From the Journals

Stress incontinence surgery found to improve sexual dysfunction

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The findings reflect the maturity of a subspecialty

At face value, this is a retrospective analysis of sexual function after surgical correction for urinary incontinence. However, the researchers looked at two well-known and well-respected randomized, controlled trials comparing two types of incontinence procedures head to head, each. So the reader gets an opportunity to examine the influence of four different surgical procedures on sexual function.

Although I expected to see there would be an initial improvement with surgical correction, I did not expect that improvement would be so well maintained over time. There was sustained – and even continued – improvement in many cases, and this suggests a closer link to urinary incontinence that just embarrassment or worry about leakage during sex. I think the “take-home message” is that women who undergo anti-incontinence procedures can expect an improvement in sexual function from baseline, with the majority happening within the first year, and maintain this improvement between years 1 and 2.

I think this is the type of study that we all envisioned being able to do 25 years ago when female pelvic medicine and reconstructive surgery was in its infancy as an “official” subspecialty, and the National Institutes of Health had developed the Urinary Incontinence Network and the Pelvic Floor Disorders Network. It is gratifying that enough good research has been done to finally enjoy the fruits of their/our labor! The study had large numbers, used a widely known, validated questionnaire, and used data generated from randomized, controlled trials. Although the subjects may not represent all demographics, the study findings can be an aid to most practicing gynecologists to help counsel their patients.

The major limitations of any retrospective study are the inability to go back and ask questions not addressed in the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form. For instance, the authors discussed that it might be nice to have an “open-ended” question about why the nonresponders were not having sex.

Patrick Woodman, DO, MS , is a urogynecologist with the Michigan State University, East Lansing. He is also the program director for the obstetrics and gynecology residency for Ascension Macomb-Oakland Hospital, Warren (Michigan) Campus. Dr. Woodman is a member of the Ob.Gyn. News editorial advisory board.



An analysis of four commonly performed surgical procedures for stress urinary incontinence found that they all improved sexual dysfunction to a similar degree over the course of 24 months.

Happy mature couple sitting at their bedroom looking at each other Juanmonino/E+/Getty Images

“There is a growing body of literature concerning female sexual function after treatment for urinary incontinence,” Stephanie M. Glass Clark, MD, of the University of Pittsburgh, and colleagues wrote in a study published in Obstetrics & Gynecology. “Pelvic floor muscle therapy has been shown to improve sexual function as well as urinary incontinence symptoms. Surgical treatment, on the other hand, has had unclear effects on sexual function.”

Dr. Glass Clark and colleagues conducted a combined secondary analysis of the SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial) and TOMUS (Trial of Mid-Urethral Slings) studies. Women in the original trials were randomized to receive surgical treatment for stress urinary incontinence with an autologous fascial sling or Burch colposuspension (SISTEr), or a retropubic or transobturator midurethral sling (TOMUS). Sexual function as assessed by the short version of the Pelvic Organ Prolapse/ Urinary Incontinence Sexual Questionnaire (PISQ-12) was compared between groups at baseline, 12 months, and 24 months.

Of the 924 women included, 249 (27%) had an autologous fascial sling, 239 (26%) underwent Burch colposuspension, 216 (23%) had a retropubic midurethral sling placed, and 220 (24%) had a transobturator midurethral sling placed. The researchers observed no significant differences in mean PISQ-12 scores between the four treatment groups at the time of baseline (P = .07) or at the 12- and 24-month visits (P = .42 and P = .50, respectively). Patients in the two studies showed an overall improvement in sexual function over the 24-month study period.

Specifically, PISQ-12 scores at baseline were 32.6 in the transobturator sling group, 33.1 in the retropubic sling group, 31.9 in the Burch procedure group, and 31.4 in the fascial sling group. At 12 months, the PISQ-12 scores rose to 37.7 in the transobturator sling group, 37.8 in the retropubic sling group, 36.9 in the Burch procedure group, and 37.1 in the fascial sling group. These scores were generally maintained at 24 months (37.7 in the transobturator sling group, 37.1 in the retropubic sling group, 36.7 in the Burch procedure group, and 37.4 in the fascial sling group), and were not statistically different than the scores tabulated at the 12-month follow-up visit (P = .97).

“This study and others demonstrate that sexual function improves with surgical improvement of stress incontinence which may suggest a possible association of urinary incontinence and sexual dysfunction,” Dr. Glass Clark and colleagues concluded. “As we continue to explore the complex and multifaceted problem of sexual dysfunction, further evaluation of the effect of pelvic floor disorders – and their treatments – will be important and necessary research.”

The researchers acknowledged certain limitations of the study, including the fact that there was a low degree of diversity among women in the studied trials, which limits the generalizability of the findings. They also pointed out that the PISQ-12 does not address sexual stimulation or nonpenetrative vaginal intercourse. “Additionally, it limits partner-related problems to erectile dysfunction and premature ejaculation; some eligible participants may be excluded secondary to sexual preferences given the assumptions inherent to the questionnaire that the partner is male,” they wrote.

This secondary analysis had no outside sources of funding. Dr. Glass Clark reported that she received a travel stipend from the Society of Gynecologic Surgeons, sponsored by OB-STATS. Her coauthors reported having no financial conflicts.

SOURCE: Glass Clark SM et al. Obstet Gynecol 2020;135(2):352-60.

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