The Impact of
Incontinence on Sexual
Health
Uro-Psychosocial
Problems & Management
Article contributed by:
Peter Lim Huat Chye, MD,
Senior Consultant
Urological Surgeon,
for New Dimension -
biannual newsletter of
the
Society for Continence,
Singapore
Urinary incontinence
affects the quality of
life of sufferers. The
sexual and psychosocial
problems of incontinent
patients are often
underreported and
inadequately managed.
Many patients have been
suffering in silence!
Clinicians who treat
incontinent patients
must also look for and
manage the associated
sexual and psychosocial
problems as to improve
the patients’ quality of
life.
Introduction
Urinary incontinence is
defined as the
involuntary loss of
urine that is asocial or
hygienic problem and
objectively
demonstrable. It
negatively affects the
quality of life of
sufferers, affecting not
only their social life
but also their work and
home-life. Recent
studies have shown that
it can result in
deterioration in
interpersonal
relationships.
Sexual problems in
patients with urinary
incontinence can be
caused by three possible
mechanisms.
Firstly, urinary
incontinence may be the
direct cause of sexual
difficulties where none
previously existed.
Secondly, it may be the
apparent cause of a
sexual problem when
there is a preexisting
but unacknowledged
sexual problem.
Thirdly, it may be the
presenting symptom of
underlying sexual
conflict and emotional
stress. Irrespective of
the causal mechanisms,
it is crucial to
investigate and treat
urinary incontinence
prior to re-establishing
satisfactory sexual
relationships.
Psychological distress
is common in the general
population. As
psychological problems
and urinary incontinence
are both common
conditions between
psychosocial problems
and the urinary
incontinence is complex.
It is important to
recognize incontinent
patients with
psychological problems,
as they may not respond
adequately to
conventional treatment.
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The Incidence of Sexual
Problems in Incontinent
Patients
Over 50% of sexually
active incontinent women
suffer sexual
dysfunction as a result
of their urinary
incontinence and 1 in 4
are incontinent during
sexual intercourse.
Hilton assessed 400
consecutive women in his
urogynaecological
clinic. Only 2 of
the 324 who were
sexually active
volunteered the specific
complaint of
incontinence during
intercourse. On
direct questioning, a
further 77 (34%)
admitted to this
problem. Many
women are too
embarrassed to disclose
such problems to their
doctors.
Sutherst conducted a
survey on 103 women from
his incontinent clinic.
Forty-eight of them
admitted having sexual
problems.
Thirty-Six women had
decreased frequency and
12 woman cease having
sex completely. The
reasons given were
depression,
embarrassment, decreased
libido and dyspareunia.
Dyspareunia resulted
from urine dermatitis or
incontinence surgery.
He also found that women
with detrusor
instability had higher
incidence of sexual
dysfunction than women
with stress urinary
incontinence.
Virehout and Granotten
studied 245 women with
urinary incontinence.
Of the 80% who were
sexually active, 34%
complained of
incontinence during
sexual activity with a
strong negative effect
on their sexual
relationship.
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Sexual Problems in
Incontinent Patients
Sexual problems can
affect any phase of the
sexual response cycle.
There may be a reduction
in the frequency of
sexual activity due to
loss of desire or sexual
avoidance. The
woman may have decreased
sexual responsiveness,
resulting in a loss of
desire, premature
ejaculation and erectile
dysfunction in the male
partner.
Lack of Libido and
diminished self-esteem
due to fear of leakage
are common as urine
leakage can occur during
penetration, or at
orgasm. Hilton
reported that woman with
stress urinary
incontinence were more
likely to leak on
penetration, whereas
those with detrusor
instability were more
likely to leak at
orgasm. Norton and
Stanton had shown that
woman with detrusor
instability had no
greater psychiatric
morbidity than other
incontinent women, but
they suffered greater
psychological distress
due to the unpredictable
nature of their
symptoms. They
were more anxious.
They feared the
unforeseeable and often
uncontrollable leakage
with orgasm and
therefore more
apprehensive about
sexual contact.
Most cases of sexual
dysfunction become worse
over time due to the
development of
performance anxiety,
where the goal of
sexuality is no longer
enjoyment but ‘getting
it right’. It is
likely that many factors
contribute to the sexual
dysfunction of
incontinent patients.
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Taking History from
Incontinent Patients
Many incontinent women
will not disclose the
history of the sexual
problems voluntarily.
They can be highly
sensitive, embarrassed
and uncomfortable.
They may be unwilling to
discuss sexual problems,
or may even have initial
denial of their
problems. When
interviewing the
patients, the clinician
must ensure privacy and
reassure
confidentiality.
Rapport must be made
between the clinician
and the patients.
Observe her body
language, her tone of
voice or the hesitations
in her speech. Try
to use simple language,
ask open-ended
questions, be sensitive
and listen attentively
to her problems.
Avoid being judgmental.
Although urinary
incontinence can cause
sexual problems, It is
still important to
elicit any preexisting
sexual problems that may
have been exacerbated by
the urinary
incontinence.
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Management of Sexual
Problems in Incontinent
Patients
When managing
incontinent patients,
full discussion of the
patients’ sexual
problems must take
place. When urinary
incontinence is not
resolved by physical
intervention, the
clinician must help the
couple come to terms
with their disability
and learn how to
maximize the quality of
their sexual
relationship. It
is important to see the
couple together and
facilitate the
communication. Ensure
that the couple talk
openly and honestly with
each other and share
their feelings about the
situation. Let
each other know their
likes and dislikes
during lovemaking.
The couple must be
encouraged to share
their feelings,
especially the more
negative ones, in an
honest and constructive
way. On the other
hand, feelings of
fulfillment and pleasure
which will reinforce the
sexual activity must
also be exchanged.
Some practical measures
can also be implemented
to minimize the effect
of urinary incontinence
on lovemaking, for
example, empty the
bladder before sex, and
use a waterproof sheet
on the bed. If
necessary, the couple
can be counseled by a
trained sex therapist.
Barber et al reported a
study where 343
incontinent women were
randomized into 3
treatment groups:
estrogen therapy,
behavioral therapy
(includes bladder
retraining and pelvic
floor exercises) or
surgical therapy (Burch
colposuspension).
They answered sexual
function questionnaire
pre-op (baseline) and 3
and 6 months after
surgery. Sexual
function improved
significantly after
surgical treatment (p =
0.02) and behavioural
therapy (p = 0.001).
Estrogen therapy did not
make a difference in
outcome.
The majority of studies
evaluating the outcome
of incontinence surgery
do so in terms of
objective urodynamic
investigation and
urinary symptom
questionnaires.
The risk of dyspareunia
caused by surgery has
been underreported.
In a prospective study
by Haase and Skibsted,
13 out of 55 women
experienced an
improvement in sexual
life, 35 out of 55 no
change and 5 out of 55 a
deterioration.
Improvement was due to a
cure of coital
incontinence and
deterioration was due to
dyspareunia caused by
posterior repair.
Burch colposuspension
elevates the anterior
vaginal wall and this
results in a ridge
formation at the
mid-section of the
posterior vaginal wall.
Haase and Skibsted
reported that it did not
lead to significant
dyspareunia.
Walter S et al and
Kamper AL et al however,
reported 8% and 17% of
their patients
experiencing
postoperative
dyspareunia
respectively. TVT
has been widely used to
treat stress urinary
incontinence in recent
years. Maaita et
al reported that of the
57 women who underwent
TVT surgery, 43 were
sexually active and 6
women complained of loss
of libido. No
patients complained of
dyspareunia.
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Psychosocial Problems in
Incontinent Patients
The psychological
consequences of urinary
incontinence are also
important. The
adverse reactions to
urinary incontinence can
become “incorporated”
into the lifestyle and
personality of patients.
These patients often
have a depressed mood
similar to other
patients suffering from
long-standing
distressing conditions.
Unfortunately, the
assessment and treatment
of urinary incontinence
are often delayed,
further compounding
psychological distress.
Patients who complained
of significant urinary
symptoms but for whom
the findings of all
investigations are
normal resent a
particular management
problem.
In the absence of a
diagnosis, response to
empirical treatment is
often suboptimal. It is
common to label and
treat them as
psychosomatic.
Significant Psychiatric
morbidity has been
identified in these
patients.
Macauley et al reported
that patients with
stress urinary
incontinence may have
psychological problems
as a consequence.
However, the incidence
is no greater than for
other physical
disorders.
Obrink et al showed that
patients receiving
surgical treatment for
stress urinary
incontinence who were
both subjectively and
objectively cured had an
improvement were
similarly improved,
whereas those
objectively but not
subjectively cured
remained both neurotic
and depressed.
Rosenweig et al also
reported a statistically
significant improvement
in psychological status
in patients who were
objectively and/or
subjectively cured.
Those for whom surgery
was unsuccessful did not
report a significant
change in their
psychological status.
Starub et al found that
unstable detrustor
contractions could be
provoked by emotional
stress in the laboratory
setting and were
reinforced and
perpetuated by a
stressful work and
social environment.
Jeffocate and Francis
found that 61% of 246
women with urge
incontinence appeared
obsessional or
depression. Using the
Psychosocial Adjustment
to Illness Scale, women
with detrusor
instability and sensory
urgency suffer greater
psychological impairment
than women with stress
urinary incontinence.
Perhaps the
unpredictability and
severity of their
urinary leakage impart
greater emotional,
social and sexual
restrictions and hence
greater quality of life
impairment. Moore
et al showed that the
severity of
psychological impairment
correlated significantly
with the severity of
urinary symptoms and the
amount of urinary
leakage.
Patients with detrusor
instability responded to
a combination of
treatment including
education, bladder
training, psychotherapy
and medication.
Long standing,
disturbing urinary
incontinence is the
source of considerable
psychological morbidity
and the severity of
urinary incontinence is
linked to the degree of
psychological
impairment.
Patients with greater
psychological morbidity
often respond less well
to treatment. The
treatment of urinary
incontinence improves
psychological distress
and failure of treatment
intensifies
psychological symptoms.
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Conclusions
Psychosocial and sexual
problems are indeed
common in incontinent
patients. They are
often neglected by the
doctors and
underreported by the
patients. To
improved patients’
quality of life, these
problems must be
thoroughly investigated
and adequately treated
in addition to the
routine therapeutic
interventions for
urinary incontinence.
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Article contributed by:
Peter Lim Huat Chye, MD,
Senior Consultant
Urological Surgeon,
Hon. Professor (Urology
& Andrology), HT Naval
Medical School,
Indonesia, Adjunct
Professor, Edith Cowan
University, Australia
Visiting Consultant, Depts of Urology, KTP
Hospital & Changi
General Hospital,
Singapore
Andrology, Urology &
Continence Centre,
Gleneagles Hospital,
Singapore
for New Dimension -
biannual newsletter of the
Society for Continence, Singapore
Dated: April 2015
|
The
Society for
Continence,
Singapore
(SFCS) is a
non-profit
organization
that
originated
from the
dedicated
efforts of a
group of
doctors,
nurses and
rehabilitation
therapists
who
recognised
the special
needs of the
incontinent
as far back
as 1988.
The mission
of the
society is to
promote
bladder and
bowel health
and to work
towards a
community
free of the
stigma and
restrictions
of
incontinence.
The society
aims to
disseminate
information
and educate
healthcare
professionals
and the
public on
methods to
promote
urinary &
bowel
continence
and to
promote the
education,
training and
rehabilitation
of the
incontinent
and their
general
interests
and welfare. |
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