Spinal cord injury or disease (SCI/D) not only has a great impact on bladder and bowel but also on sexual function. Sexual activity after SCI/D is directly affected by the loss or impairment of motor and sensory function. Furthermore, neurogenic bowel and bladder dysfunction (e.g. urine or stool incontinence) can have a negative effect on sexual activity. The majority of the current literature focuses on erectile dysfunction and semen quality after SCI/D. Sexual function and activity in women after SCI/D, and the interplay between bowel and urogenital function have been neglected, although, sexual activity ranks among the top priorities for quality of life in individuals with SCI/D. We have therefore performed a cross-sectional study to evaluate the effects of the of bowel and bladder management on sexual activity in women with chronic SCI/D.

Women with chronic (>12 months) SCI/D, who were using a suprapubic catheter (SPC) or intermittent catheterization (IC) for bladder evacuation, were recruited in the out-patient clinic of a tertiary neuro-urologic referral center. Enrolled women completed the following questionnaires: Sexual Behavior Questionnaire (SBQ), Female Sexuality Function Index (FSFI) and a self-developed questionnaire with questions about sexuality, bowel and bladder management. Furthermore, data regarding personal and SCI/D characteristics, co-morbidities and medication were collected. The effects of personal and medical characteristics, satisfaction with their bowel and bladder management (SPC vs. IC) as well as sexual function on sexual activity were evaluated with the Chi-squared or Fisher's exact test and the Mann-Whitney U test. The effect of significant factors on sexual activity was evaluated using binary logistic regression analysis. The statistical analyses were performed using the SPSS software (version 25, IBM, Somers, NY, USA). A p-value of ≤ 0.05 was considered significant.

A total of 42 women with a median age of 50 years (36 / 60 years) and a median duration of SCI/D of 18.2 years (10.9 / 29.1 years) were enrolled. The majority of the evaluated women were sexually active (59.0%) and in a partnership (69.0%). The most common reasons for sexual inactivity were "no partner" (56.0%) and "not interested" (33.0%). Almost all (98.6%) women reported sexual dysfunction, with no significant (p>0.14) differences regarding severity between women with SPC and those using IC. Sexually active women were less severely affected by sexual dysfunction with a significantly (p=0.0002) greater median FSFI of 26.0 (24.2 / 28.1) compared to the FSFI of 5.2 (3.25 / 7.75) in sexually inactive women. Furthermore, sexually active women were more often living in a partnership (96.0% vs. 29.4%) and evacuating their bladder with intermittent catherization (84.0% vs. 52.9%) compared to sexually inactive women (p<0.04). However, significantly (p=0.04) more sexually active women (56.0%) reported urinary incontinence compared to sexually inactive women (23.5%). Two-thirds (67.0%) of women with SPC reported a disturbed self-image because of the catheter, and 77.0% of women using IC reported urine leakage during sexual activity. There were no significant (p>0.05) differences regarding personal and SCI/D characteristics, satisfaction with bowel and bladder management, stool and urine incontinence as well as co-morbidities between sexually active and inactive women. The median satisfaction with bowel management was 7 (5.4 / 8.2) on a visual analog scale from 0 to 10. Stool incontinence was reported by 23.8% of the evaluated women. The FSFI and living in a partnership were significant (p<0.033) predictors of sexual activity.

The percentage of sexually active individuals is lower in women with SCI/D (i.e. 59.0%) compared to women without SCI/D (i.e. 72.5%), but higher compared to women with impaired health (i.e. 48.0% to 32.4%). Personal or SCI/D characteristics, bowel or bladder management or co-morbidities did not affect sexual activity. However, a lower degree of sexual dysfunction and living in a partnership increase the likelihood of sexual activity.

In the evaluated women with chronic SCI/D, three out of five are sexually active despite sexual dysfunction. Satisfaction with Bowel and bladder management as well as stool and urine incontinence do not seem to be relevant factors for sexual activity. However, living in a partnership and the degree of sexual dysfunction determine sexual activity. Special attention should be paid to self-image in women with SCI/D evacuating their bladder with a SPC.