[ Editorials | Departments and Series | Index ]

Advances in Urogynecology

Sexual Function in Women With Pelvic Floor Disorders

Rebecca G. Rogers, MD

Pelvic floor disorders, including urinary and anal incontinence and pelvic organ prolapse, affect nearly 33% of premenopausal women and up to 45% of postmenopausal women.¹ Incontinence and prolapse have an impact on the social, psychological, occupational, domestic, physical, and sexual well-being of women.² Studies of sexual function in women with pelvic floor disorders previously concentrated on measurements of vaginal anatomy after surgical intervention—specifically, the length and caliber of the vagina. More recent studies include quality-of-life measurements that evaluate sexual desire, arousal, orgasm, and satisfaction.

For practical purposes, measurement of sexual function is limited to patient diaries and questionnaire responses. Because of this, the choice of questionnaire is vital to the validity of the study. Ad hoc questionnaires have not undergone rigorous testing to ensure their validity. General questionnaires can be used to make comparisons between populations, while condition-specific questionnaires are sensitive for evaluating a specific patient population.³ As interest in the impact of pelvic floor disorders on quality of life has grown, research into the sexual function of patients with these disorders has expanded. This paper reviews female sexual function, as well as the literature on sexual function in women with pelvic floor disorders.

The traditional model of sexual function for women is linear, and includes four phases: desire, arousal, climax, and resolution (Figure 1).⁴ Newer models describe a more circular relationship between satisfaction and intimacy (Figure 2).⁵ Although rates of sexual activity decline with age, population-based studies indicate continued sexual activity in 47% of married women aged 66 to 71 years, and 33% of women over 78 years of age. The incidence of incontinence and prolapse are also increased in these age groups.^5-7 Factors that negatively influence sexual activity in elderly women include lack of a partner, erectile dysfunction in a partner, illness, and lack of libido. Sexual dysfunction occurs in up to 35% of American women of all ages, with lack of libido being the most commonly reported problem.⁸

Click to enlarge

Figure 1. Sexual response cycle.

Click to enlarge

Figure 2. Sexual response continuum.

back to top

PHYSIOLOGY

Normative data on the sexual function of women with urinary incontinence are scarce. A survey of 1,381 women in the United States found that urinary tract symptoms were predictive of sexual arousal disorders and pain.⁹ A large, community-based study found that incontinence negatively affected overall quality of life more than it affected sexual function.¹⁰ An evaluation of 400 incontinent women by provider interview found that many patients were reluctant to raise questions regarding sexual function, although urinary incontinence with sexual penetration or orgasm was common.¹¹

Linking vaginal anatomy to sexual function within broad parameters has not proved fruitful. Comparison of vaginal anatomy and sexual dysfunction using a general questionnaire in 80 women with pelvic organ prolapse and/or urinary incontinence and 30 continent women found that vaginal anatomy did not correlate with sexual function scores, sexual satisfaction, or complaints of dyspareunia. Although 14% of the women complained that prolapse or incontinence interfered with sexual activity, and increasing grades of prolapse predicted greater interference with sexual activity, women with prolapse or incontinence continued to be "satisfied" with their sexual relationships and did not change their frequency of intercourse.¹² Two other studies have confirmed the finding that increasing grade of prolapse is correlated with an increasingly negative effect on sex life or greater practice of abstinence.^13,14

back to top

INCONTINENCE

Incontinent women report poorer sexual function than continent women.^15,16 A comparison of 83 incontinent women with and 56 continent women without pelvic organ prolapse found that those with incontinence or prolapse reported less frequent sexual activity and a higher incidence of dyspareunia, although satisfaction with sexual activity was similar between groups. This study was the first to utilize a condition-specific questionnaire, but was limited by the lack of objective evaluation of prolapse or incontinence symptoms.¹⁷ A prospective study utilizing general questionnaires compared women with stress urinary incontinence (SUI), detrusor instability (overactive bladder), and women with normal urodynamic findings, and found that women with incontinence reported more marital problems than continent women. In addition, women with detrusor instability reported lower rates of sexual satisfaction than either of the other two groups.¹⁸ Women with detrusor instability have reported lower scores on ad hoc questionnaires and higher rates of dyspareunia than those with stress incontinence.^19,20

How does surgery for SUI affect sexual function? A prospective cohort study using an ad hoc questionnaire followed 55 patients after surgery for urinary incontinence, and found that 24% reported improved sexual function, 67% had an unchanged sex life, and 9% complained of deterioration. Women who underwent posterior colporrhaphy were found to have more complaints of dysfunction than patients without posterior repairs.²¹ A prospective evaluation of 45 patients' and their partners' attitudes following surgery for stress incontinence found that 33% of women reported increased sexual desire following surgery, while more than 50% of men reported an increase in desire following their partner's surgery. This study also utilized an ad hoc questionnaire.²² A multicenter trial evaluated 360 women before and 12 months following surgery for treatment of SUI, and reported no change in sex life for the majority of women studied, while 13% reported that their sex life improved and 22% reported that it deteriorated.²³ Using a condition-specific questionnaire, evaluation of sexual function following surgery for incontinence and/or prolapse in 102 women found that sexual function scores declined postoperatively for up to 6 months following surgery despite improvements in continence—a finding also noted in a prospective study of 32 women undergoing midurethral sling procedures.^24,25 Other reports confirm that coital continence improves after surgery, but resolution of urinary leakage with sex does not necessarily improve overall sexual function.^24-26

Evaluation of the effects of nonsurgical management of urinary incontinence on sexual function is limited. Two studies have evaluated the effect of pelvic floor exercises, and found that women showed improved desire and decreased dyspareunia after treatment in one study and improvement in sex-life variables in another.^27,28 The effects of anticholinergic medications, behavioral therapy, or pessary use on sexual function are unknown. Although anal incontinence is a common pelvic floor disorder, the sexual function of women who are anally incontinent has not been described.²⁹

back to top

PROLAPSE

Study of sexual function in women with prolapse has focused on postoperative measurement of vaginal length and caliber, or on mechanical obstruction resulting from excessive narrowing following surgical repair. Research on the effect of apical repairs on sexual function has largely focused on the length of the vagina. Measurement of vaginal lengths following three different vault suspensions found that women undergoing abdominal sacrocolpopexy had longer vaginas than did women undergoing sacrospinous ligament suspension or posterior culdoplasty.³⁰ Another report on 30 women undergoing abdominal sacrocolpopexy found that 22% complained of new-onset dyspareunia, and 41% complained of decreased libido and coital events.³¹ All three operations were complicated by complaints of vaginal "tightness" that was attributed to aggressive posterior colporrhaphy. In this series, vaginal lengths in postsurgical groups were not significantly different than those in a cohort of women who did not undergo surgery.³⁰ A retrospective series following 243 women for up to 13 years found 19% of women reported sexual dysfunction preoperatively, and 21% reported sexual dysfunction postoperatively. No measurable differences in vaginal length and caliber existed between women who complained of dyspareunia and those who did not, although 17% of patients had a constricted or shortened vagina on physical examination.³²

Repair of the posterior compartment has received more attention than other prolapse surgeries for its negative effect on sexual functioning. A retrospective review of 100 women undergoing anterior and posterior colporrhaphy found that postoperatively, 61% of patients enjoyed "regular" coitus, and 30% had stopped coital activity. After posterior colporrhaphy, a significant number of women experienced vaginal narrowing so severe that it precluded intercourse, challenging the necessity for routine posterior repair.³³ Another retrospective review compared 177 women who underwent posterior colporrhaphy with 44 women who did not, and found that excessive narrowing of the vagina was uncommon in the latter group. Apareunia and dyspareunia were common after prolapse surgery, and up to 50% of women ceased coital activity postoperatively.³⁴ More recent studies have corroborated these findings. Using a general questionnaire, a study of 81 women followed for a year after reconstruction found that posterior colporrhaphy—especially in conjunction with Burch retropubic urethropexy—placed women at risk for postoperative dyspareunia rates of up to 38%. This difference was despite no differences in vaginal anatomy found between women who underwent posterior colporrhaphy and those who did not.³⁵ These findings are consistent with studies that described routine levatorplasty as part of posterior repair, as well as those that did not. The pathophysiologic connection between surgery on the posterior compartment and dyspareunia is unclear. Mechanical narrowing can clearly cause dyspareunia. Other possible etiologies include a "tenting" effect on the posterior wall of the vagina, especially when posterior colporrhaphy is performed in conjunction with a retropubic incontinence procedure.

The occurrence of vaginal narrowing following repair is not restricted to posterior colporrhaphy. Approximately 14% of 69 women undergoing sacrospinous ligament suspension feared intercourse because the vagina was too narrow.³⁶

back to top

CONCLUSION

Incontinent women report urine leakage with sexual activity, and this incontinence may affect their sex life. Additionally, women with detrusor instability may have poorer sexual function than women with SUI. Surgery for SUI may cure incontinence without improving overall sexual function or satisfaction. Indeed, posterior colporrhaphy may place patients at higher risk for dyspareunia than patients who did not undergo posterior repair as part of prolapse surgery. The negative effects of posterior colporrhaphy may be compounded by the performance of a retropubic urethropexy.

Suggestions for treating sexual dysfunction in women with pelvic floor disorders range from advising patients to "use it or lose it," or to abstain from sexual activity altogether, or to the assumption that surgery for incontinence and/or prolapse will result in better sexual function. Assuming that the restoration of anatomy will improve sexual function has proved shortsighted. So far, the literature has been unable to prove a link between sexual function and vaginal anatomy within broad ranges of normal length and caliber. Additionally, measures of "satisfaction" may inadequately represent sexual function in terms of libido, arousal, and orgasm. Treatment of sexual function beyond restoration of anatomy in women with pelvic floor disorders has not been researched sufficiently. The effects of testosterone supplementation, devices such as the clitoral stimulator, or behavioral interventions are likewise unknown.

back to top

Rebecca G. Rogers, MD, is director, Division of Urogynecology, and associate professor, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

References

1. Brown JS, Posner SF, Stewart AL. Urge Incontinence: new health-related quality of life measures. J Am Geriatr Soc. 1999;47(8):980-988.
2. Kelleher CJ, Cardozo LD, Khullar V, Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. Br J Obstet Gynaecol 1997;104(12):1374-1379.
3. Rogers R, Kammerer-Doak D, Villarreal A, Coates K, Qualls C. A new instrument to measure sexual function in women with urinary incontinence or pelvic organ prolapse. Am J Obstet Gynecol. 2001;184(4):552-558.
4. Masters WH, Johnson VE. Human Sexual Response. Boston, Mass: Little, Brown, & Co; 1966.
5. Freedman M. Sexuality in post-menopausal women. Menopausal Medicine. 2000;8:1-4.
6. Brooks TR. Sexuality in the aging woman. The Female Patient. 1994;19(3):63-70.
7. Diokno AC, Brown MB, Herzog AR. Sexual function in the elderly. Arch Intern Med. 1990;150(1):197-200.
8. American College of Obstetricians and Gynecologists. Sexual Dysfunction (ACOG Technical Bulletin No. 211). Washington, DC: American College of Obstetricians and Gynecologists; 1995: 763-772.
9. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6): 537-544.
10. Temml C, Haidinger G, Schmidbauer J, Schatzl G, Madersbacher S. Urinary incontinence in both sexes: prevalence rates and impact on quality of life and sexual life. Neurourol Urodyn. 2000;19(3):259-271.
11. Hilton P. Urinary incontinence during sexual intercourse: a common, but rarely volunteered symptom. Br J Obstet Gynaecol. 1988;95(4):377-381.
12. Weber AM, Walters MD, Schover LR, Mitchinson A. Vaginal anatomy and sexual function. Obstet Gynecol. 1995;86(6): 946-949.
13. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol. 2001; 185(6):1332-1337.
14. Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC; Continence Program for Women Research Group. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 2002;99(2):281-289.
15. Walters MD, Taylor S, Schoenfeld LS. Psychosexual study of women with detrusor instability. Obstet Gynecol. 1990;75(1):22-26.
16. Clark A, Romm J. Effect of urinary incontinence on sexual activity in women. J Rep Med. 1993;38(9):679-683.
17. Rogers GR, Villarreal A, Kammerer-Doak D, Qualls C. Sexual function in women with and without urinary incontinence and/or pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12(6):361-365.
18. Yip SK, Chan A, Pang S, et al. The impact of urodynamic stress incontinence and detrusor overactivity on marital relationship and sexual function. Am J Obstet Gyencol. 2003; 188(5):1244-1248.
19. Gordon D, Groutz A, Sinai T, et al. Sexual function in women attending a urogynecology clinic. Int Urogynecol J Pelvic Floor Dysfunc. 1999;10(5):325-328.
20. Sutherst JR. Sexual dysfunction and urinary incontinence. Br J Obstet Gynaecol. 1979;86(5):387-388.
21. Haase P, Skibsted L. Influence of operations for stress incontinence and/or genital descensus on sexual life. Acta Obstet Gynecol Scand. 1988;67(7):659-661.
22. Berglund AL, Eisemann M, Lalos A, Lalos O. Social adjustment and spouse relationships among women with stress incontinence before and after surgical treatment. Soc Sci Med. 1996;42(11):1537-1544.
23. Black NA, Bowling A, Griffiths JM, Pope C, Abel PD. Impact of surgery for stress incontinence on the social lives of women. Br J Obstet Gynaecol. 1998;105(6):605-612.
24. Rogers RG, Kammerer-Doak D, Darrow A, et al. Sexual function after surgery for stress urinary incontinence and/or pelvic organ prolapse: a multicenter prospective study. Am J Obstet Gynecol. 2004;191(1):206-210.
25. Yeni E, Unal D, Verit A, Kafali H. The effect of tension-free vaginal tape (TVT) procedure on sexual function in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(6):390-394.
26. Baessler K, Stanton SL. Does Burch colposuspension cure coital incontinence? Am J Obstet Gynecol. 2004;190(4): 1030-1033.
27. Beji NK, Yalcin O, Erkan HA. The effect of pelvic floor training on sexual function of treated patients. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(4):234-238.
28. Bo K, Talseth T, Vinsnes A. Randomized controlled trial on the effect of pelvic floor muscle training on quality of life and sexual problems in genuine stress incontinent women. Acta Obstet Gynecol Scand. 2000;79(7):598-603.
29. Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SS. Functional Disorders of the anus and rectum. Gut. 1999;45(Suppl 2):1155-1159.
30. Given FT Jr, Muhlendorf IK, Browning GM. Vaginal length and sexual function after colpopexy for complete uterovaginal eversion. Am J Obstet Gynecol. 1993;169(2 Pt 1):284-288.
31. Virtanen H, Hirvonen T, Makinen J, Kiilholma P. Outcome of thirty patients who underwent repair of posthysterectomy prolapse of the vaginal vault with abdominal sacral colpopexy. J Am Coll Surg. 1994;178(3):283-287.
32. Paraiso MF, Ballard LA, Walters MD, Lee JC, Mitchinson AR. Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol. 1996;175(6): 1423-1430.
33. Jeffcoate TN. Posterior colpoperineorrhaphy. Am J Obstet Gynecol. 1959;77(3):490-502.
34. Francis WJ, Jeffcoate TN. Dyspareunia following vaginal operations. J Opt Soc Am. 1961;68:1-10.
35. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol. 2000;182(6):1610-1615.
36. Richter K, Albrich W. Long-term results following fixation of the vagina on the sacrospinal ligament by the vaginal route (vaginaefixatio sacrospinalis vaginalis). Am J Obstet Gynecol. 1981;141(7):811-816.

back to top