Though mid-urethral sling (MUS) surgeries are recommend as the gold standard therapy of stress urinary incontinence (SUI), the impact of MUS operations on female sexual function remains controversial. Consequently, we sought to provide high-quality evidence around the impact of MUS treatments on sexual function for female patients with SUI.

A systematic search of PubMed, EMBASE, and the Cochrane Library was conducted to identify studies which assessed the impact of MUS treatments on sexual function in sexually active women with SUI. The MUS techniques including retropubic tension-free vaginal tape (TVT), transobturator tension-free vaginal tape (outside-in, TOT; inside-out, TVT-O) and single-incision mini-sling (SIMS). All studies included were prospective randomized or non-randomized trials which assessed patients with two validated questionnaires i.e., the Female Sexual Function Index (FSFI) and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12)[1, 2]. Pre- and postoperative data pertaining to sexual functions were extracted. Comparable data were meta-analyzed using Review Manager 5.3 software.

Of the 24 studies identified, 17 utilized FSFI and seven adopted PISQ-12 to assess sexual functions. Of the 2188 patients involved, 50.55% (n = 1106) underwent transobturator approach MUS (i.e., TOT, TVT-O and Monarc), 28.06% (n = 614) retropubic route MUS (i.e., TVT), and 9.87% (n = 216) SIMS (i.e., Ajust®, MiniArc® and TVT Secur System®), while the remaining 11.52% (n = 252) were reported without clearly defined techniques and were therefore broadly categorized as ‘other MUS’. 
Pooled analysis indicates that 6-month postoperative PISQ-12 total scores were significantly higher than preoperative scores (Weighted mean difference (WMD) -3.31 points, 95% confidence interval (CI) -5.32 to -1.30, p=0.001; Fig.1A). Additionally, similar results were found at the 12-month juncture (WMD -3.30 points, 95% CI -6.01 to -0.58, p=0.02; Fig.1B) and 24-month follow-up point (WMD -4.44 points, 95% CI -5.45 to -3.44, p<0.00001; Fig.1C). Unfortunately, follow-up data from 4 to 15 years were insufficient for meta-analysis of the longer term effects. Although, findings do suggest that women’s postoperative sexual functioning is at least not inferior to preoperative sexual functions.
Consistently, pooled postoperative FSFI total scores were significantly higher than preoperative scores at 6-months (WMD -2.22 points, 95% CI -3.36 to -1.08, p=0.00001; Fig.2A) and 12-months (WMD -3.49 points, 95% CI -5.96 to -1.02, p=0.006; Fig.2B). Postoperative FSFI sub-scores at 6-months and 12-months suggest that desire, arousal, orgasm, lubrication, satisfaction and pain during sexual intercourse were also significantly higher than baseline scores (all p<0.05).

To the best of our knowledge, both the PISQ-12 and FSFI are internationally validated questionnaires and are recommended by the International Continence Society to assess sexual functions. Findings from this meta-analysis add to the evidence base demonstrating that sexually active women with SUI can experience an improved sex life after MUS treatment. The primary reason for this improvement may be the absence of incontinence and decreased negative emotional responses during intercourse[3]. Critically speaking, even though the PISQ-12 or FSFI are validated and can provide insight into sexual functioning, these questionnaires are subjective measures which may not have the capacity to explore the nuances of personal experience or concept of self. Therefore, these findings also suggest there may be a need for more unstructured qualitative research to explore the complexity of personal perceptions involved sexual desirability and comfort during, and after intercourse.

MUS treatments appear to improve sexual function for women with SUI. However, these findings should be further confirmed through well-designed prospective randomized controlled trial with larger samples and it may prove worthwhile intercalating more qualitative research into personal perceptions of stigma related to SUI and sexual performance.

Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000. 26(2): 191-208.
Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct. 2003. 14(3): 164-8; discussion 168.
Glavind K, Larsen T, Lindquist AS. Sexual function in women before and after tension-free vaginal tape operation for stress urinary incontinence. Acta Obstet Gynecol Scand. 2014. 93(10): 986-90.