CME/CE

SEPTEMBER 2008

Sexual Function in Women With Pelvic Floor Disorders

Rebecca G. Rogers, MD; Dorothy N. Kammerer-Doak, MD

The lack of research on the relationship between pelvic floor disorders and sexual function is surprising, as many women in the US have such disorders. Sexual function is linked to overall quality of life; without a clear understanding of the impact of these disorders on sexual function, providers cannot determine the impact of treatment on this important aspect of their patients’ lives.

Continuing Medical Education

GOAL To examine the relationship between various pelvic floor disorders and sexual function in women. OBJECTIVES To describe the ways in which urinary incontinence, pelvic organ prolapse, and anal incontinence do and do not affect female sexual function. To assess the impact of surgery for these disorders on sexual function. To discuss research findings and shortcomings with regard to pelvic floor disorders and sexual function. ACCREDITATION This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Albert Einstein College of Medicine and Quadrant HealthCom Inc. Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians. This activity has been peer reviewed and approved by Brian Cohen, MD, Professor of Clinical ObGyn, Albert Einstein College of Medicine. Review date: August 2008. It is designed for ObGyns, primary care physicians, and nurse practitioners. Albert Einstein College of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Participants who answer 70% or more of the questions correctly will obtain credit. To earn credit, see the instructions on page 43 and mail your answers according to the instructions on page 44. CONFLICT OF INTEREST STATEMENT The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine requires that authors participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any author whose disclosed relationships prove to create a conflict of interest, with regard to their contribution to the activity, will not be permitted to publish. The Albert Einstein College of Medicine also requires that faculty participating in any CME activity disclose to the audience when discussing any unlabeled or investigational use of any commercial product, or device, not yet approved for use in the United States. Dr Rogers reports that she is a Consultant, on the Speakers Bureau, and on the Advisory Board for Pfizer Inc. She is also receiving Grant/Research support from Pfizer Inc. The disclosure reported by the author presents no conflict of interest to this article. Dr Kammerer-Doak reports no conflict of interest. The authors report no discussion of off-label use. Dr Cohen reports no conflict of interest. The staff of CCME of Albert Einstein College of Medicine have no conflicts of interest with commercial interest related directly or indirectly to this educational activity.

Urinary and anal incontinence and pelvic prolapse are common, affecting nearly one third of adult women.1 Many women have more than one such disorder, which complicates diagnosis. All pelvic floor disorders have a significant impact on quality of life—including sexual activity and function.

Epidemiologic data on the impact of pelvic floor disorders on sexual function are sparse. A survey of 4,106 community-dwelling women found that sexual activity and satisfaction were unrelated to the presence of pelvic floor disorders after controlling for other known influences of sexual activity, including age, menopausal status, and lack of desire.2 In another survey of 2,361 older community-dwelling women that controlled for marital status and physical and mental health, 27% of subjects (mean age of 71 years) reported continued sexual activity regardless of continence status. Sexual activity was not influenced by the presence of incontinence; however, large urine losses, stress incontinence, and nocturnal incontinence had an independent negative association with sexual activity.3 These large studies demonstrate the complexity of evaluating sexual function in the setting of pelvic floor disorders, particularly in community based samples, and show that many other factors must be considered when reporting rates of sexual activity and function in these patients.

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URINARY INCONTINENCE

Urinary incontinence (UI) can affect sexual activity and function in a variety of ways, including urine loss during intercourse, sexual inhibition secondary to embarrassment, and discomfort secondary to skin and anatomical changes. The impact of UI on sexual activity and function was the focus of a study involving 1,299 women who were undergoing hysterectomy. In this cohort, 495 (38.1%) of subjects had pelvic floor disorders, and sexual dysfunction was more common in this group than women without disorders (53.2% versus 40.4%, P<.01). Sexual complaints (low libido, vaginal dryness, dyspareunia) were more common in women with UI, whereas pelvic organ prolapse (POP) was not related to any sexual problem.4 Comparable studies of women with and without UI have found that women who leak urine report less sexual satisfaction and poorer quality of life than controls.5 A qualitative study of sexually active women with overactive bladder found that subjects reported a significant impact on sexual activity and function, including fear of leakage and embarrassment.6

Conflicting data exist on the incidence of urinary leakage during sexual activity. Up to 60% of incontinent women report leakage with intercourse (ie, coital incontinence), although the precise point during sexual activity at which leakage occurs is less well defined. In general, it is thought that women with stress urinary incontinence (SUI) report urine loss with penetration, whereas women with overactive bladder (OAB) are more likely to report loss with orgasm.

Treatment of UI generally improves coital incontinence, but the impact of treatment on other areas of sexual function is less consistent. Traditional repairs (eg, Burch retropubic urethropexy, suburethral sling) improved sexual function and decreased urine leakage in 75 women followed for 3 to 6 months after repair using a validated questionnaire.7 Others have reported cure of coital incontinence following the Burch procedure.8 Midurethral sling procedures have similar positive effects on coital incontinence.9

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PELVIC ORGAN PROLAPSE

Pelvic organ prolapse—ie, herniation of the vagina and pelvic organs to or through the vaginal opening—accounts for 200,000 surgeries annually in the United States.10 Prolapse above the hymen is rarely symptomatic, and may not be noticed by the patient. When prolapse is beyond the hymen, the patient typically reports feeling a protruding “ball” or “bulge.” As long as adequate vaginal length and caliber are maintained, there is no clear link between POP and sexual complaints. In a study by Weber et al,11 women with POP had similar sexual function compared with unaffected women; advancing age was the only predictor of decreased sexual activity in this group. Another study comparing women who had POP and/or UI with unaffected controls also found that age and lack of a partner were the most common indicators of sexual inactivity.5 In a large study of women scheduled for hysterectomy, women with POP were no more likely than women without pelvic floor disorders to have sexual complaints.4 Ozel et al12 attempted to isolate the independent effects of POP on sexual function in a cohort of 116 women with UI. Sixty-nine women had UI and POP (prolapse greater than 1 cm beyond the hymen), and 47 women had UI without POP. The women with POP reported less libido and arousal, and were less likely to be orgasmic.

Few papers have described the impact of surgery for POP on sexual function, and many studies are limited by the lack of validated questionnaires. In addition, women in these studies often undergo multiple surgical procedures for various pelvic floor disorders with limited follow-up. Older studies report rates of dyspareunia as high as 50% following vaginal repair due to significant introital narrowing; abandonment of routine levatorplasty for posterior repair is thought to have reduced this outcome.13

More recent studies have documented improved sexual function following vaginal and abdominal repairs using a validated, condition-specific instrument, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). In a cohort of 75 women with UI and POP who underwent reconstructive surgery, sexual function scores improved at 3 to 6 month follow-up, although women who underwent posterior repair reported less improvement.7 In addition, a large cohort of women undergoing sacrocolpopexy also reported improvement in sexual function scores using the same validated questionnaire when followed for 2 years after surgery.14 Improvements were noted in the physical domain of the PISQ which pertains to the impact of UI, AI, and POP on sexual function, with no significant changes in the domains that related to partner issues and desire, arousal and orgasm.

Not all studies report improvement following surgical repair of POP. A study that used the Female Sexual Function Index (FSFI), a validated questionnaire not specific for UI and/or POP, reported no difference in sexual function following vaginal surgery. The authors also asked patients to report what barriers they experienced to sexual activity. Prior to surgery, patients reported that the single greatest barrier to good sexual function was POP, whereas postoperatively the greatest barrier was dyspareunia. Overall sexual function did not improve in these subjects; rather, patients appeared to have traded one sexual problem for another.15

The impact of newer surgical techniques, including the use of graft materials for vaginal repair, is less studied and lacks comparative data. Paraiso16 compared three methods of posterior repair with and without biologic grafting, and found no differences in sexual function scores in women who received a graft compared with women who did not, although the study was underpowered for this outcome. Novi17 specifically evaluated the impact of biologic grafts on sexual function in women undergoing posterior repair and found that women who underwent grafting had higher sexual function scores than women who did not. Others have reported high rates of dyspareunia following the use of synthetic graft materials. Among 63 women receiving a polypropylene–mesh–augmented anterior or posterior repair, anatomical success was 94%; however, women undergoing the anterior repair reported a 20% increase in dyspareunia, and women who had a posterior repair had an increase in dyspareunia of 63%.18 Reports on sexual function following vaginal repair using trocar-guided prolapse “kits” are lacking.

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ANAL INCONTINENCE

Research on the effects of anal incontinence on sexual function has focused primarily on third- and fourth-degree postdelivery vaginal lacerations. Few studies have addressed the impact of anal incontinence per se on rates of sexual activity. Similar to UI, women with anal incontinence report loss of stool with intercourse. No data are available on whether anal intercourse affects either anal continence or sexual function in women who practice this activity.

Two studies have evaluated sexual function following sphincteroplasty remote from delivery. Of 46 sexually active women who underwent sphincteroplasty, those with an overlapping repair were more likely to report dyspareunia than those with an end-to-end repair (24% versus 4%, P = .04). However, sexual function scores were not correlated with anal incontinence severity.19 In another small, retrospective study of 18 women following sphincteroplasty, subjects reported improved sexual function following repair.20

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CONCLUSION

The study of sexual function in women with pelvic floor disorders is still in its infancy. Better data are needed on sexual activity and function in women with these common pelvic floor problems, and on the effects of nonsurgical versus surgical treatments. The use of validated, condition-specific sexual function questionnaires will add to the understanding of the complex interactions between pelvic anatomy, symptoms, and function.

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Rebecca G. Rogers, MD, is Associate Professor and Director, Division of Urogynecology and Division of Urology; and Dorothy N. Kammerer-Doak, MD, ABQ Health Partners, is Associate Professor, both in the Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque.

References

1. Mallett VT, Bump RC. The epidemiology of female pelvic floor dysfunction. Curr Opin Obstet Gynecol. 1994; 6(4): 308-312.
2. Lukacz ES, Whitcomb EL, Lawrence JM, Nager CW, Contreras R, Luber KM. Are sexual activity and satisfaction affected by pelvic floor disorders? Analysis of a community-based survey. Am J Obstet Gynecol. 2007; 197(1):88.e1-6.
3. Tannenbaum C, Corcos J, Assalian P. The relationship between sexual activity and urinary incontinence in older women. J Am Geriatr Soc. 2006;54(8):1220-1224.
4. Handa VL, Harvey L, Cundiff GW, Siddique SA, Kjerulff KH. Sexual function among women with urinary incontinence and pelvic organ prolapse. Am J Obstet Gynecol. 2004;191(3):751-756.
5. 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.
6. Coyne KS, Margolis MK, Jumadilova Z, Bavendam T, Mueller E, Rogers R. Overactive bladder and women’s sexual health: what is the impact? J Sex Med. 2007; 4(3):656-666.
7. Rogers RG, Kammerer-Doak D, Darrow A, et al. Does sexual function change after surgery for stress urinary incontinence and/or pelvic organ prolapse? A multicenter prospective study. Am J Obstet Gynecol. 2006;195(5):e1-4.
8. Baessler K, Stanton SL. Does Burch colposuspension cure coital incontinence? Am J Obstet Gynecol. 2004;190(4): 1030-1033.
9. Glavind K, Tetsche MS. Sexual function in women before and after suburethral sling operation for stress urinary incontinence: a retrospective questionnaire study. Acta Obstet Gynecol Scand. 2004;83(10):965-968.
10. Shah AD, Kohli N, Rajan SS, Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(3): 421-428.
11. 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.
12. Ozel B, White T, Urwitz-Lane R, Minaglia S. The impact of pelvic organ prolapse on sexual function in women with urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2005;17(1):14-17.
13. Francis WJ, Jeffcoate TN. Dyspareunia following vaginal operations. J Obstet Gynaecol Br Commonw. 1961;68:1-10.
14. Handa VL, Zyczynski HM, Brubaker L, et al. Sexual function before and after sacrocolpopexy for pelvic organ prolapse. Am J Obstet Gynecol. 2007;197(6):629.e1-6.
15. Pauls RN, Silva WA, Rooney CM, et al. Sexual function after vaginal surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol. 2007;197(6):622.e1-7.
16. Paraiso MF, Barber MD, Muir TW, Walters MD. Rectocele repair: a randomized trial of three surgical techniques including graft augmentation. Am J Obstet Gynecol. 2006; 195(6):1762-1771.
17. Novi JM, Bradley CS, Mahmoud NN, Morgan MA, Arya LA. Sexual function in women after rectocele repair with acellular porcine dermis graft vs site-specific rectovaginal fascia repair. Int Urogynecol J Pelvic Floor Dysfunct. 2007; 18(10):1163-1169.
18. Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh. BJOG. 2005;112(1):107-111.
19. Trowbridge ER, Morgan D, Trowbridge MJ, Delancey JO, Fenner DE. Sexual function, quality of life, and severity of anal incontinence after anal sphincteroplasty. Am J Obstet Gynecol. 2006;195(6):1753-1757.
20. Lewicky CE, Valentin C, Saclarides TJ. Sexual function following sphincteroplasty for women with third- and fourth-degree perineal tears. Dis Colon Rectum. 2004;47(10): 1650-1654.

DISCLAIMER
The opinions expressed herein are those of the author and do not necessarily represent the views of the sponsor or the publisher. Please review complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings, and adverse effects before administering pharmacologic therapy to patients.

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