26-30). Fourth, there is only one study of low quality reporting on vaginal dryness after delivery (26). Furthermore, only two studies addressed body image dissatisfaction(26, 31). Their definition and methodology differ and their findings are inconclusive, which makes is difficult to make a statement about a possible correlation between sexual dysfunction and body image in the first after delivery.