Curr Urol Rep (2013) 14:298–308 DOI 10.1007/s11934-013-0344-7 MEN'S HEALTH (J MULHALL, SECTION EDITOR) Urinary Disorders and Female Sexual Function Jaclyn Chen & Genevieve Sweet & Alan Shindel Published online: 29 May 2013 # Springer Science+Business Media New York 2013 Abstract Overactive bladder urinary incontinence and female sexual dysfunction are common in women, but often go unreported and/or untreated. All of these conditions can have a markedly negative impact on quality of life. There is a growing body of evidence that sexual and urinary problems are often comorbid and possibly synergistic in women. Increasingly robust evidence indicates that management of urinary concerns may enhance sexual function and quality of life. It is important for health care providers who see women to consider both urinary and sexual health concerns during patient encounters. Additional research attention to the interrelationships between these genitourinary disorders is warranted. Keywords Incontinence . Stress urinary incontinence . Overactive bladder . Sexual function . Coital incontinence . Urethral slings . Antimuscarinics . Female sexual dysfunction Introduction The general term “urinary symptoms” encompasses a range of often comorbid concerns relating to micturition. Examples include overactive bladder (OAB, typically defined as recurrent and bothersome symptoms of urgency to void), urge urinary incontinence (UUI, loss of urine associated with a sudden overpowering urge to void), stress J. Chen : G. Sweet : A. Shindel (*) Department of Urology, UC Davis Medical Center, 4860 Y Street Ste 2200, Sacramento, CA 95817, USA e-mail: [email protected] J. Chen e-mail: [email protected] G. Sweet e-mail: [email protected] urinary incontinence (SUI, loss of urine associated with ValSalva or other maneuvers involving increased intraabdominal pressure), and mixed urinary incontinence (MUI, combined SUI and UUI) [1, 2, 3•, 4, 5]. Between 11 and 73 % of women in community-based studies suffer some urinary symptoms [4, 6, 7•, 8]. Between 12 and 46 % of American women experience some degree of urinary incontinence [9]. Urinary symptoms may exact a heavy toll on quality of life, and in severe cases may lead to complete social isolation. Incontinence is a particularly embarrassing and potentially disabling condition that may lead to depression, social isolation, and worsening general health [10, 11]. It is estimated that incontinence and OAB cost the US Health care system 32.1 billion dollars in 2000 [2]. Objective studies on female sexuality report relatively high prevalence (up to 50 % in some series) of female sexual dysfunction (FSD) [12–14]. However, studies that assess distress from sexual issues tend to report lower rates of bothersome symptoms, in the range of 15–20 % [15, 16]. Hence, “sexual dysfunction” as defined in some studies may not accurately reflect the subject population’s actual experience of bothersome sexual distress. Variations in sexual priorities and interest further complicate assessment of sexual distress and dysfunction in populations of women. It is intuitive that urinary symptoms may often be associated with impairment of female sexual function and/or sexual bother [6, 7•, 8, 17]. In this review, we highlight the peer-reviewed literature on the interrelationship of urinary symptoms and FSD. The body of literature from which this manuscript is drawn relies heavily on a heterogeneous collection of survey metrics and questionnaires; variations in the source data of necessity lead to somewhat heterogeneous and conflicting results [18, 19]. Regardless, there is a reasonable body of evidence that urinary and sexual symptoms are often comorbid, and that attention to urinary problems may enhance sexual quality of life. Curr Urol Rep (2013) 14:298–308 Methods We performed a PubMed search using Boolean linking language and the following terms: “overactive bladder”, “stress urinary incontinence”, “urinary incontinence”, and “sexual dysfunction.” The reference list for selected articles was consulted for additional citations of interest, some of which were incorporated into the review. We did not include unpublished abstracts in our review. Criteria for statistical significance were set at p<0.05. Sexual and Urinary Problems are Frequently Comorbid Between 19 and 50 % of women with urinary incontinence or pelvic floor disorders such as prolapse may experience sexual dysfunction, dyspareunia, reduction in sexual interest, and/or decline in their frequency of sexual activity [6, 20–27]. OAB and urinary incontinence have been associated with a wide array of impairments in sexual response, including declines in desire, arousal, lubrication, orgasm general sexual satisfaction, and increases in sexual pain relative to women without urinary symptoms [23, 28]. Some studies have suggested urinary symptoms are not always associated with sexual dysfunction [29]. Women who are younger and more likely to be sexually active tend to have greater sexual distress related to urinary issues [28, 30, 31]. In sexually inactive women distress may not be present, despite urinary issues that would in general portend sexual problems. In some cases, cessation of sexual activity is due to urinary symptoms themselves; in these circumstances, appropriate medical attention may permit a woman to resume a satisfying sexual life should she so desire [32–35]. As many as 40 % of women cite sexual intercourse as an inciting or exacerbating event for urinary symptoms [7•, 36••]. Coital incontinence, i.e. loss of urine during coital sexual activity, is surprisingly prevalent. Coital incontinence may occur in between 10 and 67 % in patients seeking treatment for urinary symptoms [1, 5, 36••, 37, 38], and in as many as 2–10 % of women in general populations [5]. Coital incontinence appears to be most prevalent in women with SUI; one study found that coital incontinence was detected in 89 % of women with SUI compared to 33 % of women with OAB [1, 39]. Coital incontinence may be subdivided into penetration incontinence (loss of urine with vaginal penetration) and orgasm incontinence (loss of urine at orgasm). Interestingly, the subtype of coital incontinence seems to vary dependent on baseline urinary symptoms. In a 1988 study of women suffering from penetration incontinence 70 % had SUI and 4 % had OAB; in women with orgasm incontinence the prevalence for SUI and OAB was 42 % and 299 3 %, respectively [1]. In a more recent study, 84 % of women with SUI experienced penetration incontinence compared to 9 % of women with OAB. Conversely, 24 % of OAB experienced orgasm incontinence compared to 5 % of patients with SUI [39]. While the percentages vary somewhat based on method of assessment it is apparent that penetration incontinence is more often associated with SUI whereas orgasm incontinence may occur in either situation [40]. Studies on Comorbidity of Sexual and Urinary Problems Using Validated Scales In a study of sexually active women, 112 women with urodynamically proven OAB and 165 healthy controls without urinary symptoms were evaluated using the Female Sexual Function Index (FSFI). Sexual dysfunction (defined as FSFI score<26.5) was seen in 47 % of OAB group and in 22 % of the controls. Women with OAB had lower mean scores for all six domains of the FSFI [31]. In a survey of 292 gynecology outpatients over age 40, 26 % reported sexual distress per the Female Sexual Distress Scale (FSDS). Particularly common problems included avoidance of sexual activity for fear of incontinence, decreased arousal, infrequent orgasms, and dyspareunia. These sexually distressed women tended to be younger (mean age 55 years versus 57 years) and also had higher rates of depressive symptoms as assessed by the Center for Epidemiologic Studies Depression Scale (CES-D). Of note, just 80 (27 %) of these subjects were initially seeking care for pelvic floor concerns; the remainder were presenting for annual gynecological visits or for treatment of other gynecological conditions [41]. In a study of 8,085 women from the general populations of the United Kingdom, Sweden, and United States, it was determined that OAB symptoms (assessed with Likert-style questions based on International Continence Society definitions for OAB) were present in 33–41 % of female subjects. Nearly two-thirds (65 %) of subjects without OAB were sexually active; sexual activity was less common in women with OAB (59 %) and in women with OAB and incontinence (51 %). Women with OAB were also at higher risk of decreased sexual enjoyment [42••]. Studies Suggesting that OAB Portends Worse Sexual Problems Compared to Other Urinary Syndromes Several studies have suggested that women with OAB in the presence of incontinence have the highest rates of dissatisfaction, worst quality of life, and highest rates of sexual impairment [43, 44]. In a urodynamic study of 118 sexually 300 active women, subjects were separated into SUI, UUI, and MUI groups. Of these patients, MUI patients had the lowest (i.e. best) pelvic organ prolapsed/urinary incontinence sexual questionnaire (PISQ-12) scores, followed by patients with SUI. Patients with UUI and urodynamic evidence of detrusor over-activity had the highest (worst) PISQ-12 scores [45]. As women with OAB in the absence of UUI were not enrolled, the incremental sexual bother of OAB alone versus OAB with UUI cannot be determined from this study. A small study from Korea using nonvalidated instruments for the assessment of sexual activity suggested that both OAB and urinary incontinence (not otherwise specified) were both associated with worse sexual function, but OAB was significantly more predictive of sexual problems than SUI [46]. Similarly, a population-based study of women in Taiwan using a translated version of the Bristol Female Urinary Tract Symptoms Questionnaire reported a progressively greater prevalence of interference in sexual life and lower overall quality of life in women with SUI, OAB, and MUI [47]. In a study of women with urodynamically proven OAB or SUI, it was determined that women with OAB had generally poorer marital adjustment scores (assessed by the Dyadic Adjustment Scale) and lower sexual satisfaction (assessed by the Derogatis Sexual Functioning Inventory) compared to women with normal lower urinary tract function. There was no significant difference in sexual interest between women with OAB and healthy women. Interestingly, a trend towards similar relationships was noted in women with SUI, but the relationship was less robust; only in global marital adjustment was there a significantly lower score in women with incontinence compared to women without urinary symptoms. It is worth noting that women in the OAB arm were younger than in the other two arms (mean age 43 years versus 49 and 50 years); this may influence the importance and bother ascribed to sexual symptoms in different groups [48]. Studies Suggesting that SUI Portends Worse Sexual Problems Compared to Other Urinary Syndromes A Korean study of women with SUI versus OAB reported a significantly greater likelihood of dyspareunia in women with SUI. There was also a trend towards more coital incontinence in women with SUI, but this did not meet strict criteria for statistical significance (p=0.056). Using the Bristol Female Lower Urinary Tract Symptoms questionnaire to assess sexual bother, the authors determined that global sexual bother was slightly higher in women with SUI, but this was not strictly statistically significant (p= 0.096) [49]. Curr Urol Rep (2013) 14:298–308 A study from Japan reported that SUI was associated with generally worse sexual function outcomes compared to other urinary complaints. From a survey population of 576 female hospital workers, 146 evaluable responses indicated that 72 women had experienced urinary symptoms, 17 had UUI, and 35 had SUI (all assessed with a urinary symptom metric validated in Japan). Women with SUI had significantly lower FSFI scores for the desire, arousal, and lubrication domains compared to women without SUI urinary symptoms. The difference in FSFI was not significant between women with or without other urinary symptoms [50]. It is safe to surmise that all women with urinary symptoms are at increased risk of sexual dysfunction and the odds of sexual dysfunction increase as the urinary symptoms become more complex and/or severe. Women with the combination of OAB and UUI or MUI appear to have worse sexual function [51]. However, there may be individual, cultural, and/or regional differences in the sexual ramifications of the various urinary syndromes [29]. Mechanisms and Etiology of Female Sexual Dysfunction in the Patient with Urinary Symptoms In some cases, a single underlying cause (e.g. vulvovaginal atrophy, gynecological surgery, pregnancy/parturition) may predispose a woman to both sexual and urinary problems [22, 41, 52]. However, there are few data to support a direct causative mechanism linking most FSD and urinary symptoms/incontinence. Perturbations of sexual function from urinary symptoms appear to be mediated in most cases by voiding symptoms and/or fear of urinary loss with sexual activity. Although there is no consistent anatomical abnormality detected in women with coital incontinence [53], urodynamic studies performed during orgasm in healthy women have demonstrated involuntary bladder contractions and urethral relaxation [54]. It is conceivable that these orgasm-related effects may predispose women with already tenuous continence mechanisms (urethral sphincter incompetence, OAB, etc.) to have coital incontinence [53]. Treatment of Urinary Symptoms and Effects on Sexual Function Therapy for urinary issues may have a positive effect on sexual function by mitigating distressing symptoms [7•]; however, treatment-related side effects or complications may attenuate sexual function gains or even worsen sexual function overall [6, 44]. Careful patient counseling and Curr Urol Rep (2013) 14:298–308 documentation of baseline sexual function are required before any therapy for urinary symptoms. Conservative Measures Education and advice may yield sexual function benefits in nearly every setting. Timed voiding, education of the patient and her partner on the benignity of exposure to sterile urine, fluid avoidance and/or voiding immediately prior to sexual activity, and use of sexual lubricants may help sexual function in virtually any type of urinary syndrome [7•]. Medical Therapy for OAB Medical therapy for OAB may reduce fear of urine loss and/or urgency during sexual activity [7•]. The positive effects of medical therapy for OAB symptoms on sexual function may be lessened by the risk of medication side effects [55]. A small trial of 30 women with OAB (assessed by ICS criteria) reported a 70 % prevalence of sexual problem as assessed by the Arizona Sexual Experience Scale. After 3 months of treatment with tolterodine in an open label fashion, the rate of sexual dysfunction was 13 % in 28 patients who followed up. Improvements were noted in sexual desire, arousal lubrication, orgasm, and orgasm satisfaction at 3-month follow-up and were more pronounced in women with severe urinary symptoms at baseline [56]. A 12-week randomized placebo controlled trial assessed tolterodine versus placebo in a population of 330 women with OAB and UUI. The PISQ-12 and the Sexual Quality of Life-Female (SQLF) questionnaire were used to assess sexual function outcomes. Tolterodine was efficacious in the treatment of OAB and UUI symptoms; women treated with tolterodine had improvements in SQLF and the physical domain of PISQ-12; there was no significant mean difference in the partner or emotional/behavioral domains of PISQ-12 in treated women between baseline and 12-week follow-up. Women treated with tolterodine had significantly greater improvements in sexual function when compared to women receiving placebo [57]. A 12-week open-label extension study in this population examined changes in 161 women who were sexually active at baseline and took tolterodine throughout all 24 weeks of the study. Mean improvements in OAB symptoms noted at 12 weeks were maintained, but there were no significant additional changes except for continued improvement in concerns relating to coital incontinence [58]. In a 6-month open label trial of oxybutynin for OAB with or without incontinence (n=2,508 women, 84 % postmenopausal, and 370 men) sexual function was assessed at baseline with sexuality specific metrics from the Beck Depression Inventory and the King’s Health Questionnaire. 301 Of note, the authors coded respondents who answered “n/a” to questions on sexuality as sexually inactive, but included all other respondents as sexually active (59 %), including those that endorsed “not at all” responses to metrics. At the end of study, coital incontinence had decreased from 23 to 19 % of the population. Improvement in sexual function was reported for 19 % of subjects, typically due to increased interest in sex, compared to 11 % of respondents who reported worsening sexual function of unclear nature [24]. There are numerous methodological limitations of this study, including assumption about absence of sexual activity without explicit questioning on this, failure to use genderspecific sexuality instruments, lack of subset analysis between gender groups, and lack of clarity on what constituted relevant change in sexual function. Furthermore, data were analyzed as a single pool; there is no comment within the paper about gender differences in responses. Anti-muscarinics are thought to have inferior efficacy in treating orgasm incontinence in women with detrusor over activity. However, there may be some utility of this class of medications for treatment of penetration incontinence [36••]. These relationships are somewhat counter-intuitive, given other publications suggesting that orgasm incontinence is more frequently associated with OAB and penetration incontinence with SUI [1, 39]. Vulvovaginal atrophy (commonly associated with natural or iatrogenic menopause) may contribute to both sexual symptoms (dyspareunia, decreased lubrication, decreased arousal, etc.) and urinary symptoms (incontinence, urgency, frequency, etc) [52]. Local or systemic estrogen therapy has been shown to ameliorate the various signs and symptoms of vulvovaginal atrophy [59], with potential benefits for both urinary and sexual function [33]. Despite substantial concerns in both the medical and lay community about hormone replacement therapy, this option should be considered in women with vulvovaginal atrophy and bothersome sexual and/or urinary symptoms [52]. Surgical Management of OAB with Sacral Neuromodulation Yih prospectively evaluated 167 women who underwent sacral neuromodulation; of note, only 106 of these patients had OAB (n=27) or OAB with UUI (n=79); the remainder had a mix of urinary retention and pelvic/bladder pain. Sexual function was evaluated with the FSFI at 12-month follow-up. The subjects were divided into a sexually functional group (n=13, all sexually active at baseline) and a less functional group (n=136, 62 [46 %] of whom were sexually active at baseline) based on the commonly used FSFI-total cut-off score of 26. In the group with higher (better) FSFI scores at baseline, there was a statistically significant decrease in mean FSFI-total score from 27 to 25; this was 302 driven primarily by a decline in mean orgasm and overall satisfaction domains. Of note, at follow-up, this group included just nine patients, so results must be interpreted with caution. Amongst women in the less sexually functional group, ten who had not previously been sexually active were sexually active at follow-up; interestingly, partner variables were responsible for initiation of sexual activity in eight of these women, with just two reporting resumption of sexual activity due to improvements in urinary symptoms. Women in this group experienced a significant increase in total FSFI score, as well as domain specific improvements in desire, orgasm, pain, and satisfaction [19]. Heterogeneity of inclusion criteria, the possibility that changes in FSFI in both groups represent regression to the mean, and some issues with endpoints and follow-up mandate interpretation of this study with caution. Gill et al. reported a subset analysis of ten sexually active women with OAB and incontinence treated with sacral nerve stimulation for overactive bladder. At first follow-up (mean 3 months), there was less concern about coital incontinence and significant improvement in mean domain scores for arousal and satisfaction amongst eight women sexually active at follow-up; two had not resumed sexual activity for fear of post-operative complications. These changes were associated with positive effects on urinary function measures [60]. The limited number of patients complicates interpretation of these data. Another study of sacral neuromodulation reported on 27 women (13 for OAB without pain and 12 for pelvic pain with urinary symptoms) who were sexually active at baseline and had at least 6-month follow-up data. In the OAB group there was a mean improvement in total-FSFI score (18.6 at baseline to 22.4 post-procedure), but this was not statistically significant. The greatest magnitude of change was noted in FSFI-satisfaction, although this did not attain statistical significance [61]. Small sample size and exclusion of women who might be sexually inactive due to pelvic floor concerns limits conclusions that can be drawn from this dataset. Peripheral percutaneous tibial nerve stimulation was used to treat in population of 121 individuals with pelvic floor complaints (76 women, 61 of whom had OAB). A nine-item survey was used to assess sexual function at baseline and 12-week follow-up. Patients who were dissatisfied with sexual function at baseline had a mean increase in sexual function scores and sexual activity at follow-up; although separate testing was not reported, female gender was associated with greater likelihood of sexual improvement. There was no net change in sexual function in patients who had neutral or good sexual function before treatment [62]. A summation of several highlights from the literature on sexual function outcomes of OAB is presented in Table 1. Curr Urol Rep (2013) 14:298–308 Management of SUI A brief summary of sexual function outcomes from SUI management with pelvic floor PT and recent studies on urethra slings is presented in Table 2. Pelvic Floor Physical Therapy Pelvic floor rehabilitation may be a useful as a monotherapy or as adjunctive therapy for SUI. One small series reported on 16 women with stress urinary incontinence on urodynamics (five of whom also had coital incontinence) who underwent a comprehensive pelvic floor rehabilitation including biofeedback, functional electrical stimulation pelvic floor muscles exercises, and vaginal strengthening exercises with retention of vaginal cones. 81 % of patients were dry after treatment (not requiring pads) and none had coital incontinence. Mean scores for all six domains of the FSFI were significantly higher 5 months post-treatment compared to baseline [34]. In another series, 70 women with urodynamic SUI were enrolled in a 12-month course of pelvic floor muscle training. Incontinence episodes decreased by 38.1 %, with a significantly improved FSFI scores from 20.3 to 26.8 [63]. Of note, subjective assessment of sexual function pre-treatment and post-treatment was not explicitly stated in either study. Surgical Management of SUI The particular sexual function benefits of SUI treatment appear to derive from reduction in fear of coital incontinence [3•, 18, 40, 64]. However, sexual function may worsen after surgical therapy for SUI due to de novo urgency symptoms, erosion of implanted mesh, dyspareunia, or failure of the procedure to correct SUI [32, 65]. There are also concerns that urethral sling placement may contribute to fibrosis and reduced elasticity of the anterior vagina [36••]. In one ultrasound study of clitoral blood flow before and after incontinence surgery, there were significant declines in peak systolic velocity in the clitoral arteries after tension free vaginal tape (TVT) placement [66]. These changes may theoretically contribute to decreased sexual sensitivity. Careful discussion of benefits and risks (established and theoretical) is critical in counseling women on potential outcomes; urodynamic testing may help guide this conversation [7•]. Surgical Management of SUI with Urethral Slings A 2011 meta-analysis of 1,578 women in 18 studies of SUI without pelvic organ prolapse managed with sub-urethral slings estimated a 32 % chance of improvement in sexual function post-operatively compared to a 13 % chance or 33 13 Gill et al. 2011 [REF 60] Ingber et al. 2009 [REF 61] Van Balken et. al 2006 [REF 62] 61 167 Yih et al. 2013 [REF 19] 3.9 mg/day transdermal oxybutynin patch changed twice weekly Tolterodine ER 4 mg daily Treatment Percutaneous Tibial Nerve Stimulation Sexual function 51 % requested continuation of therapy Mean FSFI increased to 22.4, difference not statistically significant Improvement in sexual function in group that was initially dissatisfied Improvement in sexual quality of life and physical symptoms of sexual function, no change in behavioral/emotional domain Improved coital incontinence Effects of OAB on sex life improved in 12.6 % and worsened in in 19 % of subjects, 11 % worsened. 7.5 % Improved relationship with partner and interest in sex 19.6 % 50 % Improvement in Poor sexual function group showed ICSI-PI scores improvement in FSFI subdomains (desire, orgasm, satisfaction, and pain). More sexually functional group worsened in orgasm and satisfaction. Improvement based on Improved arousal 0.7, satisfaction 1 and PGI-S, HIS, UDI-6, IIQ7 overall function 3.2 per FSFI Reduction in UUI, OAB, other symptoms Incontinence improvement Sacral Neuro-modulation Not reported here Sacral neuro-modulation 152 (91.0 %) FSFI score <26 Sacral neuro-modulation 586 (23.1 %) reported negative impact on sexual function Mean Sexual Quality of Life-Female questionnaire below normal levels % sexual dysfunction Clinical history, voiding diary, 69.7 % not sexually collection of validated and active and may or may investigator designed not be in a relationship questionnaires Clinical history, voiding diary, Mean Baseline questionnaires FSFI-total 18.6 Clinical history, voiding diary, 40 % of subjects reported questionnaires being dissatisfied or very dissatisfied Symptoms of overactive bladder syndrome (N=106), interstitial cystitis (N=49), or urinary retention (N=11) 2,878 Clinical history of urge incontinence, urgency, frequency Clinical history, voiding diary, questionnaires Rogers et al. 2008 330 [REF 57] Sand et al. 2006 [REF 24] Diagnosis at enrollment N= Table 1 Recent studies on treatments for OAB and UUI Curr Urol Rep (2013) 14:298–308 303 150 96 Dursun et al. 2013 [REF 37] Urodynamic showing pure SUI and normotonic urethral pressure Symptomatic evaluation. 48 %% with SUI, 52 %% with stress predominant mixed incontinence Subjective report, positive standardized stress test 597 Urodynamic testing 133 Urodynamic testing Clinical history and urodynamic 16 83 Urodynamic testing Stress incontinence diagnosed by? 70 Naumann et al. 2013 [REF 67] Liang et al. 2012 [REF 68] Zyczynski et al. 2012 [REF 69] Zahariouu et al. 2008 [REF 63] Rivalta et al. 2010 [REF 34] Filocamo et al. 2011 [REF 32] N= Table 2 Recent studies on treatments for SUI TOT TVT/sling Mid urethral sling TOT Mid urethral sling Pelvic floor rehabilitation Pelvic floor rehabilitation Treatment 84–88 %% resolution by negative cough stress test or improvement in continence 86 %% resolution by ICIQ-SF 93 %% anatomic success Incontinence episodes mean decrease 38.1 %% 81 %% dry, 12.5 %% improved incontinence 86 %% dry or improvement in symptoms Incontinence improvement 95 %% of coital incontinence cured, FSFI overall no change, improvement in sexual satisfaction and pain domains 40 %% of non-sexually active became active, 7.5 %% sexually active became inactive. Improvement in FSFI and all sub domains Climax and emotional response worsened based on PISQ-12 and UDI-6 Improvement in pain, incontinence, and fear based on PISQ-12. Percentage of sexually active women did not change with treatment 53.3 %% with Improved FSFI, 6.7 %% worsened, 38 %% with no change FSFI improved, each sub domain improved FSFI All domains Improved Sexual function 304 Curr Urol Rep (2013) 14:298–308 Curr Urol Rep (2013) 14:298–308 worsening sexual function [3•]. The most common cause of worsening sexual function after urethral sling placement appears to be de novo dyspareunia or urgency [18]. A separate review estimated cure rates specifically for penetration incontinence with surgical sling at about 80 % [36••]. A number of more recent reports merit mention. In an Italian study of 157 women undergoing surgical management of SUI, 22 of 54 (40 %) women who were not sexually active at baseline had resumed sexual activity 12 months after correction of SUI with a mid-urethral sling. Furthermore, there were significant changes in FSFI-total scores; at baseline, 40 of 79 (51 %) of sexually active patients had FSFI –total scores less than 26.55 (the cut point used here for risk of sexual dysfunction). At 1-year followup the prevalence of FSFI-total<26.55 in sexually active patients was significantly lower at 33 of 95 (34 %). Improvements in FSFI domain scores were distributed fairly evenly across the FSFI domains of desire, arousal, orgasm, and pain. Of note, a small proportion of the patients who were sexually active (six of 79, ~ 8 %) at baseline were not active at follow-up; four of these were not sexually active due to de novo OAB, and two because of de novo dyspareunia [32]. A 2013 study reported on 150 women with SUI randomized to either retropubic TVT or single incision sling placement. It was determined that both procedures led to significant improvement from baseline with respect to both continence and sexual function as assessed by the FSFI scores at 6-month follow-up. Interestingly, the improvement in the FSFI lubrication and orgasm domains was significantly greater in women treated with TVT compared to single incision sling [67]. Liang studied 83 women (57 of whom were sexually active at baseline) with urodynamic confirmed SUI who underwent transobturator suburethral tape (TOT). Success rate (defined as any loss of urine with ValSalva) was 93 % at 12 months. Sexual function pre-procedure and postprocedure was assessed with the PISQ-12. The overall mean PISQ-12 score did not significantly change between baseline and follow-up. However, several interesting question specific changes in PISQ-12 were noted at follow-up: coital incontinence was markedly reduced but climax during intercourse was less common and “negative emotional reaction” was more common at follow-up. There was also an increase (not strictly statistically significant with p >0.05 but less than 0.1) in dyspareunia and sensation of vaginal bulging [68]. A multi-center study assessed 597 women (68 % of whom were sexually active) with either SUI or stress predominant MUI randomized to retropubic or transobturator mid-urethral slings. Of note, some women in this series also underwent concomitant vaginal procedures not involving placement of mesh or other foreign material; it is not clear 305 from the text how many and which other procedures were performed. It was determined that sexual function (assessed by the PISQ-12) improved overall compared to baseline values in both groups. However, patients who developed de novo or worsening urgency symptoms or experienced any sort of surgical failure had an overall decline in sexual function compared to baseline [69]. Heterogeneity in the enrollment criteria (both SUI and MUI patients were enrolled) and concomitant surgical procedures make direct attribution of sexual function outcomes to sling placement difficult. In a prospective study of 96 sexually active women with SUI (36 of whom had coital incontinence), the FSFI was used to evaluate sexual function at baseline and at 6-month follow-up. Resolution of stress incontinence was seen in 87 % of subjects at six months. Of the 96 patients, 36 experienced coital incontinence, which was resolved in 33. There were statistically significant improvements in mean FSFI domain scores for satisfaction and pain; improvements in mean score for the other four domains of the FSFI did not reach statistical significance [37]. A small study of 50 patients with SUI treated with one of three urethral slings assessed subjective and objective sexual symptoms (FSFI) at a mean follow-up of about 2 years. All women reported a decline in incontinence episodes. The rate of self-reported sexual distress was 44 % at baseline and 12 % at follow up. There was a significantly lower rate of self-reported decreased sexual desire, arousal, and orgasm frequency and increases in feeling of sexual attractiveness and satisfaction with sexual life post-operatively. Interestingly, 62 % of these women had FSFI scores of less than 26.55 at follow-up, but did not report without subjective sexual bother [35]. This study is modest in scope, but is noteworthy in that it illustrates the limitations of strict reliance on the FSFI in assessing sexuality related distress in women. Conclusion Well-designed studies employing validated questionnaires are needed to further explore the relationship between urinary symptoms and sexual function in women. Prospective data on the natural history of sexual function in the setting of urinary symptoms is required, as are data on the effects of OAB and SUI treatment on female sexuality. Precise definitions of sexual dysfunction and sexual problems must be utilized in future studies. Compliance with Ethics Guidelines Conflict of Interest Dr. Jaclyn Chen reported no potential conflicts of interest relevant to this article. 306 Dr. Genevieve Sweet reported no potential conflicts of interest relevant to this article. Dr. Alan Shindel reported serving as a board member for SF Center for Sex and Culture and International Society for Sexual Medicine. Dr. Shindel reported receiving consultancies from American Medical Systems, Cerner, and GroupH. Dr. Shindel reported receiving honoraria from the International Society for Sexual Medicine, the International Society for the Study of Women's Sexual Health, Endo, and Elsevier. Dr. Shindel reported travel/accommodations expenses covered or reimbursed by the International Society for Sexual Medicine. Dr. Shindel reported receiving a grant from UC Davis Loss Prevention Program. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. References Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1. Hilton P. Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom. Br J Obstet Gynaecol. 1988;95(4):377–81. 2. Hu TW, Wagner TH, Bentkover JD, Leblanc K, Zhou SZ, Hunt T. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. 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