Urinary Incontinence & Impact of Management on Sexual Function in Women

Aims and Objectives: It was hypothesized that urinary incontinence has an impact on sexual function in women though the exact impact and its mechanism remains unproven. This thesis aimed to analyze the association between urinary incontinence and sexual function in women. The impact of different treatment modalities for urinary incontinence and their effect on sexual function was measured. This was through a series of separate experiments. Methods: It is widely accepted that urinary incontinence impacts on sexual function but the pathophysiology of sexual dysfunction remains unclear. A review of female sexual dysfunction (Paper 1) and the impact of pelvic floor problems on sexual function (Paper 2) was undertaken. As studies analyzing sexual function in women with pelvic floor disorders tend to cluster women with prolapse and incontinence it has been difficult to identify which of these has a greater impact on sexual function. A study was undertaken to compare sexual function in these 2 main disorders of the pelvic floor, prolapse and incontinence (Paper 3). The incidence of sexual dysfunction and comparison of symptoms in both groups were done using Mann-Whitney U test. The two most common causes for urinary incontinence are sphincter weakness and involuntary detrusor contractions, which usually manifest clinically as stress incontinence and overactive bladder. Traditional teaching has been that both are responsible for coital incontinence but there remains considerable controversy on the exact impact different types of urinary incontinence has. This was further explored in another study (Paper4). Data were collected as part of routine clinical care using an electronic pelvic floor questionnaire (ePAQ) and correlated with urodynamic findings. By correlating the different types of incontinence based on urodynamic diagnosis to sexual function, the exact incidence of coital incontinence, penetration and orgasm incontinence were estimated. Various treatment modalities for both types of urinary incontinence were assessed and the impact these treatments have on sexual function studied. The main treatments for Stress incontinence are Pelvic Floor Muscle Training (PFMT) and surgical treatment. To assess the former a prospective cohort randomized controlled trial was conducted looking at the impact of electrical stimulation compared to standard PFMT alone in women with urinary incontinence and the impact this has on sexual function (Paper 7). This was a single centre two arm parallel group randomised controlled trial. The interventions compared were electric stimulation versus standard pelvic floor muscle training. Outcome measures included Prolapse and Incontinence Sexual function Questionnaire (PISQ) physical function dimension at post-treatment (primary); other dimensions of PISQ, SF-36; EQ-5D, EPAQ, resource use, adverse events and cost-effectiveness (secondary outcomes). The impact of all continence surgery including the Tension free vaginal tape (TVT) on sexual function was evaluated by conducting a systematic review and meta-analysis (Paper 5). Observational studies and randomised controlled trials investigating the impact of surgical correction of stress urinary incontinence on sexual function were included. Surgical interventions included TVT, TVT-O, TOT, Burch and AFS. Studies which included patients undergoing concurrent prolapse surgery were excluded from the analysis. Coital incontinence was analyzed separately and OR with 95% CI calculated. The data were analysed in Review Manager 5 software. In addition to analyzing various treatment options we also compared the different types of midurethral tapes and their overall impact on sexual function. The mainstay of treatment for women with overactive bladder symptoms (OAB) is anticholinergics and this was assessed in a separate study. Women identified to have OAB and sexual dysfunction being commenced on anticholinergics were followed up to observe the impact of medical treatment on their sexual function (Paper 6). The ePAQ PF, PISQ 12 and PGI-I were used for the assessment of Overactive bladder and Sexual function. Sexually active women with overactive bladder were included in the study and assessed using the ePAQ-PF, PISQ 12 and PGI-I for Overactive bladder and Sexual function. Prolapse and voiding dysfunction were exclusion criteria for the study. All women were treatment naïve and followed up for 6 months. Sexual function before and after treatment was compared. The data were analysed using SPSS (version 20). Results: The individual impact of pelvic organ prolapse (POP) and urinary incontinence on sexual function was found to be similar. Patient and partner avoidance in women with POP was greater than those with stress urinary incontinence (Paper 3). Worsening urinary incontinence has a deleterious effect on sexual function. However the type of urinary incontinence as established on Urodynamic diagnosis does not correlate with the nature of underlying sexual problems, orgasm or penetration incontinence (Paper 4). PFMT improved sexual function, but there was no difference in the outcomes when comparing standard PFMT to electrical stimulation (Paper 7). Surgical correction of SUI significantly reduced coital incontinence . An analysis of overall impact on sexual function with all surgical continence procedures demonstrated an improvement, no change and deterioration in 31.9%, 55.5% and 13.1% respectively. These were similar when analyzing overall sexual function following mid urethral tapes in isolation (Paper 5). Anticholinergics and cure of overactive bladder did not however correlate to an improvement in sexual function (Paper 6). Conclusions: Sexual dysfunction is complex and multifactorial. The prevalence of sexual dysfunction is greater in women with pelvic floor disorders and the interventions for urinary incontinence have a variable impact.