THE
SHORT-TERM EFFECT OF SURGICAL TREATMENT FOR STRESS URINARY INCONTINENCE
USING SUB URETHRAL SUPPORT TECHNIQUES ON SEXUAL FUNCTION
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ANTONIO C. PINTO, FABIO BARACAT, NELSON D. MONTELLATO, ANUAR I. MITRE, ANTONIO M. LUCON, MIGUEL SROUGI
Division of Urology, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
ABSTRACT
Objectives:
To evaluate the impact of surgical treatment of stress urinary incontinence
on the sexual function of women and to identify whether such treatment
can improve their sexual function and overall quality of life.
Materials and Methods: 64 heterosexual women
with such indication were studied using the Female Sexual Function Index
(FSFI) questionnaire, modified by introducing one question to evaluate
the impact of urine loss. This was applied preoperatively and six months
after surgery.
Result: Among these 64 patients, 60.94%
had regular sexual activity, while 39.06% did not. Among sexually active
patients, 59% had urine loss during sexual intercourse and, of these,
87% had urine losses in half or more of sexual relations. There were no
statistically significant differences in assessments of desire, arousal,
lubrication, orgasm, satisfaction and pain, or in totaling the scores,
between the preoperative period and six months after surgical treatment.
However, the scores for urine losses during sexual intercourse were significantly
better after the operation.
Conclusions: Analysis of the results allowed
the following conclusions to be reached: Urine lost during sexual activity
was frequent among patients with stress urinary incontinence. Suburethral
support surgery did not jeopardize sexual activity. Patients cured of
stress urinary incontinence did not present improvement in sexual function.
Key
words: urinary incontinence, stress; prostheses and implants;
female, sex disorders
Int Braz J Urol. 2007; 33: 822-8
INTRODUCTION
Epidemiological
studies have suggested that the same pathological processes and risk factors
that are associated to male erectile dysfunction (age, hypertension, smoking,
hypercholesterolemia and previous pelvic surgery) are also associated
to female sexual dysfunction (FSD) (1).
Sexual dysfunction (SD) is highly prevalent
in both sexes, ranging from 10% to 52% among males and from 25% to 63%
among females. Data from the Massachusetts Male Aging Study (MMAS) has
shown that 34.8% of men aged 40 to 70 years have moderate SD, which is
strongly related to age, associated diseases (diabetes, hypertension and
hypercholesterolemia) and emotional state (1). Less is known about the
epidemiological aspects of FSD (2).
Female urinary incontinence (UI) is highly
prevalent. Diokno (1995) found prevalence ranging from 10% to 25% in a
population within the age group from 15 to 64 years old. The numbers may
increase if older populations are studied. It is worth emphasizing that,
in the United States, dealing with UI has an annual cost of 10 billion
dollars (3).
Although SD and UI both have high incidence,
few studies have sought to correlate them aiming at assessing the impact
of UI on women’s sexual life. Likewise, there has been little study
of the improvements that might be obtained, if any, after treatment for
UI.
Considering the high prevalence of SUI in
our environment, our objectives in the present study were to evaluate:
The impact of UI on the sexual life of women with an indication for surgical
treatment using suburethral support techniques (SST) and Whether the correction
of this dysfunction might favor these patients’ sexual lives, thereby
causing an improvement in their quality of life.
MATERIALS AND METHODS
Sixty-four
heterosexual women from the urogynecology outpatient clinic were sequentially
studied between August 2001 and September 2002. All of them were indicated
for treatment of SUI by means of SST. The patients’ ages ranged
from 33 to 86 years, with a mean of 56 years, standard deviation of 12.3
years and median of 55 years.
We chose to subjectively examine the sexual
function of all the patients studied, by means of applying a modified
version of the Female Sexual Function Index (FSFI) questionnaire, which
was devised by UMDNJ Robert Wood Johnson Medical School, Piscataway, NJ;
University of Tennessee, Memphis, TN; University of Washington, Seattle,
WA; University of Texas, Austin, TX; and Columbia University School of
Medicine, New York, NY (4). This questionnaire consists of 19 questions
and assesses the domains of desire, arousal, lubrication, orgasm, satisfaction
and pain symptoms. We added one question to this, with the aim of quantifying
the impact of urine loss during sexual intercourse.
On the eve of the surgical procedure, the
patients received detailed explanations about the study and authorization
to consent was obtained.
Firstly, the patients were asked objectively
about their basic disease, with the aim of characterizing the urine losses
that they presented. They were also asked about previous surgical procedures
that they had undergone, with emphasis on procedures with vaginal access.
Next, the modified FSFI was applied. The patients were requested to respond
spontaneously to the questionnaire and take as much time as needed to
answer it, in a calm environment without anyone else present. In the event
that doubts arose with regard to any item, the investigator was called
to provide the clarifications needed.
Six months after the surgical procedure,
the patients who had had any sexual activity were invited to attend the
urogynecology outpatient clinic at a prearranged time. First of all, they
were asked about how successful the procedure had been with regard to
urine losses and about any complications that may have occurred. Following
this, the modified FSFI was again applied, under the same conditions as
adopted previously.
For the continuous quantitative variables,
the analysis described was done by means of observing the minimum and
maximum values and calculating the means, standard deviations and medians.
For the category variables, absolute and relative frequencies were calculated.
When it was necessary to verify whether there were associations between
the category variables, the chi-squared association test was utilized,
or the Fisher exact test if at least one expected frequency was less than
five.
To verify the impact of the surgical procedure
performed, by means of comparisons between the mean scores for the items
of desire, arousal, lubrication, orgasm, satisfaction, pain and urine
losses, the non-parametric Wilcoxon signs test was applied.
The significance level utilized for the
tests was 5%.
RESULTS
In
accordance with the age distribution of the patients, they were subdivided
into two groups. The first group included patients whose ages were less
than or equal to 50 years and the second consisted of women whose ages
were over 50 years (Table-1).
Among the 64 patients who underwent surgical
treatment for SUI using the SST, 39 patients (60.94%) had had sexual activity
during the preceding four weeks, while 25 patients (39.06%) had not had
sexual activity. The distribution by age group for the patients with and
without sexual activity is shown in Table-1. Application of the chi-squared
test to these two samples gave p = 0.011; therefore, age group had an
influence on sexual activity (significant value).
Among the patients without sexual activity,
the reasons given for this abstinence were lack of partner; absence of
sexual desire; partner with illness that impeded him from having sexual
activity; and illness of the patient herself (Table-2). Only two (8%)
of the 25 patients without sexual activity presented scores of six or
over on the sexual desire question, while the range found was from 2 to
10.
Table-3 shows the means, standard deviations
and medians for the 39 patients with sexual activity, for all the domains
evaluated. Of these patients with sexual activity, 23 (59%) said they
had urine losses during the sexual act, while 20 (51%) presented urine
losses on 50% or more of the occasions when they had sexual activity (scores
of 3, 2 and 1) and 13 (33%) had losses on all such occasions (score of
1).
Among the 39 patients who underwent treatment
for SUI using SST, only one patient did not attend the outpatient clinic
six months after the surgical procedure to answer the questionnaire again.
With regard to sexual desire, 10 patients
(26.31%) presented increases in their scores, 24 remained unchanged and
four had decreases. With regard to arousal, lubrication, orgasm, satisfaction
and pain, similar distributions were found, i.e. more than 60% of the
patients kept the same scores, while 10% to 30% of the patients had upward
or downward changes in their scores. With regard to urinary loss during
sexual activity, 20 patients (52.63%) presented an improvement, while
18 (47.37%) maintained their scores. No patient mentioned any worsening
of the urine loss during sexual activity after the operation (Table-4).
Table-5 shows the mean preoperative and
postoperative scores and significance levels after applying the non-parametric
Wilcoxon signs test, which was utilized to compare the mean scores of
the different domains of the FSFI. It could be seen that the items of
arousal, lubrication, orgasm and totaling presented slight reductions,
while desire, pain and urine losses had slight increases. However, none
of these except for the domain of urine losses during the sexual act presented
significance levels of less than 5%.
COMMENTS
At
the beginning of 1999, the National Health and Social Life Survey (NHSLS)
published a study in the Journal of the American Medical Association (2)
that showed that sexual problems were more frequent than had been imagined;
43% of American women presented SD, a percentage that was higher than
for men, whose rate was 31%. These data concur with the high incidence
of women without sexual activity found in the present study, since 39.06%
of the patients (29 women) were not having sexual relations. Despite the
low number of women in the sample studied, the presence of women aged
less than 50 years in this group and the fact that this was specifically
a sample of women with SUI, it was observed that age had a significant
influence on whether or not there was sexual activity. This result finds
confirmation in the study by Diokno, with patients aged over 60 years:
the latter study demonstrated that sexual activity diminishes with age
and when the individual is single (5).
In the present study, patients explained
their lack of sexual activity in different ways, but absence of desire
was the principal factor that impeded sexual activity among these women,
which can be demonstrated from the scoring for these patients. Thus, only
two of these women (8%) had scores of greater than or equal to 7), while
21 (84%) presented scores of less than 4.
Out of the 20 patients without sexual activity
that we managed to contact after a year of surgical procedure, 3 (15%)
returned to sexual activity. In two cases, this sexual activity retaking
was associated to the fact of not presenting urinary losses to the efforts,
demonstrating that urinary losses can decrease sexual desire, considering
that both patients related such losses as the cause for the low desire
for sexual activity.
Sutherst & Brown evaluated the conjugal
relations and sexual habits of 208 patients in a urinary incontinence
clinic and observed that 43% of them said that urinary disorders had a
negative effect on their sexual relations. According to these authors,
women with vesicle instability had significantly greater incidence of
SD than did women with genuine stress urinary incontinence (6).
A study by Iosif found that 20% of the women
had diminished frequency of sexual activity and 5% were completely inactive
sexually, as a result of urine losses during coitus or during the night
(7).
In a prospective study, Haase & Skibsted
reported that 35% of their patients had diminished libido in relation
to the period prior to their urinary incontinence. Among such patients,
11 attributed the disorder to vaginal descensus or urine loss during the
sexual act, and three just to the fear that such losses might occur. Twenty-three
(42%) complained of dyspareunia (8).
In the present study, 23 women (59%) presented
urine losses during sexual intercourse and, 20 (86.96%) of them said they
had losses on at least half of such occasions, while 13 (56.72%) had urine
loses on all occasions. Although this was not objectively asked about,
it should be considered to be the preponderant factor in determining an
unsatisfactory sexual life. The insecurity brought about by urine loss
during day-to-day activities causes discontent and, with the intention
of avoiding such losses, some activities are not done. Thus, what can
be said about urine losses during intercourse? There is no doubt that
it is a factor that must be taken into account when considering the low
rates of desire, orgasm and satisfaction seen among preoperative patients.
For this reason, when dealing with patients with UI, the negative impact
that this has on female sexual life must not be forgotten. It is therefore
appropriate to objectively probe patients about urine losses during the
sexual act, as well as attempting to assess their impact.
Clark & Romm evaluated the effects of
UI on sexual function by means of a questionnaire, and found that 56%
of their patients had already experienced urine losses during sexual activity.
These rates reached 66% when the patients were asked about incontinence
or urinary urge or frequency during the relations. These data, which are
very similar to the findings of the present study, demonstrate the negative
impact that urinary incontinence may have on the quality of life of patients
with SUI (9).
Despite the high incidence of FSD and SUI,
there are few studies that have sought to correlate the two diseases.
It was found by Hilliges et al. (10) in 1995 that the more distal portions
of the vagina have more nerve components when compared to the proximal
proportions. These findings were similar with regard to the anterior and
posterior walls; and the areas that commonly undergo incision during procedures
to treat urine losses are richly innervated. Taking these findings into
consideration, it must be emphasized that it is imperative to study sexual
function after such procedures have been performed, with the aim of assessing
their effects on FSD.
Between the mean scores before and after
the surgical procedure performed, it was observed that there were slight
increases in the domains of desire and pain and the totaling of the scores,
and a large increase in the item of urine loss during sexual intercourse,
while for the variables of arousal, lubrication, orgasm and satisfaction
there were slight decreases. Upon applying the statistical test, however,
the significance level was not reached for any of them except for the
variable of urine loss during sexual intercourse, which increased from
3.34 to 4.82, which was very close to the maximum score of 5 for this
variable. This result was already expected, given that the “gold
standard” treatment for urinary incontinence today is the surgery
that was performed (11).
The diversity of the results is probably
the result of non-standardization of the studies, given that it was only
in 1998 that the American Foundation of Urologic Disease (AFUD) defined
and classified female sexual dysfunction (12).
Analysis of the literature with regard to
the treatment of SUI and patients’ sexual life after the surgical
procedure has shown greater uniformity of results, despite the low number
of published studies. Iosif (7) and Haase & Skibsted (8) demonstrated
an improvement in sexual activity and accredited the result to the greater
satisfaction and self-esteem among their patients.
Recently, Walsh et al. (13) identified improvement
in sexual function among their patients and stated that the solution for
incontinence during intercourse was strongly associated with the improvement
in sexual activity. Maaita et al. (14), in a similar study, concluded
that this surgery would not have a negative effect on their patients’
sexual lives.
The relationship between FSD and UI has
reached such proportions today that Rogers et al. (15) have proposed that
women with urinary incontinence or prolapse of pelvic organs behave differently
from other populations studied previously from a sexual point of view.
Thus, results obtained that would possibly be attributed to a series of
factors such as age, for example, may be related to UI or genital prolapse.
These authors even proposed a specific questionnaire for evaluating the
impact of these diseases.
There is constant concern regarding the
possibility of interfering in vaginal sensitivity, resulting from the
fact that the principal site of innervation is the location for the incision
in the surgical procedure for treating urinary incontinence using the
suburethral support techniques. Nonetheless, the improvement in the patients’
self-esteem produced by the absence of urine losses during the sexual
act justifies the results, even if the improvements obtained in the patients
of the present study were not significant. On the other hand, the worsening
in sexual function found in some patients was related to complications
in the procedures carried out, such as maintenance of urine losses, prolonged
urine retention, urgency, etc. The SST for treating SUI is safe and does
not worsen patients’ sexual activity, but new studies should be
conducted, using objective measurements of sexual function if possible,
with the aim of confirming the results obtained.
This work will need to be taken to greater
depth in order to obtain objective assessments of female sexual function,
perhaps with quantification of the free nerve terminations in the anterior
vaginal wall before and after the operation. This would be a way of assessing
whether the SST could cause damage to female sexual function, with the
attempt to identify, which patients might present worsening of this function
after the operation, and whether the type of suburethral support utilized
might interfere with the result obtained.
CONCLUSIONS
Analysis of the results regarding the sexual function of the women with SUI who underwent surgical treatment using SST allowed the following conclusions to be reached: age had an influence on sexual activity; urine loss during sexual activity was frequent among patients with SUI. The surgery presented cure rates of more than 90% for urine losses during the sexual act and did not jeopardize the patients’ sexual activity; the improvement in sexual function, when it occurred, was subjectively related to increased sexual desire and not the reduction in urine losses during sexual relations after the surgical treatment, and the patients cured of SUI did not present improvement in relation to sexual function.
CONFLICT OF INTEREST
None declared.
REFERENCES
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- BARACAT F: Tratamento cirúrgico da Incontinência urinária de esforço pela técnica de “sling” aponeurótico. Tese(doutorado) - Faculdade de Medicina da Universidade de São Paulo, São Paulo. 2000; pp. 1-106.
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____________________
Accepted
after revision:
July 30, 2007
_______________________
Correspondence
address:
Dr. Antonio Cardoso Pinto
Rua Cero Corá 1917 B
São Paulo,SP, 05061-350, Brazil
E-mail: antonio.cardoso@sbu.org.br