Female Sexual Dysfunctions and Urogynecological Disorders

Abstract

Female sexual dysfunctions are a highly prevalent and often-underestimated health problem and include disorders of sexual desire, arousal, orgasm and sexual pain, associated with self-distress. Pathophysiology of female sexual dysfunctions is complex and still poorly understood, although it has been related to several biological, medical and psychological factors. Amongst women, urogynecological disorders such as urinary incontinence, overactive bladder syndrome, bladder pain syndrome and pelvic organ prolapse, have been found to be associated with sexual dysfunctions, although the biological and psychological bases of these associations are poorly investigated. Data on sexual function impact of these conditions come from several cross-sectional or community-based, epidemiological studies based on self-administered validated psychometric tools. This review focuses on the most relevant available evidence on the impact of urogynecological disorders and related surgical treatments on female sexual function.

Full text

INTRODUCTION
Sexuality is one of the most important components
of quality of life (QoL) in both sexes. Female sexual
dysfunctions (FSD) have been recognised as a common
problem and its prevalence increases dramatically with
increasing age.1 Data from the National Health and Social
Life Survey (NHSLS) revealed sexual dysfunctions have a
higher prevalence in women (43%) than men (31%).2
Several studies reported that female sexual function (FSF)
is negatively influenced by lower urinary tract symptoms
(LUTS) and pelvic floor disorders (PFD).3-6
The importance of these observations is related to the high
and increasing incidence worldwide of urogynecological
conditions.7-8 Thus, all physicians dealing with women’s
health should be aware of the possible detrimental effect
of these conditions on FSF.
The aim of this article is to review the published data
on the impact of urogynecological conditions on FSF,
focusing on urinary incontinence (UI), overactive bladder
syndrome (OAB), pelvic organ prolapse (POP) and
bladder pain syndrome/interstitial cystitis (BPS/IC).
DEFINITION AND MEASURES
The second International Conference of Consensus
on Women’s Sexual Disorders9 classified the FSD in
four categories: sexual desire disorders, sexual arousal
disorders, orgasmic disorders and sexual pain disorders.
Because the Diagnostic and Statistical Manual of Mental
Disorders (DSM) IV-TR defines FSD as “disturbances in
sexual desire and in the psycho-physiological changes that
characterise the sexual response cycle and cause marked
distress and interpersonal difficulty”,10 both sexual
function and sexually-related personal distress should
be considered when assessing FSD. Although some
studies estimate that 40–50% of women report at least
one sexual complaint,11 not all sexual complaints lead to
dissatisfaction or sexual distress and, until recently, most
research on FSF has focused on sexual complaints but has
not considered the QoL impact of these complaints in
relation to sexual distress.12
The self-administered questionnaires are a reliable
standardised method for clinical evaluation of FSF.13-22
Questionnaires are also an ideal research tool to assess
outcome from various treatment modalities and can be
of use in epidemiological surveys. Most of the published
FEMALE SEXUAL DYSFUNCTIONS AND
UROGYNECOLOGICAL DISORDERS
Emilio Sacco,1 Daniele Tienforti2
Female sexual dysfunctions are a highly prevalent and often-underestimated health problem and include
disorders of sexual desire, arousal, orgasm and sexual pain, associated with self-distress. Pathophysiology
of female sexual dysfunctions is complex and still poorly understood, although it has been related to
several biological, medical and psychological factors. Amongst women, urogynecological disorders such
as urinary incontinence, overactive bladder syndrome, bladder pain syndrome and pelvic organ prolapse,
have been found to be associated with sexual dysfunctions, although the biological and psychological
bases of these associations are poorly investigated. Data on sexual function impact of these conditions
come from several cross-sectional or community-based, epidemiological studies based on self-administered
validated psychometric tools. This review focuses on the most relevant available evidence on the impact of
urogynecological disorders and related surgical treatments on female sexual function.
Keywords: bladder, pain syndrome, female sexual dysfunctions, LUTS, pelvic organ prolapse, urinary
incontinence.
UROLOGY • April 2013 EMJ EUROPEAN MEDICAL JOURNAL
92
ABSTRACT
Disclosure: No potential conflict of interest
Citation: European Medical Journal - Urology, 2013: 1, 92-99
1. Urologic Clinic, “Agostino Gemelli” Hospital, Department of Surgical Sciences, Catholic University Medical School of Rome, Italy
2. Urologic Surgery, Columbus Integrated Complex Hospital, Rome, Italy

UROLOGY • April 2013 EMJ EUROPEAN MEDICAL JOURNAL 93
studies have investigated FSF using the Female Sexual
Function Index (FSFI)18 or the POP/UI Sexual Questionnaire
(PISQ).19 The FSFI is a 19-item questionnaire that features
six areas of sexual function: desire, arousal, lubrication,
orgasm, satisfaction and pain. The PISQ includes 31 items
and assesses sexual function in women with POP and/
or UI. Their abbreviated forms have a wider applicability
in the clinic to minimise the time of administration.20
The International Continence Society (ICS) provided a
validated questionnaire, the ICIQ-Female Sexual Matters
associated with Lower Urinary Tract Symptoms (ICIQ-
FLUTSsex), which is useful for researchers and clinicians
in both primary and secondary care institutions to obtain
a brief, yet comprehensive, summary of female sexual
matters and the impact of urinary symptoms on this.21
Up until now there have been reported no standardised
values for what should be considered a ‘normal’ sexual
function and the majority of studies show the changes in
the overall score over time. However, average values of
the women with and without LUTS and UI have recently
been reported for the FSFI.22
UI AND OAB
Prevalence rates of FSD in women with UI are estimated to
range between 26–47%.23-25 All forms of UI are associated
with FSD of all phases of the sexual cycle and studies have
examined the impact of UI on individual domains of sexual
function and satisfaction.26-31
The loss of urine significantly impairs the QoL of women,
who are forced to organise exhausting strategies to
prevent or mask stains and/or odours.32 At emotional and
behavioural levels, a generalised apathy, feelings of guilt
and depressive attitude may develop to different areas of
life due to the unpredictable nature of the symptoms.33
Thus, several studies showed a correlation between UI
and major depression, which has a three times higher
incidence in incontinent patients than in continent
patients.34 Specifically, women with UI feel threatened in
their femininity, expressing feelings of shame, inadequacy
and reduced self-esteem35-37 and subsequently a
communicative and emotional inability with a strong sense
of isolation.38 The lack of libido and reduced level of self-
esteem because of a fear of uncontrolled leakage are the
main factors in women with UI and FSD.39
Nilsson et al.40 evaluated women with UI and/or urinary
urgency (the key symptom of OAB) and their partners
and reported that 22% of the men and 43% of the women
stated that the female urinary symptoms impaired their
sexual life. 49% of the women expressed worries about
having urinary leakage during sexual activity, but 94% of
their male partners did not. 23% of the men and 39% of the
women responded the woman leaked urine during sexual
activity and the majority (84%) of women considered this
a problem, yet 65% of their partners revealed they did not.
Focusing on sexual distress, Knoepp et al.41 assessed
sexual complaints among 305 women seeking outpatient
gynecologic care using the Female Sexual Distress
Scale (FSDS). 26% of the scores reflected distress, and
distressed women were more likely to be younger, have
higher depression scores and report decreased arousal,
infrequent orgasm, and dyspareunia. Women with sexual
distress were also more likely to report sexual difficulty
related to pelvic floor symptoms, including UI with sexual
activity, sexual avoidance due to vaginal prolapse, or sexual
activity restriction due to fear of UI.
Salonia et al.42 found that 47% of patients who reported
a hypoactive sexual desire had stress UI (SUI), and
46% of those who reported orgasm problems also had
significant symptoms of OAB with urgency UI (UUI). The
study concluded that patients with UI or LUTS more
frequently suffer from sexual dysfunction compared to
healthy control patients. Accordingly, Yip et al.43 found that
patients with SUI or OAB have a decreased QoL measured
with King’s Health Questionnaire (KHQ),44 less sexual
satisfaction and worse marital relations than controls. In
the study of Coksuer et al.,45 patients with a diagnosis
of mixed urinary incontinence (MUI) had significantly
lower mean PISQ-12 scores than the ones with SUI
and urodynamic detrusor overactivity (DO) whereas
patients with SUI had lower mean PISQ-12 scores than
patients with DO, so they concluded that MUI has the
greatest impact on sexual function when compared with
SUI and DO alone. Sacco et al.46 reported that, among
women with UI and/or OAB, those with UUI and MUI
reported worse FSD as compared with those with SUI
or with dry OAB. Women with urodynamically-proven
detrusor overactivity incontinence appeared in this and
other studies to have the worst FSF.43,47-48 Mechanisms
associated with the impact of OAB on FSF can be the fear
of leakage during stimulation and intercourse, coital UI
during orgasm, the need to interrupt intercourse to void,
urgency and frequency after coitus, dyspareunia and pelvic
floor dysfunction.
The fear of urine leakage during intercourse was found
in 11-45% of patients with UI.49-54 Moran et al.53 found
that 11% of 2,153 women had UI during intercourse, most
of which reported this symptom only in a questionnaire,
70% reported urine leakage during penetration, 20% only
during orgasm and 11% during both penetration

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UROLOGY • April 2013 EMJ EUROPEAN MEDICAL JOURNAL
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and orgasm. A SUI was present in 80% of women with
UI during penetration, in 93% of women with UI during
orgasm and in 92% of women with UI during both phases.
The pathophysiology leading to UI during intercourse
is not clear. During penetration, the displacement of
the anterior wall of the vagina and bladder neck or the
increase of the intra-abdominal pressure loss can cause
SUI. Detrusorial simultaneous contractions and urethral
relaxation were demonstrated in urodynamic studies
during orgasm.51
Recent studies evaluated the relationship between body
mass index (BMI), UI and FSD among perimenopausal and
postmenopausal55 or overweight and obese women,56-57
showing that UUI and SUI are more common and have
greater impact on sexual function in obese women.
Furthermore, increased BMI early in menopause
represents a risk both for UI and for FSD although the
severity of the FSD may not be directly related to the
severity of UI or obesity.
SURGERY FOR UI
Although SUI surgery is thought to improve sexual
function,39,58-59 data reporting sexual function following
surgical repair are limited and conflicting.60
Moran et al.61 evaluated 55 women with SUI and coital
incontinence treated with Burch colposuspension. Before
the procedure, 36 women (65%) had coital leakage only
with penetration, 9 women (16%) had only with orgasm
and 10 (18%) with both. After the procedure, 81%
described no further coital incontinence. In Baessler,62 a
cohort of sexually active women were affected by SUI with
concomitant coital incontinence, this problem was cured
in 70% of patient and improved in almost 7% after Burch
colposuspension. Brubaker et al.39 studied sexual function
in 655 women randomised to Burch colposuspension
or sling surgery and reported patients with successful
surgery had a greater improvement in PISQ-12 scores in
both Burch and sling groups.
Berthier et al.63 found no significant postoperative changes
regarding frequency of sexual intercourse, satisfaction
with sexual intercourse or personal importance of having
an active sexual life in 66 women undergoing tension-free
vaginal tape (TVT) procedure for SUI. These results are
in agreement with those of previous studies.64-66 Ghezzi
et al.67 reported that 62.2% of women undergoing TVT
procedure had no change in sexual function after surgery,
no significant difference in the incidence of dyspareunia
and two patients (3.8%) referred intercourse to be worse,
one because of erosion and one for ‘de novo’ anorgasmia.
Studies on trans-obturatory sling (TOT) reported
no impact or a beneficial effect of this procedure on
FSF.68-70 Filocamo et al.68 included in their study women
complaining of urodynamic SUI who were both sexually
and non-sexually active at baseline. 105 women out of
133 had a TOT procedure, while 28 out of 133 had a
retropubic procedure. Twelve months after surgery, 22
out of 54 non-sexually active women (40%) re-established
sexual activity, whereas only 6 out of 79 (7.5%) patients,
sexually active at baseline, were not sexually active one
year after surgery. The authors concluded that after a sling
procedure, FSF improves and a very relevant percentage
of non-sexually active women can recover sexual activity
after sling. Accordingly, Xu et al.70 evaluated sexual
function before and six months after a TOT procedure
in 55 sexually active women. More than half (54.5%) the
women reported an improvement in sexual function after
surgery and 45.5% reported no change, and no statistically
significant difference was found between preoperative
and postoperative total or domain scores on the FSFI, so
they concluded that TOT procedure did not significantly
affect sexual function. In a recent study, Zyczynski et al.71
described an increase of mean PISQ-12 scores after mid-
urethral sling surgery (TOT and TVT) and a reduction
of dyspareunia, incontinence during sex and fear of UI
during sex.
However, surgeons should know that vaginal sling
procedures may have a potential negative effect on
FSF due to damage to vascular and/or neural genital
structures or to ‘de novo’ dyspareunia. Baessler et al.72
reported that dyspareunia was a severe indication for
removing the posterior intravaginal synthetic sling. Bekker
et al.73 described the autonomic and somatic pathways in
relationship to sling surgery in 14 adult female dissected
hemipelves, after TVT or TOT procedures have been
performed. They concluded that the dorsal nerve of the
clitoris was not disturbed during the placement of the
TOT but the autonomic innervation of the vaginal wall
was disrupted by the TVT procedure, which could lead to
altered lubrication-swelling response.
PELVIC ORGAN PROLAPSE
Several studies investigated the specific role of POP on
FSD, with conflicting results. Intuitively, POP would seem
likely to have an adverse impact on sexual function;
however, older age and postmenopausal status, common
in women with prolapse, are also associated with sexual
dysfunctions and may confound the association between

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EMILIO SACCO, DANIELE TIENFORTI
POP and FSD.74-75
In a recent cross-sectional observational study, Athanasiou
et al.76 evaluated the effect of POP on FSF in 101 women
compared with 70 women without POP, and found that
FSF was worse in POP group than in control group, but
did not seem to worsen with an increasing grade of POP.
Based on a linear regression model, they concluded that
the presence of prolapse only partly explained impaired
sexual functioning in women with POP. Investigating 495
women scheduled for hysterectomy with evidence of PFD,
Handa et al.77 found that UI was significantly associated
with low libido, vaginal dryness, and dyspareunia and
independent of age, educational attainment and race, but
POP was not associated with any sexual complaint. Barber
et al.47 reported 81% of sexually active patients described
sexual intercourse as ‘somewhat’ or ‘very’ satisfactory,
and that neither UI nor POP significantly influenced the
answer to this question. Weber et al.50 reported women
with POP and/or UI have a similar sexual function than
women without these PFD. In this study, increasing age was
the only significant factor predictive of FSD, and increasing
grade of POP predicted interference with sexual activity,
without affecting frequency of intercourse or description
of satisfaction with the sexual relationship.
On the other hand, Novi et al.78 compared sexual function
of women with POP to that of women without POP
using the PISQ, and reported that mean PISQ score
in sexually active women with POP were significantly
lower compared to controls, with significant difference
in satisfaction with sexual relationship, actual frequency
of intercourse and ability to achieve orgasm with
masturbation, but no difference in the desired frequency of
intercourse, initiation of sexual activity, rate of anorgasmia
or subjective assessment of partner satisfaction. The
study of Digesu et al.79 reported a comparison of prolapse
symptoms and QoL with physical examination findings
and urinary, bowel and sexual dysfunctions in symptomatic
and asymptomatic women. They identified women as
symptomatic from prolapse if they complained of any of
the prolapse symptoms and/or on direct questioning the
patients reported a “sensation of dragging” or “a lump or
fullness in the vagina”. These symptoms were correlated
with anterior, posterior and apical compartment
prolapse severity. For the symptomatic women only,
sexual symptoms severity was correlated with apical
and posterior wall prolapse, so they concluded that
FSD was related to uterine displacement, likely leading
cervix to obstruct penile penetration. Displacement of
the uterus coming down, pulling the ligaments, pedicles
and peritoneum may also lead to a sensation of heaviness
or “dragging” vaginal feeling, which may interfere with
sexual function.
POP SURGERY
Functional results are as important an outcome measure
as anatomical results in the assessment of pelvic
floor surgery.80 Sexual function in particular has been
overlooked and superficially assessed in the past and
several studies of the impact of surgical intervention have
also been limited by absence of baseline data.81 Based on
data from the Colpopexy and Urinary Reduction Efforts
(CARE) study,82-83 Handa et al.74 administered the PISQ-12
to 224 sexually active stress-continent women planning
abdominal sacrocolpopexy for stage II-IV prolapse, before
and one year after the intervention. In the CARE trial,
concomitant Burch colposuspension was randomly
assigned at the time of sacrocolpopexy, and posterior
colporrhaphy was performed at the discretion of the
surgeon, so the potential impact of those procedures on
postoperative sexual function was assessed. One year
after colposacropexy, the number of sexual active women
rose significantly from 148 (66.1%) to 171 (76.3%), the
number of women who avoided sex because of vaginal
bulging decreased from 103 (47.3%) to 10 (4.6%) and the
mean PISQ-12 score among women who were sexually
active before and after surgery improved significantly.
58% of women with dyspareunia at baseline did not
report pain during intercourse after surgery and 14.5%
of women without dyspareunia reported pain one
year after sacrocolpopexy, regardless of concomitant
Burch colposuspension. The proportion of women with
infrequent sexual desire, sexually excited during sexual
activity and who reported orgasm with intercourse did
not change substantially. Only 11 of 148 women who
were sexually active before surgery became inactive
after surgery. They did not differ in age or preoperative
prolapse severity from women who continued sexual
activity after surgery and reported no postoperative
sexual interference from fear of incontinence, vaginal
bulging or pain. However, more of these women reported
infrequent sexual desire after surgery. Comparing Burch
colposuspension group versus non-Burch group, they
did not find difference in proportion of sexually active
women, dyspareunia and PISQ-12 scores one year after
surgery, while more women who underwent posterior
repair reported postoperative dyspareunia, although the
difference did not reach statistical significance. These data
are consistent with previous studies reporting a high
percentage of dyspareunia after posterior repair, both with
levator ani muscle plication narrowing of mid-vagina84-86
and with posterior colporrhaphy.87-88 The authors

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concluded that most sexually active women can expect
to continue sexual activity following sacrocolpopexy and
experience less impact from pelvic floor symptoms.74
The presence of prosthetic material in the vagina may
adversely affect sexual function, although several studies
reported contradictory results. Wang et al.80 evaluated
the short-term impact (six months) of surgical repair with
total transvaginal mesh (TVM) on FSF among 27 sexually
active women with symptomatic POP. In these patients the
TVM surgery corrected the pelvic anatomy and urinary
symptoms successfully; while there were no significant
changes in sexual desire, sexual arousal, orgasm, satisfaction,
the mean postoperative score of the lubrication and
dyspareunia domains worsened significantly, with two-
thirds of all participants showing a lower total FSFI score
postoperatively. The authors explained that changes in
vaginal blood flow and ischemia, disruption of the dense
nerve innervation of the anterior and lateral vaginal wall
during dissection and the insertion of permanent mesh in
the vagina might have contributed to the painful sensation
and loss of lubrication postoperatively. Similar results
were obtained by other studies.89-90 On the other hand,
Hoda et al.91 reported an initial deterioration of sexual
function during the first three months after transobturator
mesh implants, followed by a steady improvement that
reached a significant difference at twenty-four months
postoperatively and Dwyer and O’Reilly92 reported a
significantly decreased dyspareunia in 97 women with
recurrent or large POP undergoing polypropylene mesh
repair to reinforce anterior and posterior compartment
after six, twelve and twenty-four months.
Lowestein et al.93 evaluated sexual function, prolapse
symptoms and self-perceived body image after treatment
for POP to explore differences in body image perception
and sexual function following conservative and surgical
treatment for POP. At six-month follow-up visits, the
patients reported significant improvement in FSF from
baseline in both groups and the improvement in FSF, as
measured by PISQ-12, was not significant among sexually
active patients treated with a pessary compared with
those treated surgically. In this study, body mass index
and changes in body image perception were the only
independent factors associated with changes in PISQ-12
score following POP treatment.
BPS/IC
Sexual dysfunction issues have been reported among
women with BPS/IC and can contribute to reduced QoL
in these patients. Pelvic pain due to inflammation of the
bladder wall and neuropathic dysfunction, dyspareunia,
and fear of pain during intercourse are particularly
frequent among these patients and may cause resistance
to penetration and consequent pelvic floor overactivity,
vulvodynia, and vaginismus.94
Sacco et al.46 showed that, among women with lower
urinary tract disorders, those with BPS reported the
greatest adverse impact on FSF, mostly because of sexual
pain, followed by those with urodynamic DO, clinical
diagnosis of UUI, MUI and SUI, dry OAB and voiding-
phase LUTS.
Accordingly, Peters et al.95 sent a mailed survey to 5000
randomly selected women from the United States
(controls) and 407 women with IC (cases) from a large
referral centre, including the Female Sexual Distress
Scale (FSDS) and questions about sexual function, desire,
orgasm, and pain. A significantly greater proportion of
cases reported fear of pain and pain with intercourse. In
adulthood, a large proportion of cases reported pelvic
pain, fear of pain during intercourse, and dyspareunia.
Furthermore, after the diagnosis of IC, the number of
cases reporting moderate to high desire and orgasm
frequently and very frequently declined significantly.
Verit et al.96 evaluated 112 women complaining of chronic
pelvic pain (CPP) with a comprehensive history, including
FSFI, compared with a group of 108 healthy women
without CPP. Among 112 CPP patients, 78 (69.6%) of them
had FSD and 34 (30.4%) patients did not have FSD in this
study. Among patients with FSD, 42 patients (53.8%) had
hypoactive sexual desire disorder, 26 patients (33.3%) had
sexual arousal disorder, 17 patients (21.7%) had orgasmic
disorder and finally 58 patients (74.3%) had sexual pain
disorder. In compliance with these findings, using FSFI to
compare FSD in 75 patients affected by IC with 22 controls,
Ottem et al.97 reported that total adjusted FSFI scores
differed between patient and controls and that 51 patients
(68%) had an abnormal FSFI score versus 3 controls (14%),
concluding that patients with IC have sexual dysfunction,
including pain, dyspareunia, sexually related distress and
significant declines in desire and orgasm frequency, more
commonly than do controls.
In a survey of 1469 women who met criteria for BPS/IC
diagnosis, 88% of those with a sexual partner reported ≥1
general sexual dysfunction symptom and 90% reported
≥1 BPS/IC-specific sexual dysfunction symptom in the
past four weeks.98 In the multivariate models, BPS/IC-
specific sexual dysfunction was significantly associated
with more severe BPS/IC symptoms, younger age, worse
depression symptoms, and worse perceived general health.
Of note, only a small proportion (about 10-20%) of those
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UROLOGY • April 2013 EMJ EUROPEAN MEDICAL JOURNAL 97
EMILIO SACCO, DANIELE TIENFORTI
women with sexual dysfunction sought medical help for
the condition.
CONCLUSIONS
Sexual dysfunctions are common health issues in women
suffering from urogynecological disorders and have a great
impact on quality of life. However, findings of published
studies are often conflicting, particularly on the role of
POP. Data on the relative impairment of sexual function in
women with different types of urogynecological disorders
are deficient. The consistency of published studies is often
limited by several biases such as use of non-condition-
specific instruments, lack of a control group and of
urodynamic evaluation.
The diagnosis of FSD requires a complete anamnesis
with regard to the sexual history, and self-administered
questionnaires represent useful tools not only for research
but also for patient-clinician discussions on sexuality.
Although urogynecological surgery is thought to improve
sexual well-being, data reporting sexual function following
surgical repair are still limited and often diverging. More
research is needed using standardised assessment tools to
define clear endpoints in this field.
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