INTRODUCTION — In women, sexual dysfunction and pelvic floor disorders (PFDs) are common problems, both of which diminish quality of life. This topic will review the impact of PFDs (pelvic organ prolapse, stress urinary incontinence, urgency urinary incontinence/overactive bladder syndrome, anal incontinence) and their treatment on sexual function. Detailed discussions specific to female sexual function can be found separately.
●(See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation".)
●(See "Overview of sexual dysfunction in females: Management".)
Despite increasing awareness of the full range of sexual orientation and practices of individuals identifying as women, the literature has not always recognized nor has it fully described sexual function in all populations of women, particularly regarding pelvic floor and lower urinary tract disorders. The literature regarding these issues, as presented subsequently, has largely been confined to cisgender, heterosexual women. Clinicians are encouraged to have a clear understanding of sexual identity and practices prior to counseling.
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender expansive individuals.
SIGNIFICANCE — The high prevalence of sexual dysfunction in women with PFDs is significant because sexuality is an important component of overall quality of life [1]. Avoidance of intercourse has been reported to occur in 11 to 45 percent of women with urinary incontinence [2-6]. Women with symptomatic pelvic organ prolapse are less likely to engage in sexual relations and more likely to note sexual dysfunction compared with their asymptomatic counterparts [2,7-10]. In a retrospective review of women undergoing urogynecologic surgery, nearly one-third indicated that they avoided sexual activity because of pelvic floor symptoms [11]. Treatment of PFD can reduce sexual dysfunction. Studies using validated questionnaires report improved sexual function in up to 70 percent of women treated for PFD [2,12,13]. In a qualitative study of women undergoing surgery for PFDs, women rated postoperative sexual complaints as a serious adverse event [14].
Women with prolapse also report poorer body image [15]. In one study, women with prolapse of stage 2 or greater reported feeling isolated and less attractive and often changed sexual intimacy practices or avoided sexual intimacy altogether [16].
The extent of sexual dysfunction in women with PFD is difficult to ascertain because of varied definitions of dysfunction and because affected patients may not present for treatment or report the problem [17-26].
RESEARCH TOOLS FOR ASSESSMENT OF SEXUAL FUNCTION — In research studies, the validated questionnaires specifically developed to assess sexual function in women with urinary incontinence and/or pelvic organ prolapse are the Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ) and its 12-question short form, the PISQ-12 [13,27-30]. Limitations of the PISQ include that it has only been validated in female heterosexual activity, it has not been validated in women with anal incontinence, and it was designed to be administered to women who have engaged in sexual relations in the last six months. An international group of investigators revised the PISQ; the newer version, PISQ-IR, includes both women who report that they are sexually active as well as women who report no sexual activity. Importantly, women with fecal incontinence were included in the validation [31-33]. A summary score has been generated for the PISQ-IR, as well as a cutoff score for impaired sexual function [34,35].
Multiple other questionnaires exist to evaluate sexual function but are not condition specific. General questionnaires that focus on sexual function include the Female Sexual Function Index (FSFI) and the Sexual History Form 12, which were designed to evaluate sexual function and have undergone validation and reliability testing in a general population [13]. Ongoing limitations in current sexual function questionnaires are that they focus on cisgender women. In addition, general questionnaires are not condition specific and may not be sensitive enough to detect differences due to PFD.
CLINICAL FINDINGS AND DIAGNOSIS — Patients with PFD typically have urinary or anal incontinence and/or symptoms of pelvic organ prolapse, which include vaginal bulging, pelvic pressure, and splinting or digitation to pass urine or stool [36]. Incontinence is diagnosed with history, physical examination, and simple office tests. Pelvic examination confirms the anatomy of prolapse. (See "Pelvic organ prolapse in women: Diagnostic evaluation" and "Female urinary incontinence: Evaluation", section on 'Evaluation'.)
Female sexual dysfunction takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity. The diagnosis of female sexual dysfunction is based on the presence of diagnostic criteria obtained through a medical and sexual history. To meet criteria for sexual dysfunction, a sexual problem must be recurrent or persistent and cause personal distress or interpersonal difficulty [37]. The international community has published an article outlining terminology to be used in reporting sexual function among women with PFDs [38].
A detailed discussion of diagnosis of female sexual dysfunction can be found separately. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Diagnostic criteria'.)
OUR APPROACH — Since PFDs affect sexual activity and function, we obtain a sexual history in all women presenting for care, discuss the impact of their disease and treatment options on sexual function, and evaluate for issues that may alter treatment choice. In general, we begin treatment with less invasive options and proceed to surgical options as needed, or if the patient desires a different treatment. (See "Overview of sexual dysfunction in females: Epidemiology, risk factors, and evaluation", section on 'Sexual history'.)
Assess sexual activity status and sexual function — While validated questionnaires to evaluate sexual function exist, most are too long to screen for sexual problems in the clinical setting. A questionnaire consisting of three questions has proved as effective as in-depth interviews in identifying sexual problems and is readily implemented in the clinical setting [39]. Based on this, we ask the following questions:
●Are you sexually active?
●Do you have any problems with sexual activity?
●Do you have any pain with sexual activity?
●Are you in a same sex relationship, heterosexual relationship, or both?
Discuss the impact of PFD and PFD treatment on sexual function — Many women and their partners feel that sexual activity is contraindicated or impossible in the setting of prolapse and/or incontinence and that sexual activity will lead to harm of the patient or her partner. We provide reassurance that sexual activity will not harm the patient or the partner, nor worsen the prolapse or incontinence.
As these are difficult topics for many patients to discuss, we initiate specific conversations regarding sexual function and dysfunction, expectations for sexual function after treatment, the timing of resumption of sexual activity after surgery, the use of lubricants if sexual activity has not been attempted for a prolonged period of time, and what to do if sexual problems arise.
Following reconstructive vaginal or urinary anti-incontinence surgery, there is no evidence that sexual activity harms repairs, and couples can be reassured that they can resume sexual activity after clearance by their provider. Treatment of the underlying pelvic floor dysfunction typically results in resolution of sexual symptoms specifically associated with the dysfunction. For example, women with coital incontinence are likely to report improvement in coital incontinence after treatment but less likely to report improvement in desire, arousal, and orgasm [8].
Screen for sexual issues that may impact treatment
Desire for vaginal sex — Desire for future vaginal sexual activity will dictate what type of treatment the patient will be offered. As an example, women who choose colpocleisis, or vaginal obliterative procedures, need to be counseled that future vaginal intercourse is impossible after the procedure. Among women who elect colpocleisis and who are not sexually active, regret is low and satisfaction high [40]. For women who choose a pessary for treatment of their pelvic floor dysfunction, pessary satisfaction is associated with improved sexual function and body image. Among women using a pessary, most remove their pessary during sexual activity secondary to partner concerns about sex with the pessary in place [41].
Sexual pain — Most PFDs are not painful, and women reporting sexual pain disorders such as dyspareunia in the setting of prolapse and/or incontinence are counseled that treatment of their PFD will not necessarily result in improvement in their underlying pain with sex. Conversely, among women with PFD who do not have sexual complaints at baseline, a small but significant number of women report worsened sexual function following treatment, including de novo dyspareunia. As an example, in a meta-analysis of native-tissue pelvic organ prolapse repair, 4 percent of women had new onset dyspareunia [42].
Because of the association of mesh with pain following surgery, many surgeons advise against the placement of mesh in these women, or placement only following extensive counseling [43]. Likewise, use of a pessary to treat either incontinence or prolapse in the setting of pelvic floor pain is challenging and will likely result in exacerbation of the pain and discontinuation of use of the pessary.
Sexual practices — In general, varied sexual practices are not contraindicated or of concern in women with pelvic floor dysfunction. For women with anal incontinence, anoreceptive intercourse may be an exception. Up to 20 percent of women regularly engage in anal intercourse [44,45]. While data are limited, studies in men report that anoreceptive intercourse has been associated with decreased sphincter tone and squeeze strength [46], and most surgeons would caution against anal intercourse following sphincteroplasty. Analysis of the National Health and Nutrition Examination Survey found that reports of anal incontinence were associated with anoreceptive intercourse [47].
PELVIC ORGAN PROLAPSE
Impact on sexual function — Sexual function generally worsens with increasing severity of pelvic organ prolapse (POP) [9]. Women with symptomatic prolapse have lower sexual function scores on validated questionnaires and are less likely to engage in sexual relations compared with their asymptomatic counterparts [2,7,9,10]. The sexual function domains typically affected by symptomatic prolapse include arousal, orgasm, and pain [9,10,48]. One study noted 64 percent of women referred to a urogynecologic practice reported some degree of sexual dysfunction [49]. A different review of 50 studies noted that sexual dysfunction was reported by over half of women with POP while the range of reported obstructed intercourse was 37 to 100 percent [50].
Impact of pelvic organ prolapse treatment on sexual function
Nonsurgical treatments — Nonsurgical treatment of POP may improve sexual dysfunction in some women and has no harmful effects.
Pessary use was associated with significantly improved sexual function (specifically desire, lubrication, and sexual satisfaction) compared with pre-pessary function in one observational study that used a validated questionnaire to assess sexual function [51]. In two prospective observational studies that compared pessary use versus surgical therapy in women with prolapse, one study reported equivalent improvement in sexual function and the other reported sexual function was worse with pessary use [52,53].
The use of pelvic floor muscle training (PFMT) to treat prolapse-associated sexual dysfunction has not been specifically studied, although a systematic review concluded that PFMT benefits prolapse symptoms overall [54]. One retrospective cohort study of 778 women referred for PFMT noted an 80 percent improvement in symptoms of pain (including sexual pain) for those women who completed at least five therapy sessions, but sexual dysfunction was not independently assessed [55].
Surgical treatment — Despite the heterogeneous nature of the anatomy of prolapse (anterior, apical, posterior, or combined) and types of surgical repair (abdominal, vaginal, native tissue, synthetic mesh), surgical repair of POP is generally associated with improvements in rates of sexual dysfunction and dyspareunia [42,56-60]. With regard to sexual function or onset of dyspareunia, similar outcomes have been reported for transvaginal mesh, native tissue repair, biologic grafts, and sacrocolpopexy [61].
●Sexual dysfunction – When validated questionnaires are used to assess sexual function before and after prolapse surgery, rather than the isolated symptom of dyspareunia, the majority of studies have reported stable or improved sexual function following surgery [12,48,57,58,62-67]. Some of the variation in response among these studies may reflect the heterogeneity of surgical repairs performed. Improvement in postoperative sexual function following prolapse repair may be related to improved body image as well as reversal of physical symptoms [16,53,68,69]. Body image studies highlight the multifactorial nature of sexual health in women with prolapse and the need to address physical and mental components of sexual health in any treatment plan.
Representative studies include:
•The 2007 CARE trial that evaluated sexual function before and after abdominal sacrocolpopexy reported improved mean Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ) scores one year after prolapse repair surgery [62]. In addition, 45 percent of women in the trial became newly sexually active postoperatively. Seven percent of women who had been sexually active preoperatively became sexually inactive following surgery. Similar trends have been seen with robotic-assisted laparoscopic prolapse repair; 25 women who underwent robotic sacrocolpopexy had good sexual function on the PISQ-12 at baseline, three months, and one year after surgery [58].
•A 2015 meta-analysis of 14 studies of women undergoing native-tissue prolapse repair reported an improvement in sexual function following surgery as assessed by pre- and postoperative questionnaires [42].
•A 2020 systematic review of 67 original studies of multiple POP surgeries reported improved postoperative scores on the PISQ-12 for mixed native tissue repairs, anterior repairs, uterosacral suspensions, sacrospinous suspensions, and sacrocolpopexy; pre- and postoperative scores were similar for posterior repairs, transvaginal mesh, and biologic grafts [60].
●Dyspareunia – A systematic review of 67 original studies, including 44 randomly assigned trials, reported lower rates of postoperative dyspareunia across multiple types of POP surgery compared with preoperative rates; reported rates of de novo dyspareunia ranged from 0 to 9 percent with insufficient data available for posterior repair [60]. This review contrasts with earlier studies that reported postoperative dyspareunia rates ranging from 0 to 50 percent following various prolapse repair procedures [56,62-64,67,70-76]. High postoperative dyspareunia rates in early series may have reflected a failure to record de novo dyspareunia, inclusion of individuals with chronic pain syndromes, or use of nonvalidated questionnaires or assessment tools.
•Etiology – Possible mechanisms for de novo dyspareunia include postoperative nerve injury, vaginal narrowing, shortened vaginal length, and use of transvaginal mesh augmentation of the prolapse repair [72-79]. Use of levatorplasty has been associated with de novo postoperative dyspareunia, while posterior repairs performed without levatorplasty report unchanged or improved dyspareunia rates postoperatively [70,80-82].
•Impact of transvaginal mesh – Studies of prolapse repair with transvaginal mesh have reported overall postoperative dyspareunia rates of 9 to 15 percent and de novo dyspareunia rates up to 28 percent [60,75].
-A 2011 systematic review that evaluated studies of vaginal prolapse repair with graft materials reported overall dyspareunia rates of 9 percent (70 studies) and de novo dyspareunia rates of 2 to 28 percent [75].
-A 2020 systematic review that evaluated dyspareunia across multiple types of POP surgeries reported reduced overall dyspareunia rates following transvaginal mesh surgery (22 percent preoperatively versus 15 percent postoperatively) and a de novo dyspareunia rate of 9 percent (14 studies) [60].
-For comparison, studies of native tissue repair have reported de novo dyspareunia rates of 1 to 15 percent following various prolapse procedures [56,62,71].
Persistently increased rates of complications from transvaginal mesh, including mesh exposure and pain, have resulted in multiple governing agencies advising a limited role for transvaginal mesh and removal of these products from several markets. A detailed discussion can be found elsewhere. (See "Transvaginal synthetic mesh: Complications and risk factors".)
URINARY INCONTINENCE
Impact of incontinence on sexual function — Urinary incontinence, including stress urinary incontinence (SUI) and urgency urinary incontinence (UUI)/overactive bladder (OAB) syndrome (ie, urinary urgency or frequency, with or without incontinence) are all associated with sexual dysfunction [7,83-89].
●All urinary incontinence – In a questionnaire study of 509 multi-ethnic, middle-aged, community-dwelling US women who were sexually active and experienced at least monthly urinary incontinence, 25 percent reported experiencing urine leakage during sexual activity in the prior three months [90]. Sixteen percent restricted sexual activity because of fear of leakage. Among 1299 women in the Maryland Women's Health Study, urinary incontinence was associated with decreased libido, increased vaginal dryness, and increased dyspareunia independent of age, educational attainment, or race [91]
●Urgency incontinence – An observational study of 883 sexually active community-dwelling women reported that pure urgency incontinence was associated with decreased sexual lubrication and more sexual pain, and mixed incontinence was associated with less sexual satisfaction [92].
●Mixed urinary incontinence – A study of 510 women with lower urinary tract symptoms including stress, urgency, and mixed incontinence reported that women with mixed incontinence noted poorer sexual function than women with either stress or urgency incontinence alone [93].
The impact of interstitial cystitis/bladder pain syndrome on sexual function is discussed separately. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis", section on 'Associated conditions'.)
Stress urinary incontinence
Impact of treatment — Physical, medical, and surgical therapies for SUI have been associated with improvement in sexual function, although data directly comparing the treatment modalities are limited. All options are discussed when counseling patients regarding treatment choices for urinary incontinence and sexual dysfunction. In general, we suggest conservative management, including pelvic floor therapy or pessary use, prior to proceeding with surgery for urinary incontinence.
Nonsurgical treatment — Women with urinary incontinence who received pelvic floor muscle training (PFMT) reported improvement in sexual function in observational and randomized trials [94-96]. While the exact mechanism is unknown, PFMT in women with SUI has been reported to improve sexual desire and ability to achieve orgasm, and reduce dyspareunia, which is significant as dyspareunia may be worsened by surgery [94]. A study of 445 women randomly assigned to behavioral therapy (PFMT and continence strategies), pessary therapy, or combined therapy reported that successful treatment of SUI was associated with greater improvement in sexual function, greater reduction in incontinence during sexual activity, and greater reduction in restriction of sexual activity related to fear of incontinence [97]. Among those successfully treated for SUI, improvement in continence during sexual activity was greater in both behavioral therapy groups compared with the pessary-only group.
Reports of sexual function following SUI treatment with a pessary are sparse. In one prospective analysis, women treated with a pessary reported improved sexual function as measured by the Pelvic Organ Prolapse Incontinence Sexual Questionnaire (PISQ) [41].
Surgical treatment — The impact of SUI surgery on female sexual function varies, but the majority of women have reported unchanged or improved sexual function following multiple types of urinary incontinence procedures [48,98-112]. A systematic review that analyzed studies published prior to 2009 and excluded studies with concomitant prolapse repair reported 55 percent of women had no change in sexual function after surgery, 32 percent had improved sexual function, and 13 percent had worsened sexual function after surgical treatment for SUI [8]. The subanalysis of 1252 women who underwent midurethral sling procedures reported similar results. A later secondary analysis of two trials evaluating four urinary incontinence surgeries reported similar improvement in PISQ scores at two years of follow-up after all four procedures (autologous fascial sling, Burch colposuspension, retropubic midurethral sling, and transobturator midurethral sling) [111].
Women who reported worsening of sexual function postoperatively often cited de novo dyspareunia as the cause [98,104,108,113-118]. A US Food and Drug Administration literature review of midurethral sling associated dyspareunia rates reported rates of 0.64 to 13.7 percent [119]. The occurrence of preexisting dyspareunia in women with stress incontinence complicates performance of these analyses. Studies have reported the prevalence of preoperative dyspareunia to be as high as 34 to 55 percent [105,108,120].
Impact of obesity — Obesity appears to be independently associated with worsening of both sexual dysfunction and urinary incontinence [121-124]. However, the available data on the complex interaction of sexual function, obesity, and urinary incontinence in women are mixed, and further studies are needed to understand the interactions. As examples:
●In one study of 366 obese and overweight women randomly assigned to a weight loss regimen, the intervention group lost significantly more weight and had greater reductions in urinary incontinence episodes [122]. However, despite the greater weight loss in the intervention group, a subanalysis of sexually active women did not report improved sexual function compared with controls [125].
●In contrast, subsequent studies of bariatric surgery have reported improvement in quality of life, including sexual function, after weight reduction [126,127].
Urgency urinary incontinence/Overactive bladder
Impact of treatment on sexual function — Similar to SUI treatments, nonsurgical and surgical treatments of UUI/OAB have been associated with improvement in sexual function. Direct comparisons of different UUI/OAB treatments on sexual function are lacking. As with pelvic floor disorders (PFDs) in general, decisions regarding treatment choice should be based on shared decision-making between patients and providers, with consideration of risks and benefits.
Nonsurgical therapy — A 2020 review that attempted to assess the impact of UUI/OAB treatment on sexual function reported an absence of studies evaluating pelvic floor physical therapy and sexual function in women with OAB [128]. The same review reported pharmacologic treatments improved sexual function in women with OAB, as supported by case series describing solifenacin [129], tolterodine [130], and mirabegron [131] and cohort studies evaluating mirabegron [132], tolterodine [133], and other anticholinergics [134]. A trial comparing tolterodine with placebo among 411 women reported improved OAB symptoms were associated with improved sexual quality of life-female (SQOL-F) and improved pelvic organ prolapse/incontinence sexual questionnaire (PISQ) total scores at 12 weeks [135]. A follow-up study revealed that these affects were sustained at six months [136].
Surgery — Studies evaluating surgical or procedural treatment of UUI/OAB are increasing in number and suggest that reduction in symptoms is associated with improved sexual function. Definitive conclusions are limited by the mostly observational study designs and small numbers of included patients.
●Onabotulinum toxin injection – A meta-analysis of sexual function in women with OAB treated with intravesical onabotulinumtoxinA (n = 119) found that total female sexual function index (FSFI) scores improved, with concomitant improvement in desire, lubrication, orgasm, and satisfaction domains [137]. The analysis concluded that though study numbers were relatively small, treatment appeared to positively affect sexual function.
●Posterior tibial nerve stimulation – A case series (n = 41) of women treated with posterior tibial nerve stimulation (PTNS) or OAB "dry" (ie, OAB without incontinence) found that FSFI scores improved following treatment [138].
●Sacral neuromodulation – Evidence suggesting improved sexual function following sacral neuromodulation (SNM) in women involve even smaller case series. One followed eight women and reported total FSFI scores improved approximately 3 points (22.6 [17.7-25.2] to 25.8 [19.2-29.7], p = 0.02) from baseline to follow-up [139]. Another involving seven women also reported that total FSFI scores improved, as did desire, lubrication, orgasm, satisfaction, pain, and sexual frequency [140].
ANAL INCONTINENCE
Impact on sexual function — Anal incontinence (AI; involuntary loss of flatus and/or feces) and fecal incontinence (involuntary loss of feces, solid or liquid) have been implicated in contributing to sexual dysfunction and are a reason for avoiding sexual relations [141]. Several studies of women with AI reported that women with AI were as likely as women without AI to be sexually active, but they reported less desire and satisfaction with sexual activity [33,142,143]. The association of AI with poor sexual function was consistent across these studies despite the use of different assessment tools (Female Sexual Function Index [FSFI], Pelvic Organ Prolapse Incontinence Sexual Questionnaire 12 [PISQ-12], and PISQ-IR).
Impact of anal incontinence treatment on sexual function — Few studies have assessed the impact of anal incontinence treatment on sexual function. Almost all evidence is inferential, drawn from analysis of nonobstetric patients with fecal incontinence treated with sphincteroplasty. Several studies of women treated with sphincteroplasty for anal incontinence reported no improvement sexual function scores despite variable improvement in incontinence [144-146]. However, these studies were limited by small sample size and lack of a condition-specific sexual function questionnaire for anal incontinence at the time of these studies [31,32]. There are no studies that have prospectively reported on sexual function in women with fecal incontinence before and after sphincteroplasty.
Postoperative counseling — As discussed above, there may be an exception for having anoreceptive intercourse after sphincteroplasty that was done for the indication of anal incontinence. Up to 20 percent of women regularly engage in anal intercourse [44,45]. While data are limited, studies in men report that anoreceptive intercourse has been associated with decreased sphincter tone and squeeze strength [46] and most surgeons would caution against anal intercourse following sphincteroplasty.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pelvic organ prolapse".)
SUMMARY AND RECOMMENDATIONS
●Quality of life – The high prevalence of sexual dysfunction in women with pelvic floor disorders (PFD) is significant because sexuality is an important component of overall quality of life. Women with pelvic organ prolapse (POP) also report poorer body image. (See 'Significance' above.)
●Common clinical presentations – Patients with PFDs typically have urinary or anal incontinence and/or symptoms of POP, which include vaginal bulging, pelvic pressure, and splinting or digitation to pass urine or stool. Urinary incontinence is diagnosed with history, physical examination, and simple office tests. Pelvic examination confirms the anatomy of prolapse. (See 'Clinical findings and diagnosis' above.)
●Impact of female sexual dysfunction – Female sexual dysfunction takes different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity. To meet criteria for sexual dysfunction, a sexual problem must be recurrent or persistent and cause personal distress or interpersonal difficulty. (See 'Clinical findings and diagnosis' above.)
●General approach – To evaluate these complex patients, we take a sexual history, discuss the impact of both the PFD(s) and treatment on sexual function, and screen for specific issues that may impact treatment choice (eg, dyspareunia or anal incontinence). In general, we begin treatment with less invasive options and proceed to surgical options as needed or if the patient desires a different treatment. (See 'Our approach' above.)
•Pelvic organ prolapse – Sexual function generally worsens with increasing severity of POP. Nonsurgical treatment of POP with a pessary or pelvic floor muscle training may improve sexual dysfunction in some women and has no harmful effects. Surgical repair of prolapse is generally associated with improvements in sexual dysfunction but may also cause de novo dyspareunia in up to 28 percent of women, especially if levatorplasty or transvaginal mesh is used in the repair. (See 'Pelvic organ prolapse' above.)
•Lower urinary tract disorders – Lower urinary tract disorders, such as stress urinary incontinence (SUI), urgency urinary incontinence (UUI)/overactive bladder syndrome (OAB), and interstitial cystitis/bladder pain syndrome, are all associated with sexual dysfunction. Improvement in SUI and UUI/OAB symptoms are both generally associated with improvement in sexual function.
-SUI treatment outcomes – Treatment of SUI with pelvic floor muscle therapy or a pessary may improve sexual function. Meta-analysis of surgical treatments of stress incontinence reported approximately 55 percent of women had unchanged sexual function postoperatively, 32 percent had improved sexual function, and 13 percent had worsened sexual function. (See 'Urinary incontinence' above.)
-UUI/OAB treatment outcomes – Treatment of UUI/OAB is also oftentimes associated with improved sexual function. Medications, including antimuscarinics [128-131,133-136], mirabegron [132], and intravesical botulinum injection [137,138] have also been associated with improved sexual function. The impact of sacral neuromodulation (SNM) on sexual function in patients with OAB is sparse, however, small case series also demonstrate improvement [128,139,140]. (See 'Urgency urinary incontinence/Overactive bladder' above.)
•Accidental bowel leakage (anal incontinence) – Accidental bowel leakage may adversely affect sexual function in women with PFDs and has been implicated as a reason for avoidance of sexual activity. The effect of surgical treatment of anal incontinence on sexual function is unclear. (See 'Anal incontinence' above.)
