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sintomas urinarios y disfuncion sexual

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Curr Urol Rep (2013) 14:298–308
DOI 10.1007/s11934-013-0344-7
MEN'S HEALTH (J MULHALL, SECTION EDITOR)
Urinary Disorders and Female Sexual Function
Jaclyn Chen & Genevieve Sweet & Alan Shindel
Published online: 29 May 2013
# Springer Science+Business Media New York 2013
Abstract Overactive bladder urinary incontinence and female sexual dysfunction are common in women, but often
go unreported and/or untreated. All of these conditions can
have a markedly negative impact on quality of life. There is
a growing body of evidence that sexual and urinary problems are often comorbid and possibly synergistic in women.
Increasingly robust evidence indicates that management of
urinary concerns may enhance sexual function and quality
of life. It is important for health care providers who see
women to consider both urinary and sexual health concerns
during patient encounters. Additional research attention to
the interrelationships between these genitourinary disorders
is warranted.
Keywords Incontinence . Stress urinary incontinence .
Overactive bladder . Sexual function . Coital incontinence .
Urethral slings . Antimuscarinics . Female sexual
dysfunction
Introduction
The general term “urinary symptoms” encompasses a range
of often comorbid concerns relating to micturition.
Examples include overactive bladder (OAB, typically defined as recurrent and bothersome symptoms of urgency to
void), urge urinary incontinence (UUI, loss of urine associated with a sudden overpowering urge to void), stress
J. Chen : G. Sweet : A. Shindel (*)
Department of Urology, UC Davis Medical Center,
4860 Y Street Ste 2200,
Sacramento, CA 95817, USA
e-mail: Alan.shindel@ucdmc.ucdavis.edu
J. Chen
e-mail: Jaclyn.chen@ucdmc.ucdavis.edu
G. Sweet
e-mail: Genevieve.sweet@ucdmc.ucdavis.edu
urinary incontinence (SUI, loss of urine associated with
ValSalva or other maneuvers involving increased intraabdominal pressure), and mixed urinary incontinence
(MUI, combined SUI and UUI) [1, 2, 3•, 4, 5]. Between
11 and 73 % of women in community-based studies suffer
some urinary symptoms [4, 6, 7•, 8]. Between 12 and 46 %
of American women experience some degree of urinary
incontinence [9].
Urinary symptoms may exact a heavy toll on quality of
life, and in severe cases may lead to complete social isolation. Incontinence is a particularly embarrassing and potentially disabling condition that may lead to depression, social
isolation, and worsening general health [10, 11]. It is estimated that incontinence and OAB cost the US Health care
system 32.1 billion dollars in 2000 [2].
Objective studies on female sexuality report relatively
high prevalence (up to 50 % in some series) of female sexual
dysfunction (FSD) [12–14]. However, studies that assess
distress from sexual issues tend to report lower rates of
bothersome symptoms, in the range of 15–20 % [15, 16].
Hence, “sexual dysfunction” as defined in some studies may
not accurately reflect the subject population’s actual experience of bothersome sexual distress. Variations in sexual
priorities and interest further complicate assessment of sexual distress and dysfunction in populations of women.
It is intuitive that urinary symptoms may often be associated with impairment of female sexual function and/or
sexual bother [6, 7•, 8, 17]. In this review, we highlight
the peer-reviewed literature on the interrelationship of urinary symptoms and FSD. The body of literature from which
this manuscript is drawn relies heavily on a heterogeneous
collection of survey metrics and questionnaires; variations
in the source data of necessity lead to somewhat heterogeneous and conflicting results [18, 19]. Regardless, there is a
reasonable body of evidence that urinary and sexual symptoms are often comorbid, and that attention to urinary problems may enhance sexual quality of life.
Curr Urol Rep (2013) 14:298–308
Methods
We performed a PubMed search using Boolean linking
language and the following terms: “overactive bladder”,
“stress urinary incontinence”, “urinary incontinence”, and
“sexual dysfunction.” The reference list for selected articles
was consulted for additional citations of interest, some of
which were incorporated into the review. We did not include
unpublished abstracts in our review. Criteria for statistical
significance were set at p<0.05.
Sexual and Urinary Problems are Frequently Comorbid
Between 19 and 50 % of women with urinary incontinence
or pelvic floor disorders such as prolapse may experience
sexual dysfunction, dyspareunia, reduction in sexual interest, and/or decline in their frequency of sexual activity [6,
20–27]. OAB and urinary incontinence have been associated with a wide array of impairments in sexual response,
including declines in desire, arousal, lubrication, orgasm
general sexual satisfaction, and increases in sexual pain
relative to women without urinary symptoms [23, 28].
Some studies have suggested urinary symptoms are not
always associated with sexual dysfunction [29].
Women who are younger and more likely to be sexually
active tend to have greater sexual distress related to urinary
issues [28, 30, 31]. In sexually inactive women distress may
not be present, despite urinary issues that would in general
portend sexual problems. In some cases, cessation of sexual
activity is due to urinary symptoms themselves; in these
circumstances, appropriate medical attention may permit a
woman to resume a satisfying sexual life should she so
desire [32–35].
As many as 40 % of women cite sexual intercourse as an
inciting or exacerbating event for urinary symptoms [7•,
36••]. Coital incontinence, i.e. loss of urine during coital
sexual activity, is surprisingly prevalent. Coital incontinence
may occur in between 10 and 67 % in patients seeking
treatment for urinary symptoms [1, 5, 36••, 37, 38], and in
as many as 2–10 % of women in general populations [5].
Coital incontinence appears to be most prevalent in women
with SUI; one study found that coital incontinence was
detected in 89 % of women with SUI compared to 33 %
of women with OAB [1, 39].
Coital incontinence may be subdivided into penetration
incontinence (loss of urine with vaginal penetration) and
orgasm incontinence (loss of urine at orgasm).
Interestingly, the subtype of coital incontinence seems to
vary dependent on baseline urinary symptoms. In a 1988
study of women suffering from penetration incontinence
70 % had SUI and 4 % had OAB; in women with orgasm
incontinence the prevalence for SUI and OAB was 42 % and
299
3 %, respectively [1]. In a more recent study, 84 % of
women with SUI experienced penetration incontinence
compared to 9 % of women with OAB. Conversely, 24 %
of OAB experienced orgasm incontinence compared to 5 %
of patients with SUI [39]. While the percentages vary somewhat based on method of assessment it is apparent that
penetration incontinence is more often associated with SUI
whereas orgasm incontinence may occur in either situation
[40].
Studies on Comorbidity of Sexual and Urinary Problems
Using Validated Scales
In a study of sexually active women, 112 women with
urodynamically proven OAB and 165 healthy controls without urinary symptoms were evaluated using the Female
Sexual Function Index (FSFI). Sexual dysfunction (defined
as FSFI score<26.5) was seen in 47 % of OAB group and in
22 % of the controls. Women with OAB had lower mean
scores for all six domains of the FSFI [31].
In a survey of 292 gynecology outpatients over age 40,
26 % reported sexual distress per the Female Sexual Distress
Scale (FSDS). Particularly common problems included
avoidance of sexual activity for fear of incontinence, decreased arousal, infrequent orgasms, and dyspareunia. These
sexually distressed women tended to be younger (mean age
55 years versus 57 years) and also had higher rates of
depressive symptoms as assessed by the Center for
Epidemiologic Studies Depression Scale (CES-D). Of note,
just 80 (27 %) of these subjects were initially seeking care
for pelvic floor concerns; the remainder were presenting for
annual gynecological visits or for treatment of other gynecological conditions [41].
In a study of 8,085 women from the general populations
of the United Kingdom, Sweden, and United States, it was
determined that OAB symptoms (assessed with Likert-style
questions based on International Continence Society definitions for OAB) were present in 33–41 % of female subjects.
Nearly two-thirds (65 %) of subjects without OAB were
sexually active; sexual activity was less common in women
with OAB (59 %) and in women with OAB and incontinence (51 %). Women with OAB were also at higher risk of
decreased sexual enjoyment [42••].
Studies Suggesting that OAB Portends Worse Sexual
Problems Compared to Other Urinary Syndromes
Several studies have suggested that women with OAB in the
presence of incontinence have the highest rates of dissatisfaction, worst quality of life, and highest rates of sexual
impairment [43, 44]. In a urodynamic study of 118 sexually
300
active women, subjects were separated into SUI, UUI, and
MUI groups. Of these patients, MUI patients had the lowest
(i.e. best) pelvic organ prolapsed/urinary incontinence sexual questionnaire (PISQ-12) scores, followed by patients
with SUI. Patients with UUI and urodynamic evidence of
detrusor over-activity had the highest (worst) PISQ-12
scores [45]. As women with OAB in the absence of UUI
were not enrolled, the incremental sexual bother of OAB
alone versus OAB with UUI cannot be determined from this
study.
A small study from Korea using nonvalidated instruments for the assessment of sexual activity suggested that
both OAB and urinary incontinence (not otherwise specified) were both associated with worse sexual function, but
OAB was significantly more predictive of sexual problems
than SUI [46]. Similarly, a population-based study of women in Taiwan using a translated version of the Bristol Female
Urinary Tract Symptoms Questionnaire reported a progressively greater prevalence of interference in sexual life and
lower overall quality of life in women with SUI, OAB, and
MUI [47].
In a study of women with urodynamically proven OAB
or SUI, it was determined that women with OAB had
generally poorer marital adjustment scores (assessed by the
Dyadic Adjustment Scale) and lower sexual satisfaction
(assessed by the Derogatis Sexual Functioning Inventory)
compared to women with normal lower urinary tract function. There was no significant difference in sexual interest
between women with OAB and healthy women.
Interestingly, a trend towards similar relationships was noted
in women with SUI, but the relationship was less robust;
only in global marital adjustment was there a significantly
lower score in women with incontinence compared to women without urinary symptoms. It is worth noting that women
in the OAB arm were younger than in the other two arms
(mean age 43 years versus 49 and 50 years); this may
influence the importance and bother ascribed to sexual
symptoms in different groups [48].
Studies Suggesting that SUI Portends Worse Sexual
Problems Compared to Other Urinary Syndromes
A Korean study of women with SUI versus OAB reported a
significantly greater likelihood of dyspareunia in women
with SUI. There was also a trend towards more coital
incontinence in women with SUI, but this did not meet strict
criteria for statistical significance (p=0.056). Using the
Bristol Female Lower Urinary Tract Symptoms questionnaire to assess sexual bother, the authors determined that
global sexual bother was slightly higher in women with
SUI, but this was not strictly statistically significant (p=
0.096) [49].
Curr Urol Rep (2013) 14:298–308
A study from Japan reported that SUI was associated
with generally worse sexual function outcomes compared
to other urinary complaints. From a survey population of
576 female hospital workers, 146 evaluable responses indicated that 72 women had experienced urinary symptoms, 17
had UUI, and 35 had SUI (all assessed with a urinary
symptom metric validated in Japan). Women with SUI had
significantly lower FSFI scores for the desire, arousal, and
lubrication domains compared to women without SUI urinary symptoms. The difference in FSFI was not significant
between women with or without other urinary symptoms
[50].
It is safe to surmise that all women with urinary symptoms are at increased risk of sexual dysfunction and the odds
of sexual dysfunction increase as the urinary symptoms
become more complex and/or severe. Women with the combination of OAB and UUI or MUI appear to have worse
sexual function [51]. However, there may be individual,
cultural, and/or regional differences in the sexual ramifications of the various urinary syndromes [29].
Mechanisms and Etiology of Female Sexual Dysfunction
in the Patient with Urinary Symptoms
In some cases, a single underlying cause (e.g. vulvovaginal
atrophy, gynecological surgery, pregnancy/parturition) may
predispose a woman to both sexual and urinary problems
[22, 41, 52]. However, there are few data to support a direct
causative mechanism linking most FSD and urinary
symptoms/incontinence. Perturbations of sexual function
from urinary symptoms appear to be mediated in most cases
by voiding symptoms and/or fear of urinary loss with sexual
activity.
Although there is no consistent anatomical abnormality
detected in women with coital incontinence [53],
urodynamic studies performed during orgasm in healthy
women have demonstrated involuntary bladder contractions
and urethral relaxation [54]. It is conceivable that these
orgasm-related effects may predispose women with already
tenuous continence mechanisms (urethral sphincter incompetence, OAB, etc.) to have coital incontinence [53].
Treatment of Urinary Symptoms and Effects on Sexual
Function
Therapy for urinary issues may have a positive effect on
sexual function by mitigating distressing symptoms [7•];
however, treatment-related side effects or complications
may attenuate sexual function gains or even worsen sexual
function overall [6, 44]. Careful patient counseling and
Curr Urol Rep (2013) 14:298–308
documentation of baseline sexual function are required before any therapy for urinary symptoms.
Conservative Measures
Education and advice may yield sexual function benefits in
nearly every setting. Timed voiding, education of the patient
and her partner on the benignity of exposure to sterile urine,
fluid avoidance and/or voiding immediately prior to sexual
activity, and use of sexual lubricants may help sexual function in virtually any type of urinary syndrome [7•].
Medical Therapy for OAB
Medical therapy for OAB may reduce fear of urine loss
and/or urgency during sexual activity [7•]. The positive
effects of medical therapy for OAB symptoms on sexual
function may be lessened by the risk of medication side
effects [55].
A small trial of 30 women with OAB (assessed by ICS
criteria) reported a 70 % prevalence of sexual problem as
assessed by the Arizona Sexual Experience Scale. After
3 months of treatment with tolterodine in an open label
fashion, the rate of sexual dysfunction was 13 % in 28
patients who followed up. Improvements were noted in
sexual desire, arousal lubrication, orgasm, and orgasm satisfaction at 3-month follow-up and were more pronounced
in women with severe urinary symptoms at baseline [56].
A 12-week randomized placebo controlled trial assessed
tolterodine versus placebo in a population of 330 women
with OAB and UUI. The PISQ-12 and the Sexual Quality of
Life-Female (SQLF) questionnaire were used to assess sexual function outcomes. Tolterodine was efficacious in the
treatment of OAB and UUI symptoms; women treated with
tolterodine had improvements in SQLF and the physical
domain of PISQ-12; there was no significant mean difference in the partner or emotional/behavioral domains of
PISQ-12 in treated women between baseline and 12-week
follow-up. Women treated with tolterodine had significantly
greater improvements in sexual function when compared to
women receiving placebo [57]. A 12-week open-label extension study in this population examined changes in 161
women who were sexually active at baseline and took
tolterodine throughout all 24 weeks of the study. Mean
improvements in OAB symptoms noted at 12 weeks were
maintained, but there were no significant additional changes
except for continued improvement in concerns relating to
coital incontinence [58].
In a 6-month open label trial of oxybutynin for OAB with
or without incontinence (n=2,508 women, 84 % postmenopausal, and 370 men) sexual function was assessed at
baseline with sexuality specific metrics from the Beck
Depression Inventory and the King’s Health Questionnaire.
301
Of note, the authors coded respondents who answered “n/a”
to questions on sexuality as sexually inactive, but included
all other respondents as sexually active (59 %), including
those that endorsed “not at all” responses to metrics. At the
end of study, coital incontinence had decreased from 23 to
19 % of the population. Improvement in sexual function was
reported for 19 % of subjects, typically due to increased
interest in sex, compared to 11 % of respondents who
reported worsening sexual function of unclear nature [24].
There are numerous methodological limitations of this study, including assumption about absence of sexual activity
without explicit questioning on this, failure to use genderspecific sexuality instruments, lack of subset analysis between gender groups, and lack of clarity on what constituted
relevant change in sexual function. Furthermore, data were
analyzed as a single pool; there is no comment within the
paper about gender differences in responses.
Anti-muscarinics are thought to have inferior efficacy in
treating orgasm incontinence in women with detrusor over
activity. However, there may be some utility of this class of
medications for treatment of penetration incontinence
[36••]. These relationships are somewhat counter-intuitive,
given other publications suggesting that orgasm incontinence is more frequently associated with OAB and penetration incontinence with SUI [1, 39].
Vulvovaginal atrophy (commonly associated with natural
or iatrogenic menopause) may contribute to both sexual
symptoms (dyspareunia, decreased lubrication, decreased
arousal, etc.) and urinary symptoms (incontinence, urgency,
frequency, etc) [52]. Local or systemic estrogen therapy has
been shown to ameliorate the various signs and symptoms
of vulvovaginal atrophy [59], with potential benefits for
both urinary and sexual function [33]. Despite substantial
concerns in both the medical and lay community about
hormone replacement therapy, this option should be considered in women with vulvovaginal atrophy and bothersome
sexual and/or urinary symptoms [52].
Surgical Management of OAB with Sacral
Neuromodulation
Yih prospectively evaluated 167 women who underwent
sacral neuromodulation; of note, only 106 of these patients
had OAB (n=27) or OAB with UUI (n=79); the remainder
had a mix of urinary retention and pelvic/bladder pain.
Sexual function was evaluated with the FSFI at 12-month
follow-up. The subjects were divided into a sexually functional group (n=13, all sexually active at baseline) and a less
functional group (n=136, 62 [46 %] of whom were sexually
active at baseline) based on the commonly used FSFI-total
cut-off score of 26. In the group with higher (better) FSFI
scores at baseline, there was a statistically significant decrease in mean FSFI-total score from 27 to 25; this was
302
driven primarily by a decline in mean orgasm and overall
satisfaction domains. Of note, at follow-up, this group included just nine patients, so results must be interpreted with
caution. Amongst women in the less sexually functional
group, ten who had not previously been sexually active were
sexually active at follow-up; interestingly, partner variables
were responsible for initiation of sexual activity in eight of
these women, with just two reporting resumption of sexual
activity due to improvements in urinary symptoms. Women
in this group experienced a significant increase in total FSFI
score, as well as domain specific improvements in desire,
orgasm, pain, and satisfaction [19]. Heterogeneity of inclusion criteria, the possibility that changes in FSFI in both
groups represent regression to the mean, and some issues
with endpoints and follow-up mandate interpretation of this
study with caution.
Gill et al. reported a subset analysis of ten sexually active
women with OAB and incontinence treated with sacral
nerve stimulation for overactive bladder. At first follow-up
(mean 3 months), there was less concern about coital incontinence and significant improvement in mean domain scores
for arousal and satisfaction amongst eight women sexually
active at follow-up; two had not resumed sexual activity for
fear of post-operative complications. These changes were
associated with positive effects on urinary function measures [60]. The limited number of patients complicates
interpretation of these data.
Another study of sacral neuromodulation reported on 27
women (13 for OAB without pain and 12 for pelvic pain
with urinary symptoms) who were sexually active at baseline and had at least 6-month follow-up data. In the OAB
group there was a mean improvement in total-FSFI score
(18.6 at baseline to 22.4 post-procedure), but this was not
statistically significant. The greatest magnitude of change
was noted in FSFI-satisfaction, although this did not attain
statistical significance [61]. Small sample size and exclusion
of women who might be sexually inactive due to pelvic
floor concerns limits conclusions that can be drawn from
this dataset.
Peripheral percutaneous tibial nerve stimulation was
used to treat in population of 121 individuals with
pelvic floor complaints (76 women, 61 of whom had
OAB). A nine-item survey was used to assess sexual
function at baseline and 12-week follow-up. Patients
who were dissatisfied with sexual function at baseline
had a mean increase in sexual function scores and
sexual activity at follow-up; although separate testing
was not reported, female gender was associated with
greater likelihood of sexual improvement. There was
no net change in sexual function in patients who had
neutral or good sexual function before treatment [62].
A summation of several highlights from the literature on
sexual function outcomes of OAB is presented in Table 1.
Curr Urol Rep (2013) 14:298–308
Management of SUI
A brief summary of sexual function outcomes from SUI
management with pelvic floor PT and recent studies on
urethra slings is presented in Table 2.
Pelvic Floor Physical Therapy
Pelvic floor rehabilitation may be a useful as a monotherapy
or as adjunctive therapy for SUI. One small series reported
on 16 women with stress urinary incontinence on
urodynamics (five of whom also had coital incontinence)
who underwent a comprehensive pelvic floor rehabilitation
including biofeedback, functional electrical stimulation pelvic floor muscles exercises, and vaginal strengthening exercises with retention of vaginal cones. 81 % of patients were
dry after treatment (not requiring pads) and none had coital
incontinence. Mean scores for all six domains of the FSFI
were significantly higher 5 months post-treatment compared
to baseline [34]. In another series, 70 women with
urodynamic SUI were enrolled in a 12-month course of
pelvic floor muscle training. Incontinence episodes decreased by 38.1 %, with a significantly improved FSFI
scores from 20.3 to 26.8 [63]. Of note, subjective assessment of sexual function pre-treatment and post-treatment
was not explicitly stated in either study.
Surgical Management of SUI
The particular sexual function benefits of SUI treatment
appear to derive from reduction in fear of coital incontinence [3•, 18, 40, 64]. However, sexual function may worsen after surgical therapy for SUI due to de novo urgency
symptoms, erosion of implanted mesh, dyspareunia, or failure of the procedure to correct SUI [32, 65]. There are also
concerns that urethral sling placement may contribute to
fibrosis and reduced elasticity of the anterior vagina [36••].
In one ultrasound study of clitoral blood flow before and
after incontinence surgery, there were significant declines in
peak systolic velocity in the clitoral arteries after tension
free vaginal tape (TVT) placement [66]. These changes may
theoretically contribute to decreased sexual sensitivity.
Careful discussion of benefits and risks (established and
theoretical) is critical in counseling women on potential
outcomes; urodynamic testing may help guide this conversation [7•].
Surgical Management of SUI with Urethral Slings
A 2011 meta-analysis of 1,578 women in 18 studies of SUI
without pelvic organ prolapse managed with sub-urethral
slings estimated a 32 % chance of improvement in sexual
function post-operatively compared to a 13 % chance or
33
13
Gill et al. 2011
[REF 60]
Ingber et al. 2009
[REF 61]
Van Balken et. al
2006 [REF 62]
61
167
Yih et al. 2013
[REF 19]
3.9 mg/day transdermal
oxybutynin patch
changed twice weekly
Tolterodine ER
4 mg daily
Treatment
Percutaneous Tibial
Nerve Stimulation
Sexual function
51 % requested continuation
of therapy
Mean FSFI increased to 22.4, difference
not statistically significant
Improvement in sexual function in group
that was initially dissatisfied
Improvement in sexual quality of
life and physical symptoms of
sexual function, no change in
behavioral/emotional domain
Improved coital incontinence Effects of OAB on sex life improved
in 12.6 % and worsened in
in 19 % of subjects, 11 % worsened.
7.5 %
Improved relationship with partner
and interest in sex 19.6 %
50 % Improvement in
Poor sexual function group showed
ICSI-PI scores
improvement in FSFI subdomains
(desire, orgasm, satisfaction, and pain).
More sexually functional group worsened
in orgasm and satisfaction.
Improvement based on
Improved arousal 0.7, satisfaction 1 and
PGI-S, HIS, UDI-6, IIQ7
overall function 3.2 per FSFI
Reduction in UUI, OAB,
other symptoms
Incontinence improvement
Sacral Neuro-modulation Not reported here
Sacral neuro-modulation
152 (91.0 %) FSFI score <26 Sacral neuro-modulation
586 (23.1 %) reported
negative impact on sexual
function
Mean Sexual Quality of
Life-Female questionnaire
below normal levels
% sexual dysfunction
Clinical history, voiding diary, 69.7 % not sexually
collection of validated and
active and may or may
investigator designed
not be in a relationship
questionnaires
Clinical history, voiding diary, Mean Baseline
questionnaires
FSFI-total 18.6
Clinical history, voiding diary, 40 % of subjects reported
questionnaires
being dissatisfied or very
dissatisfied
Symptoms of overactive
bladder syndrome (N=106),
interstitial cystitis (N=49),
or urinary retention (N=11)
2,878 Clinical history of urge
incontinence, urgency,
frequency
Clinical history, voiding
diary, questionnaires
Rogers et al. 2008 330
[REF 57]
Sand et al. 2006
[REF 24]
Diagnosis at enrollment
N=
Table 1 Recent studies on treatments for OAB and UUI
Curr Urol Rep (2013) 14:298–308
303
150
96
Dursun et al. 2013
[REF 37]
Urodynamic showing pure
SUI and normotonic urethral
pressure
Symptomatic evaluation. 48 %%
with SUI, 52 %% with stress
predominant mixed incontinence
Subjective report, positive
standardized stress test
597
Urodynamic testing
133
Urodynamic testing
Clinical history and urodynamic
16
83
Urodynamic testing
Stress incontinence diagnosed by?
70
Naumann et al.
2013 [REF 67]
Liang et al. 2012
[REF 68]
Zyczynski et al.
2012 [REF 69]
Zahariouu et al.
2008 [REF 63]
Rivalta et al.
2010 [REF 34]
Filocamo et al.
2011 [REF 32]
N=
Table 2 Recent studies on treatments for SUI
TOT
TVT/sling
Mid urethral sling
TOT
Mid urethral sling
Pelvic floor rehabilitation
Pelvic floor rehabilitation
Treatment
84–88 %% resolution by negative
cough stress test or improvement
in continence
86 %% resolution by ICIQ-SF
93 %% anatomic success
Incontinence episodes mean
decrease 38.1 %%
81 %% dry, 12.5 %% improved
incontinence
86 %% dry or improvement
in symptoms
Incontinence improvement
95 %% of coital incontinence cured,
FSFI overall no change, improvement
in sexual satisfaction and pain domains
40 %% of non-sexually active became
active, 7.5 %% sexually active became
inactive. Improvement in FSFI and
all sub domains
Climax and emotional response worsened
based on PISQ-12 and UDI-6
Improvement in pain, incontinence,
and fear based on PISQ-12. Percentage
of sexually active women did not change
with treatment
53.3 %% with Improved FSFI, 6.7 %%
worsened, 38 %% with no change
FSFI improved, each sub domain improved
FSFI All domains Improved
Sexual function
304
Curr Urol Rep (2013) 14:298–308
Curr Urol Rep (2013) 14:298–308
worsening sexual function [3•]. The most common cause of
worsening sexual function after urethral sling placement
appears to be de novo dyspareunia or urgency [18]. A
separate review estimated cure rates specifically for penetration incontinence with surgical sling at about 80 % [36••].
A number of more recent reports merit mention. In an
Italian study of 157 women undergoing surgical management of SUI, 22 of 54 (40 %) women who were not sexually
active at baseline had resumed sexual activity 12 months
after correction of SUI with a mid-urethral sling.
Furthermore, there were significant changes in FSFI-total
scores; at baseline, 40 of 79 (51 %) of sexually active
patients had FSFI –total scores less than 26.55 (the cut point
used here for risk of sexual dysfunction). At 1-year followup the prevalence of FSFI-total<26.55 in sexually active
patients was significantly lower at 33 of 95 (34 %).
Improvements in FSFI domain scores were distributed fairly
evenly across the FSFI domains of desire, arousal, orgasm,
and pain. Of note, a small proportion of the patients who
were sexually active (six of 79, ~ 8 %) at baseline were not
active at follow-up; four of these were not sexually active
due to de novo OAB, and two because of de novo
dyspareunia [32].
A 2013 study reported on 150 women with SUI randomized to either retropubic TVT or single incision sling placement. It was determined that both procedures led to significant improvement from baseline with respect to both continence and sexual function as assessed by the FSFI scores
at 6-month follow-up. Interestingly, the improvement in the
FSFI lubrication and orgasm domains was significantly
greater in women treated with TVT compared to single
incision sling [67].
Liang studied 83 women (57 of whom were sexually
active at baseline) with urodynamic confirmed SUI who
underwent transobturator suburethral tape (TOT). Success
rate (defined as any loss of urine with ValSalva) was 93 % at
12 months. Sexual function pre-procedure and postprocedure was assessed with the PISQ-12. The overall mean
PISQ-12 score did not significantly change between baseline and follow-up. However, several interesting question
specific changes in PISQ-12 were noted at follow-up: coital
incontinence was markedly reduced but climax during intercourse was less common and “negative emotional reaction” was more common at follow-up. There was also an
increase (not strictly statistically significant with p >0.05 but
less than 0.1) in dyspareunia and sensation of vaginal bulging [68].
A multi-center study assessed 597 women (68 % of
whom were sexually active) with either SUI or stress predominant MUI randomized to retropubic or transobturator
mid-urethral slings. Of note, some women in this series also
underwent concomitant vaginal procedures not involving
placement of mesh or other foreign material; it is not clear
305
from the text how many and which other procedures were
performed. It was determined that sexual function (assessed
by the PISQ-12) improved overall compared to baseline
values in both groups. However, patients who developed
de novo or worsening urgency symptoms or experienced
any sort of surgical failure had an overall decline in sexual
function compared to baseline [69]. Heterogeneity in the
enrollment criteria (both SUI and MUI patients were enrolled) and concomitant surgical procedures make direct
attribution of sexual function outcomes to sling placement
difficult.
In a prospective study of 96 sexually active women with
SUI (36 of whom had coital incontinence), the FSFI was
used to evaluate sexual function at baseline and at 6-month
follow-up. Resolution of stress incontinence was seen in
87 % of subjects at six months. Of the 96 patients, 36
experienced coital incontinence, which was resolved in 33.
There were statistically significant improvements in mean
FSFI domain scores for satisfaction and pain; improvements
in mean score for the other four domains of the FSFI did not
reach statistical significance [37].
A small study of 50 patients with SUI treated with one of
three urethral slings assessed subjective and objective sexual
symptoms (FSFI) at a mean follow-up of about 2 years. All
women reported a decline in incontinence episodes. The rate
of self-reported sexual distress was 44 % at baseline and
12 % at follow up. There was a significantly lower rate of
self-reported decreased sexual desire, arousal, and orgasm
frequency and increases in feeling of sexual attractiveness
and satisfaction with sexual life post-operatively.
Interestingly, 62 % of these women had FSFI scores of less
than 26.55 at follow-up, but did not report without subjective sexual bother [35]. This study is modest in scope, but is
noteworthy in that it illustrates the limitations of strict reliance on the FSFI in assessing sexuality related distress in
women.
Conclusion
Well-designed studies employing validated questionnaires
are needed to further explore the relationship between urinary symptoms and sexual function in women. Prospective
data on the natural history of sexual function in the setting of
urinary symptoms is required, as are data on the effects of
OAB and SUI treatment on female sexuality. Precise definitions of sexual dysfunction and sexual problems must be
utilized in future studies.
Compliance with Ethics Guidelines
Conflict of Interest Dr. Jaclyn Chen reported no potential conflicts
of interest relevant to this article.
306
Dr. Genevieve Sweet reported no potential conflicts of interest
relevant to this article.
Dr. Alan Shindel reported serving as a board member for SF Center
for Sex and Culture and International Society for Sexual Medicine. Dr.
Shindel reported receiving consultancies from American Medical
Systems, Cerner, and GroupH. Dr. Shindel reported receiving honoraria from the International Society for Sexual Medicine, the International
Society for the Study of Women's Sexual Health, Endo, and Elsevier.
Dr. Shindel reported travel/accommodations expenses covered or reimbursed by the International Society for Sexual Medicine. Dr. Shindel
reported receiving a grant from UC Davis Loss Prevention Program.
Human and Animal Rights and Informed Consent This article
does not contain any studies with human or animal subjects performed
by any of the authors.
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