9.5: Treatment of Urinary Incontinence and Female Sexual Dysfunction

In most studies looking at the outcomes of treatment for urinary incontinence, objective measures of continence outcomes are usually the primary aims and sexual function is usually assessed as a secondary outcome.

Conservative treatment

These measures usually reduce urinary incontinence and improve QOL and sexuality. The International Continence Society (ICS) includes pelvic floor muscle training (PFMT) as first line therapy for stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence. A number of small studies have been done to evaluate the impact of PFMT on coital incontinence. In a RCT of 59 women with SUI , Bo et al reported a 50% decrease in coital incontinence in the group receiving PFMT compared to a reduction of only 10% in the placebo group. Admittedly, this was a small study but it certainly supports the role of PFMT as a first line in reducing coital incontinence. For some patients, simple advice such as emptying the bladder prior to intercourse or a change in position are effective in reducing coital urinary incontinence.

Women with overactive bladder find the symptoms particularly more bothersome compared to those patients complaining of stress urinary incontinence since urinary leakage is not the only symptom. Bladder training and anticholinergic drugs are the treatments of choice, but the cure rates and the impact on sexuality remain unclear.

Surgical treatment and sexual function

When surgery is planned the risk of post-operative dyspareunia related to each type of operation, should always be considered. An increasing number of papers have raised the issue of FSD in women who undergo urogynaecological surgery but conflicting data have been reported. In the past the Burch colposuspension was most commonly performed operation for the surgical treatment of stress urinary incontinence. During the last decade, however, the mid-urethral tapes, employing polypropylene monofilament mesh, have become the gold standard. Baessler et al were the first to report, in a retrospective study on Burch colposuspension, on a 70% decrease in coital incontinence following surgery. It decreases incontinence at penetration by 80% and during orgasm by 75%.
A review of vaginal surgery for SUI and female sexual function reports that the retropubic TVT does not appear to adversely affect overall sexual function. Other retrospective and prospective studies have reported varying results ranging from deterioration to equivocal with some reporting improvement in outcomes. (Table I) Mesh erosion is an important cause of dyspareunia for both sexual partners. In a prospective study looking at urodynamic stress incontinence treated with either retropubic TVT or transobturator TVT, overall scores as measured by the PISQ sexual questionnaire improved significantly with specific improvements in the physical and partner related domains. The behavior/emotive domain showed no significant improvement.

Table \(\PageIndex{1}\): Sexual function after tension-free vaginal tape procedure

Function % Reference:	Study type	Number of Patients	Unchanged	Improved	Worsened
Maaita et al (2002)	Retrospective	43	72	5	14
Yeni et al (2003)	Prospective	32	No pre- and postoperative difference
Elzevier et al (2004)	Retrospective	65	72	26	1.6
Glavind and Tetche(2004)	Retrospective	48	60	25	6
Mazouni et al (2004)	Prospective	55	74	2	24
Ghezzi et al (2006)	Prospecgtive	53	62	34	4

Other treatment

Estrogen treatment requires further research, but currently it does not appear to be of value in the treatment of urinary incontinence.

Conclusions

Sexuality is complex and the etiology of female sexual dysfunction is multidimensional. FSD is common and the taboo nature of sexuality and urinary incontinence is a challenge for the clinician. Coital incontinence and urinary incontinence can cause FSD. Validated questionnaires, evaluating sexuality will render more reliable and objective data in the future. These instruments also have a role in assessing FSD pre- and post treatment. The use of pelvic floor muscle training should be considered as the first line of treatment for coital incontinence. Simple advice to empty the bladder prior to intercourse should also be offered. Surgical treatment for stress urinary incontinence does not adversely affect female sexual function but further research, specific to mixed urinary incontinence, is required. Sexuality should be an essential outcome measure with intervention studies on the surgery for SUI.