Sexual Pain, Pelvic Floor

Urinary incontinence and/or pelvic organ prolapse affects nearly a third of premenopausal women and as many as 45% of postmenopausal women. The problems associated with incontinence and prolapse impacts the social, psychological, occupational, domestic, physical and sexual well-being of women. Studies of sexual function in women with incontinence and/or pelvic organ prolapse fall into two groups: those that concentrate on vaginal anatomy and those that evaluate sexual function.

Just because the surgery is considered successful in repairing vaginal damage does not mean that the surgery has ?cured? any sexual dysfunction. Much of the literature on sexual function in women with pelvic floor disorders is limited by its retrospective design, small numbers, and the bias of physicians who evaluate the outcome of their own operations. Until recently, evaluation of sexual function in women with pelvic floor disorders was also limited by the lack of a condition-specific validated questionnaire. Use of non-validated or general questionnaires to evaluate quality of life outcomes may have led to understatements of the effect on sexual function because of the questionnaires? insensitivity to differences within a specific group of women. Yet as interest in the impact of pelvic floor disorders on quality of life has grown, research into sexual function of patients with such disorders has expanded.  

{mosbanner:id=1:right:0}The traditional model of sexual function for men and women is linear and includes four phases: desire, arousal, climax and resolution. Newer models describe a more circular relationship between satisfaction and intimacy. Although rates of sexual activity decline with age, population based studies indicate continued sexual activity  in 47% of married women aged 66 ?71 and a third of women over 78.  The incidence of incontinence and prolapse are increased in these age groups. Factors which negatively influence sexual activity in elderly women include lack of a partner, erectile dysfunction of a partner, medical illness, and lack of a libido. Sexual dysfunction occurs in up to 35 percent of American women with lack of libido being the most common form  Actual data on the sexual function of women with urinary incontinence is scarce. An evaluation of 103 female patients of an incontinence clinic found that 46% admitted urinary symptoms affected their sexual life. Women with overactive bladder problems (detrusor instability) were more likely to complain of vaginal pain (dyspareunia) than women with stress incontinence. Another evaluation of 400 incontinent women found many patients were reluctant to raise questions regarding sexual function with their providers, although urinary incontinence with sexual penetration or with orgasm was common. Recent studies comparing women with stress incontinence and overactive bladder found that women with overactive bladder report poorer sexual functioning than women with stress urinary incontinence. However, none of these studies used validated or reliable questionnaires and most were limited by small numbers of patients involved.  A recent comparison of women with and without urinary incontinence and/or pelvic organ prolapse found that those with incontinence or prolapse reported less frequent sexual activity and a higher incidence of dyspareunia, although measurements of satisfaction with sexual activity were similar between groups. This study was the first to use a condition-specific validated and reliable questionnaire, but was limited by the lack of objective evaluation of prolapse or incontinence symptoms. In summary, incontinent women report incontinence with sexual activity and their incontinence may affect their sexual lives.  Additionally, women with bladder control problems may have poorer sexual function than women with stress incontinence.

How does surgery for stress urinary incontinence affect sexual function?  A prospective cohort study followed 55 patients after surgery for urinary incontinence.  Of these patients, 24 % reported that their sexual function improved, 67% found their sex life unchanged, and 9% complained of deterioration of their sex life. Women who underwent posterior surgery were found to have more complaints of dysfunction than patients without posterior repairs.   More recently, 45 women were followed prospectively after surgery for stress urinary incontinence.  Both the partners?and the patients? attitudes following surgery were evaluated.  Approximately one-third of women reported increased sexual desire following surgery for incontinence, while greater than 50% of men reported an increase in desire following their partner?s surgery. A large multicenter trial evaluated 360 women prior to and at three, six, and 12 months following surgery for stress urinary incontinence.  The majority of women reported no change in their sex life following surgery, while 13% reported that their sex life improved and 22% reported that it deteriorated. Overall, prospective studies evaluating sexual function have revealed conflicting results regarding change in sexual function that does not seem to be linked to resolution of the patient?s incontinence.