Stress Urinary Incontinence & Sexual Function

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1 Stress Urinary Incontinence & Sexual Function Lior Lowenstein, MD, MS Associate Professor Deputy Chairman of Obstetrics and Gynecology Department Rambam Health Care Campus Haifa Israel

2 No Disclosures Disclosures

3

4 Introduction Increasing interest in the field of SF especially by female urologist and gynegologists Over the last 3 decades, more than 400 studies in the field of urinary incontinence and sexual function have been published

5 Introduction Sexual problems are not discrete and often cooccur Co morbidity between female sexual disorder and medical conditionsurologic, gynecologic, proctologic, cardiovascular etc

6 Urine Incontinence Urinary incontinence is a common and distressing problem in women, with a reported prevalence of 45% 43% of women who had urinary problems stated that this problem influenced their sexual function Sexual dysfunction varies among different types of incontinence Irwin D et al. Worldwide prevalence estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction BJU Int 2011 Oct;108(7): Shaw C. A systematic review of the literature on the prevalence of sexual impairment in women with urinary incontinence and the prevalence of urinary leakage during sexual activity. European urology Nov;42(5): Field S. M. HP. The prevalence of sexual problems in women attending for urodynamic investigation International Urogynecology Journal. 2003; Volume 4(4):212-5.

7 Stress urinary incontinence Symptom is the complaint of involuntary leakage on exertion or on sneezing or coughing Sign is the observation of involuntary urinary loss from the urethra synchronous with exertion, sneezing, or coughing Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

8 UI & FSD Direct affect: Desire Lubrication Orgasm, and sexual satisfaction Indirectly: Dermatitis and vulvar irriatation Dyspareunia Fear engaging in sexual

9 Coitus & Incontinence Major concerns of women with urinary incontinence is having an episode of urine leakage during intercourse The exact prevalence of this problem is unknown: Epidemiologic study that surveyed 2860 women randomly selected from a civil registration in Denmark found a rate of 10% Moller LA, Lose G, Jorgensen T. The prevalence and bothersomeness of lower urinary tract symptoms in women years of age. Acta obstetricia et gynecologica Scandinavica 2000;79(4): Lam GW, Foldspang A, Elving LB, Mommsen S. Social context, social abstention, and problem recognition correlated with adult female urinary incontinence. Danish medical bulletin 1992;39(6):

10 Coitus & Incontinence Other studies conducted on different types of populations, age groups, and severity of incontinence found a wide range of prevalence from 16% to 56% CUI during orgasm is most likely due to DO, however, if it occurs at penetration or during thrusting, it is more likely related to SUI

11 Types of Sexual dysfunction 34% reported hypoactive sexual desire 23%of the incontinent women reported sexual arousal disorder 11% reported orgasmic deficiency Patients with urinary incontinence also had lower desire, lubrication, and sexual satisfaction compared with continent Salonia A, Zanni G, Nappi RE, et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross sectional study. European urology 2004;45(5):642 8;

12 Behavioral Tx. Emptying the bladder before sexual activity, avoiding ingestion of fluids for 1 hour before lovemaking Having intercourse in the female recumbent position (which decreases prolapse pressure and leakage) Using a water soluble lubricant or vaginal estrogen before penetration can decrease trauma

13 Physical Tx. Pelvic floor rehabilitation, none of the patients reported UI during sexual activity, and 25% of subject experienced complete remission of UI symptoms. All patients showed improvement of the FSFI scores in all domains at 5 months after the conclusion of pelvic floor rehabilitation Both the orgasm and arousal function are related to better PFM function Rivalta M, Sighinolfi MC, Micali S, De Stefani S, Bianchi G.. J Sex Med 2010;7:1200 Lowenstein L, Gruenwald I, Gartman I, Vardi Y.Int Urogynecol J May;21(5):553 6

14 Pessary

15 Pessary Treatment of urinary incontinence with a combination of pessaries and pelvic floor muscle exercises Successful treatment of urinary incontinence was associated with a significant improvement in sexual function less incontinence with sexual activity less restriction of sexual activity due to fear of incontinence compared with women who were not successfully treated. Handa VL, Whitcomb E, Weidner AC, et al. Sexual function before and after non-surgical treatment for stress urinary incontinence. Female pelvic medicine & reconstructive surgery

16 TVT O

17 Possible complications

18 SUI surgery and SF

19 TVT O Due to its proximity to the dorsal clitoral nerve a possible impact on genital sensation exists An ongoing study is currently evaluating the impact of incontinence surgery on genital sensation and sexual function Topographic relation of mid-urethral sling for stress incontinence to critical female genital structures. Lowenstein L. J Sex Med. 2009

20 Adverse events Surgical dissection may result in tissue damage, devascularization, and denervation involved, the result can be decreased vaginal blood flow and increased fibrosis Slings repairs may cause dyspareunia due to mesh erosion into the vagina De novo OAB symptoms

21 SUI surgery and SF Burch colposuspension, 81% described no further CUI SISTEr trial, at 2 years after surgery, PISQ-12 scores improved from baseline in both groups Women with CUI showed a significantly better improvement in sexual function after surgery compared with women without Moran P, Dwyer PL, Ziccone SP. Burch colposuspension for the treatment of coital urinary leakage secondary to genuine stress incontinence. J Obstet Gynaecol 1999;19: Tennstedt S, Urinary Incontinence Treatment Network. Design of the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Urology 2005;66: Bekker M, Beck J, Putter H, Venema P, A Nijeholt AL, Pelger R, Elzevier H. Sexual function improvement following surgery for stress I ncontinence: The relevance of coital incontinence. J Sex Med 2009;6:

22 Hispareunia Brubaker L, Editorial: partner dyspareunia (hispareunia) IJO 2006 Jun;17(4):311.

23 De novo dyspareunia Analgesics, anti inflammatory drugs, and muscle relaxants Local infiltration of anesthetics, nerve blocks, and steroid injections at the trigger points Transvaginal injection of botulinum toxin A (Botox) for relief of the spasm can be efficacious

24 Thank you

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