Diseases affecting the spinal cord may have significant physical, psychological, social and economic consequences. Most patients with SCI (spinal cord injury)  have neurogenic lower urinary tract dysfunction (N-LUTD) and bowel dysfunction. Urinary incontinence is highly prevalent in women with N-LUTD and may have a significant impact on their sexual life. In this study we evaluated the lower urinary tract symptoms and the sexual function of women with diseases that affect the spinal cord, and analyzed the predictors of sexual activity and sexual dysfunction, with a special attention to the interrelationships between sexual and lower urinary tract dysfunctions.

In this observational study, we evaluated a consecutive series of 98 adult women with traumatic (T) or non-traumatic (NT) diseases affecting the spinal cord, from an academic referral specialty hospital. Patients were invited to participate when they presented for a routine medical visit with a physiatrist, neurologist or urologist. They agreed to participate after full disclosure of the study purposes and written consent was obtained from all participants. All subjects were older than 18 years of age and had a neurological condition diagnosed for more than one year that was considered stable for at least 6 months. The only exclusion criterion was the presence of cognitive impairment. This study was approved by the Institutional Review Board of our hospital. 
We assessed clinical and epidemiological data such as age, marital status, menopausal status, etiology of the spinal cord disease, duration of neurological disease and neurological impairment based on the need of a wheelchair for mobility. We used a structured questionnaire specifically developed for this study and the Neurogenic Bladder Symptom Score short form (NBSS-SF) to evaluate the method of bladder management and urinary incontinence which was defined when the patient reported she had urinary leakage a few times a week or more in the NBSS-SF. The Female Sexual Function Index (FSFI) was used to evaluate the sexual function and women and FSFI score ≤26.55 were considered as having sexual dysfunction. Women were considered to be satisfied with the sexual life when they reported being satisfied or very satisfied in the question 21 of the WHO-QoL questionnaire which has a Likert scale varying from very unsatisfied to very satisfied.

The median age of the 98 participants was 42.5 ± 12.1years. Forty-two (42.9%) were married and 28 (28.6%) were menopausal. Spinal cord injury was traumatic in 14 (14.3%) patients and NT in 84 (85.7%). The main causes of NT SCI were multiple sclerosis (47.9%), myelitis (12.2%) and myelomeningocele (14.3%). The mean duration of neurological disease was 10.5 ±5.0 years. Most patients had significant neurological deficits including 21 (21.4%) who were wheelchair bound. 

Bladder management and incontinence: A total of 65 (66.3%) women were able to void spontaneously, 25 (25.5%) performed clean intermittent catheterization and 8 (8.2%) used an indwelling catheter. Urinary incontinence was reported by 51 (52.0%) women. The mean NBSS-SF was 9.1 ± 6.4
Sexual function: 48 (49.0%) women had been sexually active in the past 6 months. Increasing age, being single, menopause, wheelchair bound, having urinary incontinence and worse NBSS-SF scores were associated with a higher chance of being sexually inactive, but on multivariate analysis, age, marital status and urinary incontinence were the only independent factors (Table 1). The mean FSFI score was 22.0 ± 10.0 and 28 (58.3%) women were considered to have sexual dysfunction. Among the sexually active women, 29 (60.4%) were satisfied with sexual life. On a multivariate analysis, being married (13.8 CI 4.2-45.4; p< 0.001) and being continent (6.0 CI 2.0-18.2; p= 0.001) were the only independent factors associated with sexual satisfaction. The sexual domains that were most affected by urinary incontinence were satisfaction, discomfort, orgasm and arousal (Table 2)

The sexual function of women with diseases affecting the spinal cord may be significantly affected. Increasing age, being single, menopause, wheelchair bound, having urinary incontinence and worse NBSS-SF scores were associated with a higher chance of being sexually inactive. Urinary incontinence was also an independent predictor of satisfaction with sexual life. Because urinary incontinence is a common and treatable condition in women with SCI, it is of utmost importance that healthcare professionals involved in the treatment of women with SCI be aware of these findings and prepared to offer effective treatment when needed.

Urinary incontinence has a significantly impact on sexual function of women with SCI.