Key words
overactive bladder - sexual disorder - coital incontinence - stress urinary incontinence
- quality of life
Schlüsselwörter
überaktive Blase/Dranginkontinenz - sexuelle Störung - koitale Inkontinenz - stressbedingte
Harninkontinenz - Lebensqualität
Brief Summary
OAB patients had significantly lower scores for the FSFI questionnaire in general
and in all subdomains compared to stress-incontinent women and controls.
Introduction
Many publications have reported impairments in the sexual life of women with urinary
incontinence. Most of these publications are studies on sexual function after urinary
stress incontinence operations [1], [2]. The most common cause of preoperative sexual dysfunction is coital incontinence.
More than 40% of women with urinary stress incontinence report that this interferes
with their sexual function. The prevalence of coital incontinence is reported to be
between 24 – 31% [3]. It is important to distinguish between urinary loss during penetration and during
orgasm. The former is mostly due to urinary stress incontinence [4], the latter is mostly associated with overactivity of the detrusor muscle [5].
Barber et al. reported that 22% of incontinent women had decreased sexual function
and a reduction in libido caused by the fear of incontinence during intercourse or
orgasm [6]. Sutherst and Brown found that 43% of women reported an adverse effect of incontinence
on their sexual relations [7]. Other studies also report reduced lubrication and dyspareunia in incontinent women
[8]. Women with sexual complaints report more pelvic floor disorders [9].
Rogers et al. reported libido reduction, arousal problems, disturbance of orgasm and
dyspareunia in 46% of incontinent patients [10]. Korda and colleagues interviewed 4000 women between the ages of 19 and 82 about
the impact of urinary incontinence on their sexual life. 46.5% of the incontinent
women below the age of 50 reported decreased sexual arousal. This difference was not
seen in older women (> 50 years old) [9].
A recent study by Gomes et al. showed a high prevalence of SD in women with urinary
incontinence, irrespective of the type of UI. The greater the severity of UI, the
worse the FSFI sexuality questionnaire scores [11].
There are only a few reports about a correlation between OAB and sexual function.
Asoglu et al. reported more anxiety disorders and a reduced quality of life in women
with OAB compared to women with urinary stress incontinence [12]. A Norwegian study by Bo et al. found that women with mixed incontinence reported
greater levels of sexual dysfunction than those with stress incontinence alone [13]. Coyne et al. investigated 43 women with OAB, the majority of whom were incontinent
OAB-patients (n = 23), who reported a reduction in their sexual interest. All of them
reported a negative impact on their sexual life and difficulties in reaching orgasm
[14].
The aim of our study was to investigate the prevalence of sexual dysfunction in women
with OAB and urinary stress incontinence in patients presenting to the urogynecological
outpatient clinic of our pelvic floor center. which has a high incidence of patients
with sexual disorders due to OAB.
Materials and Methods
Study cohort
In this prospective cohort study, patients presenting to our outpatient clinic between
2016 and 2018 for urogynecological examination were enrolled in the study. A total
of 106 women were included in the study and were divided into the following groups:
stress incontinence alone (n = 34), overactive bladder alone (n = 35) and continent
women presenting for routine check-ups or minor non-urogynecological disorders as
the controls (n = 31). Six refused to complete the questionnaire. We enrolled sequential
patients in the OAB group. As these patients were the rarest, other patients were
included based on the number of included OAB-patients to prevent a time shift.
Exclusion criteria were: prolapse (> stage 1) or previous pelvic floor operations
or incomplete clinical examination. Patients with OAB and SUI who had not had prior
medical therapy for urinary incontinence were included. Psychiatric patients and patients
with severe diseases which could impede sexual function were excluded. Women with
chronic pelvic pain and those who reported pelvic pain during examination were also
excluded from the study.
All incontinent women underwent a full urodynamic examination [15] with
-
urogynecological history including
-
micturition symptoms
-
micturition chart
-
sexual history
-
bowel symptoms
-
gynecological status including POPQ
-
hormonal status based on vaginal smear
-
urodynamic examination (urethrocystometry with stress test in supine and standing
positions)
-
3-/4-D pelvic floor sonography
The information was recorded using a standardized, non-validated log and included
a micturition log of at least 48 hours.
Stress incontinence was defined as the loss of urine in the absence of a detrusor
contraction without any symptom of overactive bladder. Overactive bladder was diagnosed
based on the ICS definition: urgency and/or frequency in the absence of any other
detectable bladder disease. All patients with overactive bladder included in this
study suffered from incontinence (incontinent OAB). Patients with mixed incontinence,
including those with a previous history of stress incontinence surgery or medical
treatment for incontinence within the last six months, were excluded.
Questionnaire analysis
Sexual history was recorded using the validated German-language “Female Sexual Function
Index” (FSFI-d) questionnaire following informed consent. The questionnaire, developed
by Rosen [16], was validated in German by Berner [17] and is the sole questionnaire in German which assesses female sexual function. It
records the last four weeks of sexual activity for the domains: libido, sexual arousal,
lubrication, orgasm, emotional satisfaction, and painful sensations. Each question
has 5 possible answers rated with a maximum of 5 points which are linked to a special
factor ranking for the different domains. Each of the six domains studied can be validated
with a maximum score of six. A total score of between 0 and 36 is possible ([Table 1]).
Table 1 FSFI domain scores and full-scale score [17].
|
Domain
|
Questions
|
Score range
|
Factor
|
Minimum score
|
Maximum score
|
|
FSFI: Female Sexual Function Index
|
|
Sexual interest
|
1, 2
|
1 – 5
|
0.6
|
1.2
|
6.0
|
|
Arousal
|
3, 4, 5, 6
|
0 – 5
|
0.3
|
0
|
6.0
|
|
Lubrication
|
7, 8, 9, 10
|
0 – 5
|
0.3
|
0
|
6.0
|
|
Orgasm
|
11, 12, 13
|
0 – 5
|
0.4
|
0
|
6.0
|
|
Satisfaction
|
14, 15, 16
|
0 (or 1) –5
|
0.4
|
0.8
|
6.0
|
|
Pain
|
17, 18, 19
|
0 – 5
|
0.4
|
0
|
6.0
|
|
|
Full-scale score range
|
|
2.0
|
36
|
Individual domain scores and full-scale FSFI scores were obtained using a computational
formula. Individual domain scores were obtained by adding the scores of individual
items comprising the domain and multiplying the sum by the domain factor. The full-scale
score was obtained by adding the six domain scores. The score correlates positively
with sexual function.
The FSFI-d allows us to discriminate between “sexual dysfunction” and “no sexual dysfunction”,
with a threshold value of 26.55 considered optimal [18].
In 2000, Rosen et al. published a study of healthy women with a score of 30.5 ± 5.29
[16]. Communal et al. defined sexual function as “good” when the score was 30 – 36, “moderate”
when it was 23 – 29 and “weak” when the score was below 23 [19].
Written consent was obtained from all patients who agreed to participate in the study.
All patients signed a consent form.
Statistical methods
Statistical analysis was performed using the SPSS program, version 23.
We did not formally calculate a sample size because we had no pilot study for the
groups to create data for a sample size calculation before this study. However, we
estimated that recruiting 30 patients per group would provide enough preliminary data
to reach a statistical power of 80% for the study, based on other studies comparing
female sexual function in cases with different types of urinary incontinence [33].
Differences between the three groups were calculated with Mann-Whitney U-test. The
results of explorative statistics were calculated with a significance of 5% (p ≤ 0.05).
Kruskal-Wallis test was used to compare sexual function domains and subtypes of UI
and controls.
Results
The overall median age was 57.5 years (IQR 40.0; 64.75). Median age in the OAB group
was 60.0 (25 – 75) years; in the SUI group it was 57.5 (30 – 76) years, and in the
control group it was 54.0 (29 – 77) years (Kruskal-Wallis test: p = 0.397). There
were no statistical differences between the different groups.
Total FSFI score
Overall, questionnaire scores ranged between 2 and 35.1 points (maximum: 36). The
median score was 22.4. Women with OAB had a median score of 17.6, those with SUI had
a median score of 22.0 and the control group had a score of 26.5 ([Table 2]).
Table 2 Mean scores for sexual function domains of the FSFI according to UI type for 100
women included in the study.
|
Domain
|
OAB
n = 35
Median [IQR]
|
SUI
n = 34
Median [IQR]
|
Control
n = 31
Median [IQR]
|
p value
|
|
n: number of women, SD: standard deviation, OAB: overactive bladder, SUI: stress urinary
incontinence, FSFI: Female Sexual Function Index
sig.: p < 0.05
|
|
Total score
|
17.6 [4,8; 27.3]
|
22.0 [5.7; 29.0]
|
26.5 [21.8; 30.5]
|
0.010
|
|
Sexual interest
|
2.3 [1.2; 3.0]
|
3.2 [2.3; 3.6]
|
3.4 [2.8; 3.6]
|
0.024
|
|
Arousal
|
2.7 [0.3; 3.9]
|
3.2 [1.0; 4.6]
|
3.9 [2.7; 4.8]
|
0.030
|
|
Lubrication
|
3.3 [0.0; 5.4]
|
3.8 [0.0; 5.8]
|
4.8 [3.9; 6.0]
|
0.046
|
|
Orgasm
|
2.8 [0.0; 4.8]
|
3.8 [0.0; 5.3]
|
4.8 [3.6; 5.6]
|
0.014
|
|
Satisfaction
|
3.6 [2.4; 4.8]
|
3.8 [2.4; 5.2]
|
4.8 [3.2; 5.6]
|
0.046
|
|
Pain
|
3.2 [0.0; 6.0]
|
3.8 [0.0;6.0]
|
6.0 [4.8; 6.0]
|
0.010
|
Variance analysis calculated with the Kruskal-Wallis test showed a highly significant
difference of 0.01 between the total scores of the three groups. Mann-Whitney U-test
showed no significant difference between the two groups with incontinence (OAB, SUI)
(p = 0.275) but a noticeable difference of 4.55 points between stress-incontinent
women and controls, although the difference was not statistically significant (p = 0.051).
However, the difference between OAB patients and controls was highly significant (p = 0.004).
Categories/FSFI subgroups
Sexual interest
The subgroup “sexual interest” has two questions:
-
Over the past 4 weeks, how often did you feel sexual desire or interest?
-
Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
We found the OAB group had the lowest scores with 2.3, while stress-incontinent women
scored 3.2 and controls scored 3.4. Mann-Whitney U-test showed no difference between
controls and women with stress incontinence but a significant difference (p = 0.046)
between OAB patients and stress-incontinent women and a highly significant difference
between OAB patients and controls (p = 0.001).
Sexual arousal
Questions 3 to 6 of the FSFI-d concerned sexual arousal. Scores ranged from 0 to a
maximum of 6.0 points.
Here again, the lowest median was found for the group of OAB patients (2.7), while
the group of women with stress incontinence had a median of 3.2 and the control group
had the highest score with 3.9; the differences were significant.
Mann-Whitney U-test showed a significant difference between the OAB group and the
control group (p = 0.048) but not between the other groups (OAB/stress incontinence
p = 0.522; stress incontinence/controls p = 0.212).
Lubrication
Questions 7 – 10 were on lubrication. The overall score in this subgroup ranged from
0.0 to 6.0. The highest score was for the control group (median value 4.8), while
stress-incontinent women had a median value of 3.8 and women with OAB only had a score
of 3.3. There was a significant difference between the OAB group and the control group
(p = 0.018) but not between OAB/stress incontinence (p = 0.503) or stress incontinence/controls
(p = 0.116).
Orgasm
Questions 11 to 13 of the FSFI focused on orgasm. The overall score was the same as
that for the subgroups “lubrication” and “arousal”. The OAB group had a median score
of 2.8, patients with stress incontinence scored 3.8, and controls scored 4.8. There
was a highly significant difference between the OAB group and controls (p = 0.006)
but not between the stress-incontinent women and controls (p = 0.062) and between
incontinent groups (p = 0.402).
Satisfaction
This area was covered by questions 14 – 16, with scores ranging from 0.8 to 6.0. Satisfaction
had higher scores compared to other domains (OAB 3.6; SUI 3.8; controls 4.8). The
difference between the OAB group and the control group was highly significant (p = 0.014)
but comparisons between other groups were not.
Pain
Questions 17 – 19 focused on pain during intercourse, with the same scores are reported
above. Here, the difference between the OAB group and controls (p = 0.008) was highly
significant and the difference between stress-incontinent women and controls (p = 0.01)
was also significant but not the difference between women with OAB and women with
stress incontinence (p = 0.828).
We found significant differences between the OAB group and the control group in the
FSFI-d scores for sexual function in all subgroups of this domain. This was most evident
for the category “sexual interest” (p = 0.001) ([Table 2]).
There was also a significant difference between OAB patients and the stress-incontinence
group in this subgroup. Patients with urinary stress incontinence only differed significantly
from controls in the domain “pain” (p = 0.01).
Particular questions in the FSFI
80% of women with OAB responded to Question 1: “Over the past 4 weeks, how often did you feel sexual desire or interest?” with “A few times (less than half the time)”
or “Almost never or never”. 64.7% of respondents in the group with stress incontinence
and 48.4% of patients in the control group also gave these answers.
In response to Question 2: “Over the past four weeks, how would you rate your level
(degree) of sexual interest?”, 74% of the OAB group answered “low” or “very low or
none at all”, 17.1% replied “moderate” and only 8.6% answered “high”, but none of
them answered “very high”. Patients with stress incontinence rated their sexual desire
higher: almost half of them answered “low” or “very low or none at all”, 41.2% answered
“moderate”, and 8.8% “high” or “very high”.
One of the 21 sexually active patients with OAB and 4 of 22 patients with SUI reported
involuntary loss of urine during intercourse (controls n = 0/28).
Discussion
Patients with pelvic floor disorders show reduced sexual well-being. The median age
in our study was 57.7 years, demonstrating the late onset of a diagnosis of incontinence
in the higher age groups, although younger women also suffer from this complaint.
The age distribution was similar in all three groups.
Due to the higher mean age, the level of sexual disorder was higher; only 37 out of
100 participants achieved a total score of more than 26.55, which is the level of
normal sexual function [18]. Women in all of the groups were matched according to age.
Assessment of the questionnaires
Contradictory or divergent results were seen when evaluating the different questions.
One possible answer to Questions 3 to 14 and 17 to 19 was “no sexual activity”. But
this answer was not often given in response to these particular questions. In the
control group, this possible answer was given in 12.9 to 16.1% of cases; it was given
in 26.5 – 32.4% of cases in the group with urinary stress incontinence, and in 20.0 – 40.0%
of cases in the group of OAB patients. Although the questionnaire was suitable for
women without sexual activity (due to the lack of a partner), some questions were
confusing for a number of patients and some forms were therefore answered inaccurately.
Very often the answer to Question 15 “Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?” was not completed,
mostly in cases when women did not have a partner, because there was no possible answer
apart from “no sexual activity”. We added this question when interviewing the patient.
Many studies [1], [2], [3], [20] have shown the impact of urinary stress incontinence on sexual function. Our results
also show an impact but found no significant difference between continent women and
those with urinary stress incontinence. Only a few studies have reported a correlation
between OAB and sexual dysfunction [21], [22], [23], [24]. In our study, we found that women with OAB are significantly more likely to have
sexual dysfunction than continent women, based on the total scores for the questionnaire
(p = 0.004). Women with urinary stress incontinence had lower scores than healthy
subjects, but this difference was not significant (p = 0.051).
In the analysis of all subgroups, patients with OAB reported a significant negative
impact compared to controls, while comparisons of the SUI group with control patients
and of the OAB/SUI groups did show any significant differences. The results of this
study support the higher negative impact of OAB on sexual life.
Wiegel et al. [18] determined the threshold value of the FSFI-d questionnaire to be 26.55 points as
an indication of some degree of sexual dysfunction. Based on this, in our study 71.4%
of the OAB group, 67.6% of the urinary stress-incontinent patients, and 48.4% of controls
showed some sexual dysfunction. This seems to be very high in our opinion. Communal
et al. [19] defined less than 23 points as dysfunctional. In this case, 62.9% of the OAB group,
58.8% of the urinary stress-incontinent patients, and 35.5% of the controls had sexual
dysfunction.
As regards the different domains of the questionnaire (sexual interest, arousal, lubrication,
orgasm, satisfaction) we found a significant difference between OAB and controls for
all of the domains.
Our study showed statistical differences in sexual interest between OAB and controls
and OAB/SUI patients. These findings correlate with those of other studies: Coyne
et al. [14] reported reduced sexual interest in half of OAB-patients. Gordon et al. [20] noted sexual dysfunction in 71% of OAB-patients. Coyne reported reduced sexual interest
in more than half of incontinent patients and a negative impact of OAB on the sexual
life of these patients, including difficulties in reaching orgasm [14]. The reduction of sexual interest was particularly noticeable in our study. 80%
of our patients with OAB answered the question about the frequency of sexual interest
with “sometimes (about half the time)”, “a few times (less than half the time)” or
even “almost never or never”. 64.7% of the group of stress-incontinent women and 48.4%
of the control group gave the same response. The
degree of sexual interest question was also answered with “low” or “very low
or none at all” by 74.4% of OAB-patients.
A similar picture was also seen for the category “arousal”, with the OAB group showing
significantly lower values and a median of 2.70 compared to controls which had a median
of 3.90 (p = 0.048). The control group had better results than the group of women
with urinary stress incontinence, but the difference between the two groups was not
significant.
Disturbances of orgasm in women with incontinence has been reported in several studies
[3], [25], [26]. We found a significant difference between the OAB group and the healthy group (p = 0.006),
but no significant difference between stress-incontinent and continent women (p = 0.062).
Handa et al. [8] reported a reduction of libido in women with incontinence as well as reduced lubrication
and increased dyspareunia. We also found a significant difference between the OAB
group and controls (p = 0.018), but no statistically significant difference between
the other two groups. Our results were similar to the findings of Handa et al. in
terms of pain during intercourse and dyspareunia. In our study, there was a significant
difference between controls and women with urinary stress incontinence but almost
no difference between OAB women and stress-incontinent women (p = 0.828). What was
notable was that the difference between stress-incontinent women and controls for
the subgroup “pain” was significant, but the difference for the total score and other
domains was not. This could be explained by anatomical changes in these women.
There was also a significant difference between OAB-patients and continent women (p = 0.0149)
but not between the other groups for the domain “satisfaction”. The low scores of
patients with OAB can be explained by the high prevalence of sexual inactivity in
this group.
Sexual inactivity
34% of OAB patients and 29% of the stress-incontinent group but only 14% of the continent
women reported being sexually inactive. One of the weaknesses of this questionnaire
is the lack of differentiation between cohabitation with a partner and masturbation
without a partner. Sometimes older women were not able to answer all of the questions
accurately.
Incontinence during intercourse
While other studies have reported a loss of urine during intercourse in 24 – 35% [20], [27], only 15% of stress-incontinent patients, one patient with OAB and none of the continent
women reported this symptom in our study.
Barber et al. [4] differentiated between loss of urine during penetration and incontinence during
orgasm. Our questionnaire did not differentiate between the two.
Arousal, lubrication, orgasm, and satisfaction
40% of the OAB patients reported achieving orgasm without or only with little difficulty,
as did 47% of women with urinary stress incontinence and 67% of the continent women.
25% of the OAB group said they found it impossible or very difficult to achieve orgasm.
But this figure was very similar across all the groups: 23.5% of the stress-incontinent
group and 19.3% of the continent women reported the same problem.
“Discomfort and pain” was the only subgroup where the values of OAB patients were
better than those of the stress-incontinent women (18% versus 12% in OAB patients);
only 3% of healthy women reported discomfort and pain. One reason for this could be
anatomical changes in women with pelvic floor weakness.
It is not clear whether OAB impairs sexual life or vice versa, or if there is a common
cause. The FSFI-d questionnaire only asks about the last four weeks of sexual activity,
so we have no definite knowledge about the period of incontinence or about the disturbance
of sexual function. In our experience, women who are sexually inactive in their partnership
report this some years before the onset of OAB. But this should be clarified by further
studies.
Studies report an impact of OAB symptoms on sexual function and that OAB itself is
often correlated with psychosomatic disease [5], [20], [28]. Women with OAB suffer more often from depression and anxiety disorders than those
with urinary stress incontinence [28], [29], [30].
A recent study has shown that after one year, about 18% of women with urinary stress
incontinence develop combined stress/urge incontinence [31]. MRI studies have shown that women with OAB show activity in other brain regions
in relation to urinary urgency than healthy controls, indicating a recruitment of
alternative pathways when loss of bladder control is feared. In fact, we all train
our brain to control two reflexes which are not under the control of our senses, i.e.,
micturition and defecation [32]. The regulation of sexual reflexes occurs later in life and possibly follows similar
pathways to those of micturition, targeting the same organ system. This could explain
the fact that disorders in both systems are significantly often found together. It
would be of interest to see whether our clinical observation that disturbances of
sexual function appear years before OAB symptoms can be verified, as this
hypothesis could offer a new approach for the therapy of OAB and of sexual disorders.
Conclusion
OAB and stress urinary incontinence have a significant negative impact on sexual life.
There is a high prevalence of SD in women with urinary incontinence, irrespective
of the type of UI. A higher degree of incontinence is related to lower FSFI scores.
When all FSFI domains were analyzed, patients with OAB had significant sexual dysfunction
compared to controls. Comparisons between SUI and control patients and OAB/SUI did
not show significant differences with the exception of sexual interest. The results
of this study support a higher negative impact of OAB on sexual life. There are more
differences between OAB patients and controls than between SUI patients and controls.
Further studies should focus more on the impact of OAB on sexual function.
Authors Contributions
Naumann: Project development, data collection, management data analysis, manuscript writing/editing.
Hitschold: Project development, management data analysis. Frohnmeyer: Data collection, management data analysis. Majinge: Project development, manuscript writing/editing. Lange: Project development, data collection, management data analysis, manuscript writing/editing.
