Pelvic floor dysfunctions may impair female sexuality (1, 2, 3). However, sexual health was not routinely assessed in those women. The aim of our study was to analyse sexual activity and function of women who seek care for pelvic floor dysfunctions, through a condition-specific validated tool.

Cross-sectional study about sexual health of women attended in an urogynaecology unit of a tertiary university hospital started in 2022. The first consultation of women visited to assess and treat pelvic floor dysfunctions (urinary incontinence [IU], anal incontinence [IA], pelvic organ prolapsed [POP]) were selected consecutively. Exclusion criteria included women with language barriers, unable to understand questionnaires or who reject to fill-in the sexual questionnaire. The study was approved by the Ethics Committee and written informed consent was obtained from all the participants. 

Women attended in our urogynaecology unit, follow a standardized health care procedure: a first telematic visit performed by the urogynaecologist and, afterwards, a “pack LUTS” presential appointment which involve 2 visits (urogynaecologist and urogynaecology specialized nurse) and 2 test (urodynamics and pelvic floor ultrasound) scheduled the same day. 

Women reported demographical data and 4 Spanish validated questionnaires. To evaluated urinary, anal and prolapse symptoms we used: the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI-SF) which evaluates frequency, severity and impact on quality of life, range 0-21 (no UI = 0; mild UI = 1-5, moderate UI = 6-12, severe UI = 13-18, more severe UI = 19-21). Moreover, it includes 8 questions regarding the type of UI (just descriptive data, no scoring). The Bladder Control Self-Assessment Questionnaire (B-SAQ) has 8 items to assess symptoms of urgency, frequency, nocturia and UI and the associated bother, based on a 4-points Likert-scale: 0 (not at all), 1 (a little), 2 (moderately), 3 (a great deal), range 0-12 (REF). The Pelvic Floor Distress Inventory-20 (PFDI-20) involves 3 subscales: Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), Colorectal Anal Distress Inventory 8 (CRADI-8) and Urinary Distress Inventory 6 (UDI 6) is 100, range 0-100 (each subscale) or 0-300 (overall). Based on reported symptoms, we performed a pelvic floor dysfunction clinical diagnosis: 1) IU: ICIQ>0 + BSAQ Q4 symptoms>0 + PFDI-20 Q16 o Q17>0; 2) POP: PFDI-20 Q3>0; 3) IA: PFDI-20 Q9 o Q10 o Q11 >0.  To evaluate sexual activity and function we used: the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA Revised (PISQ-IR), a condition-specific questionnaire for assessing sexuality in both sexually active (SA) and non-sexually active (NSA) patients according to Q1. It includes 14 items (6 subscales) addressed to SA patients and 5 items (4 subscales) for NSA. The scores were calculated with the mean calculation method. Higher scores in SA patients indicate better sexual function, while in NSA patients, these indicate a greater impact on sexual function. Global sexual function was analyzed according to the single summary score of PISQ-IR only available for SA women. We considered dyspareunia for both SA and NSA women: when the SA patient reported sometimes, usually or always to Q11 or coital activity avoidance due to pain, and when NSA women reported pain as a cause of inactivity (Q2e). We considered satisfactory sexual life the answer “1” or “2” to the Q4a (NSA) or Q19a (SA).  

At the presential appointment a systematic pelvic examination was performed to all the participants. In the present study we exclusively analyzed: the stage of POP based on POPQ and the pelvic floor muscle function based on the modified Oxford-scale. 

Data analysis: 
All analyses were performed using the IBM SPSS Statistics 23.0 software (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.) Data were summarized as frequency and percentage for categorical variables and mean and standard deviation (SD) for quantitative ones. Chi-squared test and Student’s t test were used for comparisons. The statistical significance level was established at p-value<0.05.

Among 111 women attended during the firsts months of 2022, 2 who rejected to fill-in the sexual questionnaire were excluded. 92.5% of participants reported UI symptoms, one-third AI (34.6%) and the 28% of women has a symptomatic POP. The more frequently isolated pelvic floor dysfunction was UI (43.9%). Nearly one-third of the participants informed double incontinence symptoms (27.1%). 43.1% of women presented 2 pelvic floor dysfunctions, whereas 5.6% had 3 of them (UI + AI + POP). Table 1 shows the baseline characteristics of the sample. 

NSA rate was 47.7%. The main reason for their sexual inactivity was lack of interest (72.5%), followed by not having a partner (56.9%). The pelvic floor dysfunction, other health issues and the pain were the inactivity reason in a lower proportion (11.7%, 9.8% y 7.8%, respectively). 12 (23.5%) NSA women reported avoidance of sexual activity due to fear related to UI /AI or POP. Most of NSA participants stated to be satisfied with their sexual life (82.3%) without bother about their sexual inactivity.  

Related to SA women (n=57), 29.7% informed about UI/ AI during sexual activity (17.5% rarely, 7.0% sometimes, 3.5% usually y 1.7% always), however, 53.9% of the SA participants limited sexual activity due to fear related to UI /AI or POP (24.6% a little, 17.0% some, 12.3 % a lot). Dyspareunia was present in 54.0% SA women (35.0% sometimes, 8.0% usually, 10.0% always). Barely more than a half of SA women stated to be satisfied with their sexual life (57.9%).

Only a half of the assessed women were SA. Among them, one out of two diminished their usual sexual frequency due to their pelvic floor dysfunction. Sexual function was affected by dyspareunia and urinary/anal incontinence symptoms in a relevant proportion of SA women with pelvic floor dysfunctions. Consequently, nearly half of these women were unsatisfied with their sexual life. 

On the other hand, the pelvic floor dysfunction was the third reason for sexual inactivity, reported only by one out of nine NSA women. Moreover, four out of five NSA with pelvic floor dysfunctions were satisfied with their sexual life. The lower impact of the pelvic floor dysfunction in that subgroup, may be related to NSA women were older, with higher rates of menopause and without a partner than SA participants.

Most of the women with pelvic floor dysfunctions are interested in their sexuality assessment. Pelvic floor dysfunctions may affect sexual activity among NSA and SA women, as well as worsen sexual function on SA women. So, satisfaction with the sexual life could be impaired. 

It is key to apply standardized and validated tools to systematically assess sexuality to identify the subgroup of patients with unsatisfied sexual life due to pelvic floor dysfunctions and, then, to plan the follow-up and tailored treatment according patient’s expectations.

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Sílvia Escura Sancho, Laura Ribera Torres, Camil Castelo-Branco, Sònia Anglès-Acedo. Impact of urinary incontinence on women’s sexuality. Clin Exp Obstet Gynecol. 2022, 49(2), 49. https://doi.org/10.31083/j.ceog4902049

Continence 2S2 (2022) 100386
DOI: 10.1016/j.cont.2022.100386