Sexual dysfunction following rectal surgery for IBD has been reported in 1-27% of cases but dysfunction is often partial and transient [119, 128, 132, 133, 142-148]. This is usually due to damage of neurological structures during pelvic dissection, although psychogenic or vasculogenic factors may contribute .
Normal sexual function in males is under the control of both the sympathetic and parasympathetic system: erection is mainly mediated by parasympa-thetic fibres, while sympathetic fibres are primarily responsible for deposition of the semen in the posterior urethra and contemporaneous closure of the bladder neck during ejaculation. Damage of this mechanism will result in retrograde ejaculation.
Parasympathetic fibres from the second, third and fourth sacral foramen give rise to the nervi erigentes. They run on either site of the pelvic wall into the lateral rectal ligaments where they constitute, together with the presacral nerves, the inferior hypogastric (or pelvic) plexus. Presacral nerves start from the superior hypogastric plexus, which is the continuation of the preaortic plexus and contain sympathetic fibres from the twelfth thoracic and the first two lumbar segments. They run on the posterolateral aspect of the pelvis, protected by the presacral fascia (Waldey-er's fascia), but at the level of the mid-distal rectum, they perforate the presacral fascia and run more laterally to reach the pelvic plexus. Cavernous nerves take origin from the most caudal portion of the pelvic plexus and descend towards the penis in a plane anterior to Denonvilliers' fascia, running along the postero-lateral aspect of the prostate .
As already seen in the previous paragraph on urinary retention, the most critical areas are represent ed by the lateral ligaments and anteriorly by the plane of Denonvilliers' fascia, where both sympathetic and parasympathetic branches can be injured. Sympathetic nerves can be also damaged near the promontory of the sacrum or during lateral dissection of the rectum. For this reason, proctectomy for benign diseases has traditionally been carried out with perimuscular dissection and possibly inter-sphincteric dissection [150-152] and this has resulted in a much lower incidence of sexual complications as compared to surgery for malignancy . However, recent studies have argued that identification of autonomic nerves, as it happens during total mesorectal excision, is the best way to lower the incidence of urinary and sexual problems both in malignant and benign rectal surgery, provided that the anterior Denonvillier's fascia is respected [111, 116-119, 154].
There are no randomised controlled trials on this aspect and the only study that has compared results after mesorectal (111 patients) or close rectal (45 patients) dissection for IBD, did not show significant differences between the two techniques in terms of permanent impotence (4.5% vs. 2.2%) or minor erectile difficulties (13.5% vs. 13.3%) . In the event of postoperative impotence, a period of observation is always indicated, because dysfunction is transitory in the majority of cases. In the mean time, other possible causes such as psychological or vascular causes should be excluded.
Problems that persist beyond 3-6 months are likely to be permanent. In these cases, the therapeutic options are injection of the cavernous corpora with vasodilatory drugs (papaverine, prostaglandin) or surgical implant of either a malleable or inflatable prosthesis . The last are preferred because they give a more natural appearance to the penis  and a higher grade of satisfaction . New drugs such as sildenafil citrate (Viagra, Pfizer, NY, USA) require an intact penile innervation to work. In practice they are only effective in patients with partial but inadequate erections .
Retrograde ejaculation, which is the result of isolated damage of the sympathetic nerves, may be treated with sympathomimetic drugs. If they fail and the patient desires to procreate, sperm can be drawn from the bladder for artificial insemination [157, 158]. In view of this possible complication, some authors suggested that young male patients should cryopreserve sperm before elective proctectomy , while others find this expedient unnecessary and expensive .
Rectal surgery may also have negative effects on sexual function in women: in fact dorsocaudal dislocation of the vagina after proctectomy or formation of postoperative scarring angulating the vagina may be responsible for dyspareunia and chronic infections secondary to retained secretions [161, 162]. These problems are less frequent after restorative proctocolectomy, where the presence of the ileal-pouch contributes towards maintaining the vagina in its normal position . This has been confirmed in a survey that compared sexual function in women after restorative proctocolectomies or after procto-colectomy and Kock pouch: the incidence of dys-pareunia was 18 and 38% respectively and none of the patients in the first group complained of vaginal discharge, compared to 18% of the second group .
Finally, sexuality may be negatively influenced by surgery when this results in stoma formation. In fact it has been demonstrated that the presence of stoma is a strong psychological deterrent to sexual intercourse [164,165].
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