Hypothesis / aims of study
Up to 60% of women attending Urogynaecology clinics report sexual dysfunction (SD), however, only a minority are consistently screened for sexual complaints . An assessment of the practice of members of the British Society of Urogynaecology and found that only 50% of clinicians regularly asked about SD .
The primary aim of this investigation was to screen sexual function (SF) in all women attending our one stop Urodynamics (UDS) clinic. The secondary aims were to evaluate why women were not sexually active (NSA), to assess if this was bothersome to them, to evaluate variations in SA according to UDS diagnosis and to compare questionnaire responses between the SA and NSA groups.
Study design, materials and methods
All women attending a UDS clinic were sent the Prolapse and Incontinence Sexual Questionnaire – IUGA Revised (PISQ-IR) as part of the pre-visit information pack. These were collected and reviewed when the women attended for assessment. Initial analysis was performed using descriptive statistics and recorded in association with demographic data and UDS diagnosis. Following this, a multivariate binary logistic regression was used to analyse the risk of being sexually active (SA) as a function of potentially contributing factors identified in the PISQ-IR. All factors were entered as covariates in the initial model via a forced entry method. The resulting model’s goodness-of-fit was determined using the Hosmer-Lemeshow statistic.
The analyses were performed three times to investigate 1. All women attending the UDS clinic, 2. Only women diagnosed with detrusor overactivity (DO) and 3. Only women complaining of overactive bladder (OAB) symptoms with normal UDS parameters.
Four hundred questionnaires were completed over 9 months. 193 presented with urinary incontinence (UI), 34 with Pelvic organ prolapse (POP), 117 with UI and POP and 56 with other Lower Urinary Tract Symptoms (LUTS) including voiding difficulties and recurrent urinary tract infections.
Group 1 - Of the women assessed, two hundred and thirty two (58%) were SA and one hundred and sixty eight (42%) were NSA. Eighty nine women (53%) were NSA because of lack of a partner. Of the 79 women who were NSA but had a partner, 60% reported that this was secondary to their bladder symptoms, 45% due to other health problems, 53% reported having no interest and 58% were bothered ‘A lot’ by their sexual status. 363 went on to have full subtracted cystometry.
Group 2 - Ninety five women were found to have DO on UDS. Of these, 60% were SA. One hundred percent of the women who were NSA reported UI and 93% of the SA women reported UI. For 47% (n=18) of these it was because of lack of a partner. Only 9 women reported having a partner and the other women did not answer.
Group 3 - Sixty seven women reported symptoms of OAB but had normal UDS findings. Of these only 45% were SA. Of the SA women 87% complained of OAB wet compared 70% of the women who were NSA. 65% (n=22) were NSA because of lack of a partner. Only 6 women reported having a partner and the other women did not answer.
In the NSA group, the relationship between bothersomeness and age was analysed using an independent T-test. This showed that those who were not bothered were, on average, 10.46 [95% CI: 4.861, 16.068] years older than those who were bothered (t(126) = 3.696, p <0.000). ?
Those who had no interest in sex were almost 5 times more likely to be bothered by their sexual inactivity, while those who were NSA due to their UI / POP problems were almost nine times more likely to be bothered.
Those with POP were 2.5 times more likely to avoid sex through fear of bulge /leaking than those without (χ2(1) = 8.339, p = 0.004).
In women with OAB, having at least one live birth made a significant contribution, resulting in a 42-fold increase in the chances of UI during sex. However, the mode of delivery was not assessed in this group.
Overall, these analyses found that more women with OAB are NSA compared to the other UDS findings, yet women with POP are more likely to avoid sex. Younger age, lack of interest and being NSA due to bladder and bowel problems are predictors of increased bothersomeness of sexual inactivity. Parous women with OAB are 42 times more likely to experience Coital Incontinence than nulliparous women with OAB.
Interpretation of results
There were no factors identified in this study to help understand who may and may not be SA. This is not unexpected as sexual activity is dependent on more than just age, parity and UDS diagnosis but is also under the influence of a wide range of external and internal factors such as religion, personal beliefs, family / cultural influences, education, availability of a sexual partner, views of peers and these were not considered in this study.
This study suggests that the PISQ-IR may have a role in routine clinical practice. It may help us to gain a deeper understanding of patients SF, which may help clinicians to understand which patients are most troubled by sexual problems in order to tailor assessment and therapy to meet their needs. However, without the clinician actively reviewing it with the patient it could become just another paper exercise. It may therefore be better used in women who report a sexual problem when questioned instead of as a screening tool for all women in clinics.
It is important to remember that when discussing the prevalence of SA in this setting that it is a biased group of women as they have all sought help for a UI or POP problem. There are many women in the community who have not sought help for a variety of different reasons and then impact of UI / POP on their sexual function remains unknown.