Fecal incontinence decreases sexual quality of life, but does not prevent sexual activity in women

The impact of anal incontinence: psychosocial and sexual consequences and factors associated with QoL in a Norwegian outpatient population

OBJECTIVES

Anal incontinence (AI) is a distressing condition with grave impact on many aspects of life, including quality of life (QoL), social life and sexual activities. This study explored how AI and bowel symptoms impact QoL in a Norwegian population by (1) describing the psychosocial and sexual consequences of AI, and (2) investigating factors most often associated with AI-specific QoL.

MATERIALS AND METHODS

A cross-sectional study among patients with AI referred to hospital outpatient clinics was conducted. A Norwegian version of ICIQ-B was used to measure bowel control, bowel symptoms, sexual impact, and impact on QoL.

RESULTS

A total of 208 persons with AI completed the questionnaire. The results demonstrated that these patients are overall embarrassed, make plans according to the bowels, ensure the presence of a nearby toilet, and many abstain from sexual activities. After adjusting for other variables included in a multivariable model, we found that having bowel accidents on one's mind had the greatest relative impact on QoL, followed by lower bowel control, using more medications to stop bowels, having more pain/soreness around the back passage, lower age, and more straining to open the bowels.

CONCLUSIONS

AI has substantial consequences for the psychosocial function and sexual activities of persons with AI. This study indicates that worrying about potential faecal accidents and the social stigma associated with this have greater impact on QoL than actual bowel leakages. Future studies should therefore focus on the emotional burden, patient coping, and health education related to bowel function and AI.

Effects of bariatric surgery on sexual function and fertility: A narrative review

Obesity has emerged as a prevalent global health concern, with its detrimental effects on the reproductive system and sexual function garnering increasing attention. Both men and women affected by obesity face a heightened risk of fertility challenges and sexual dysfunction. Although fertility and sexual function are distinct topics, they are intricately linked and mutually influential in both medical and societal contexts. Bariatric surgery (BS) has generated promising results in alleviating sexual dysfunction and enhancing fertility, results which are often gender specific. In men, improvements in sexual function can often be attributed to weight loss and subsequent optimizations in sex hormone levels. However, improving female sexual function may be related to a range of factors beyond weight loss. Bariatric procedures have shown limited benefits for male fertility; in fact, in some situations it can even be detrimental, leading to a decrease in sperm count and quality. Conversely, BS may positively impact female fertility, improving pregnancy and neonatal outcomes. Nevertheless, it is essential to consider the potential risks related to the adverse effects of malnutrition and rapid weight loss following BS, making it advisable to wait for 12-18 months before attempting pregnancy.

Pelvic floor disorders and impact on sexual function: a cross-sectional study among non-sexually active and sexually active women

Background

Pelvic floor disorders are common and associated with impaired sexual function in women.

Aim

To assess women with pelvic floor disorders and describe factors associated with not being sexually active and those associated with sexual function in sexually active women.

Methods

A cross-sectional study was conducted that included nonpregnant women with symptoms of pelvic floor disorders who were referred to the urogynecologic and surgical outpatient clinic at 2 Norwegian university hospitals: St Olavs Hospital, Trondheim University Hospital, and the University Hospital of Northern Norway, Tromsø. Women answered a questionnaire anonymously.

Outcomes

Pelvic Organ Prolapse Incontinence Sexual Questionnaire-IUGA Revised.

Results

Of 157 respondents, 111 (71%) reported being sexually active (with or without a partner), and 46 (29%) reported not being sexually active. As compared with sexually active women, not sexually active women were older (mean ± SD, 60.2 ± 13.3 vs 51 ± 12.1 years; P < .001), more were menopausal (78% vs 47%, P = .001), and more had symptom debut <1 year (31% vs 9%, P < .001). They reported more distress related to pelvic floor disorders, especially pelvic organ prolapse. In a multivariate logistic regression analysis, menopausal women and women with symptom debut <1 year were 4 times more likely to be not sexually active than premenopausal women (odds ratio, 4.0; 95% CI, 1.7-9.2) and women with symptom debut ≥1 year (odds ratio, 4.0; 95% CI, 1.5-10.7). In sexually active women, colorectal-anal distress was negatively associated with 5 of 6 domains of sexual function: arousal/orgasm (ß = -0.36; 95% CI, -0.02 to -0.005), partner related (ß = -0.28; 95% CI, -0.01 to -0.002), condition specific (ß = -0.39; 95% CI, -0.002 to -0.009), global quality (ß = -0.23; 95% CI, -0.02 to -0.002), and condition impact (ß = -0.34; 95% CI, -0.02 to -0.006).

Clinical Implications

Health care professionals should discuss sexual function in patients with pelvic floor disorders, especially menopausal women and women with colorectal-anal symptoms.

Strengths and Limitations

The study used condition-specific measures and recruited women from 2 university hospitals with wide range of age. Limitations include the small sample size and wide confidence intervals. The number of women who considered themselves not sexually active was low, and item nonresponse levels among these women where somewhat high. Of 625 eligible women, 200 (32%) answered the questionnaire. Sexual health and sexual function are still surrounded with taboo, and some women were probably not comfortable answering the questions.

Conclusion

Menopausal women and women with recent onset of symptoms of pelvic floor disorders are more likely to be sexually inactive, and colorectal-anal symptoms have the most negative impact on sexual function in sexually active women.

Association between obesity and female sexual dysfunction: a review

INTRODUCTION

Obesity is a global health crisis that has been growing over the past few decades. The economic burden associated with obesity is substantial as it is associated with multiple disabling chronic diseases, such as cardiovascular disease, certain cancers, osteoarthritis, chronic pain, and mental illness. Obesity is known to be a risk factor for sexual dysfunction in men, but this association is less well understood in women.

AIMS

To provide a narrative review of the available literature on the relationship between overweight/obesity and female sexual dysfunction, elaborate on the possible mechanisms explaining this association, and discuss the effects of weight loss on sexual function in those with obesity.

METHODS

A search of the medical literature was carried out in PubMed and Medline, focusing on original research and systematic reviews of original research on obesity and sexual function in women.

RESULTS

The relationship between obesity and female sexual function is not consistent across studies. While women with obesity are more likely to have worse sexual function and avoid sexual activity, many studies have failed to identify these associations. Lifestyle changes resulting in weight loss lead to better sexual function, and bariatric surgery has been shown to improve sexual function in the first couple of years following the procedure; yet, the long-term effects of weight loss and bariatric surgery are still uncertain.

CONCLUSIONS

The evidence on the relationship between obesity and female sexual function is mixed. Nevertheless, weight loss has been shown to improve sexual function in women with obesity. The impact of weight loss medications and the long-term effect of bariatric surgery on female sexual function require further study.

Female sexual dysfunction in urinary and double incontinence

OBJECTIVES

To evaluate the sexual function of women with urinary incontinence (UI) and double incontinence (DI) comparing with a healthy control group by using the Female Sexual Function Index (FSFI).

METHODS

This study was designed as a retrospective study consisting of UI, DI, and a control group, each containing age-matched 40 patients. Statistical comparisons were made among the UI, DI, and control groups in terms of the FSFI total score as well as each domain's score.

RESULTS

The FSFI total scores were found to be 22.92, 20.53, and 20.32 for the control, UI, and DI groups, respectively, and no statistically significant difference was found among the groups. A statistically significant difference existed among the groups only in terms of satisfaction and pain. Significantly higher pain was found in the UI and DI groups compared with the control group (p=0.007 and p<0.001). Although there was significantly lower satisfaction in the DI group compared with the control group (p=0.012), no significant difference was found between the UI and control groups.

CONCLUSION

The pain in the UI group and the pain and the low satisfaction in the DI group might be parameters that cause sexual dysfunction.

Sexual and Reproductive Health Concerns in Adults With Cloacal Anomalies: A Qualitative Study

STUDY OBJECTIVE

Long-term gynecologic data are lacking to inform the care of patients with cloacal malformations. We seek to examine perceived sexual and reproductive health challenges of patients born with cloacal anomalies and characterize the experiences of patients as adults.

DESIGN AND SETTING

Virtual semi-structured focus groups and single-participant interviews were conducted using an online video platform. Retrospective chart review was performed to abstract available demographics and surgical history.

PARTICIPANTS

Adult patients were contacted from a database of 143 patients born with cloaca who had been seen at or referred to a tertiary care pediatric colorectal center. Participants were recruited until data collection reached thematic saturation. Twenty patients aged 18-53 years participated in 5 focus groups and 3 single-participant interviews. The hospital IRB determined the research activities to be exempt from IRB review and oversight.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Interviews and focus groups were transcribed and analyzed using the constant comparative method to identify themes regarding sexual and reproductive health and compared with medical and surgical history abstracted from chart review.

RESULTS

Participants reported many perceived barriers to intercourse and intimacy including bowel and bladder continence management. All participants reported discussion of pregnancy and fertility with healthcare providers as important. Other common themes included concerns about independence and transitioning from pediatric to adult providers.

CONCLUSION

Anorectal malformations are associated with sexual and reproductive health concerns. Patients seek guidance on family building, intimacy, and transition to adult care. Future quantitative study of these topics is needed to develop best practices for counseling and clinical management of these patients.

LEVEL OF EVIDENCE

Level VI.

TYPE OF STUDY

Prognosis Study.

Flatus Incontinence and Fecal Incontinence: A Case-Control Study

BACKGROUND

Incontinence to gas can be a troublesome symptom impacting quality of life for patients even in the absence of fecal incontinence. Whether isolated flatus incontinence represents part of the spectrum of true fecal incontinence or a separate condition with a different pathophysiology remains unclear.

OBJECTIVE

This study aimed to evaluate the clinical features and anorectal physiology in women presenting with severe isolated flatus incontinence compared to women with fecal incontinence and healthy asymptomatic women.

DESIGN

This was a retrospective case-control study of prospectively collected data.

SETTINGS

Data from participants were obtained from a single tertiary Neurogastroenterology Unit in Sydney, Australia.

PATIENTS

Data from 34 patients with severe isolated flatus incontinence, 127 women with fecal incontinence' and 44 healthy women were analyzed.

MAIN OUTCOME MEASURES

The primary outcomes were clinical (including demographic, obstetric, and symptom variables) and physiological differences across the 3 groups.

RESULTS

Patients with flatus incontinence were significantly younger (mean 39 versus 63 years; p = 0.0001), had a shorter history of experiencing their symptoms ( p = 0.0001), and had harder stool form than patients with fecal incontinence ( p = 0.02). Those with flatus incontinence had an adverse obstetric history and impaired anorectal physiology (motor and sensory, specifically rectal hypersensitivity) but to a lesser extent than patients with fecal incontinence.

LIMITATIONS

This study was limited by its retrospective design and modest sample size.

CONCLUSIONS

Anorectal physiology was impaired in patients with flatus incontinence compared to healthy controls, but to a lesser extent than in those with fecal incontinence, raising the possibility that flatus incontinence could be a precursor to fecal incontinence. As clinical and physiological findings are different from healthy controls (including the presence of visceral hypersensitivity), isolated flatus incontinence should be considered a distinct clinical entity (like other functional GI disorders), or possibly part of an incontinence spectrum rather than purely a normal phenomenon. See Video Abstract at http://links.lww.com/DCR/B946 .

INCONTINENCIA DE FLATOS E INCONTINENCIA FECAL UN ESTUDIO DE CASOS Y CONTROLES

ANTECEDENTES:La incontinencia de gases puede ser un síntoma molesto que afecta la calidad de vida de los pacientes incluso en ausencia de incontinencia fecal. Aún no está claro si la incontinencia de flatos aislada representa parte del espectro de la incontinencia fecal verdadera o una condición separada con una fisiopatología poco clara.OBJETIVO:Evaluar las características clínicas y la fisiología anorrectal en mujeres que presentan incontinencia grave aislada de flatos, en comparación con la incontinencia fecal y mujeres sanas asintomáticas.DISEÑO:Este fue un estudio retrospectivo de casos y controles de datos recolectados prospectivamente.AJUSTE:Los datos de los participantes se obtuvieron de una sola Unidad de Neurogastroenterología terciaria en Sydney, Australia.PACIENTES:Se analizaron los datos de 34 pacientes con incontinencia grave aislada de flatos, junto con 127 mujeres con incontinencia fecal y 44 mujeres sanas.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron clínicos (incluidas las variables demográficas, obstétricas y de síntomas), así como las diferencias fisiológicas entre los tres grupos.RESULTADOS:Los pacientes con incontinencia de flatos eran significativamente más jóvenes (media de 39 años frente a 63 años, p = 0,0001), tenían un historial más corto de experimentar sus síntomas (p = 0,0001) y tenían heces más duras que los pacientes con incontinencia fecal (p = 0,02). Aquellos con incontinencia de flatos tenían antecedentes obstétricos adversos y fisiología anorrectal alterada (motora y sensorial, específicamente hipersensibilidad rectal); aunque en menor medida que las pacientes con incontinencia fecal.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y tamaño de muestra modesto.CONCLUSIONES:La fisiología anorrectal se vio afectada en las pacientes con incontinencia de flatos en comparación con las controles sanos, pero en menor medida que en aquellas con incontinencia fecal, lo que plantea la posibilidad de que la incontinencia de flatos pueda ser un precursor de la incontinencia fecal. Dado que los hallazgos clínicos y fisiológicos son diferentes a los de los controles sanos (incluida la presencia de hipersensibilidad visceral), la incontinencia de flatos aislada debe considerarse como una entidad clínica distinta (al igual que otros trastornos gastrointestinales funcionales), o posiblemente como parte de un espectro de incontinencia en lugar de un trastorno puramente a un fenómeno normal. Consulte Video Resumen en http://links.lww.com/DCR/B946 . (Traducción-Dr Yolanda Colorado ).

Introducing a Clinical Practice Guideline in Physiotherapy to Address Sexuality in Adults with a Neuromuscular Disorder

Purpose:

We present the development and the key elements of a clinical practice guideline (CPG) in physiotherapy aiming to address sexuality, more specifically impairments and limitations that can interfere with sexual activity in adults with a neuromuscular disorder (NMD).

Method:

The CPG was based on the Rare Knowledge Mining Methodological Framework (RKMMF) and included a literature review, consultation with physiotherapists, and validation by an interdisciplinary team. The EX-PLISSIT (extended, permission, limited information, specific suggestions, intensive therapy) model and the Competency Profile for physiotherapists in Canada were also used as frameworks to divide the CPG into sections. Here, we present the methodology for the CPG development and key elements related to physiotherapy assessment and treatment related to sexual activity in people with NMDs.

Results:

An extensive CPG was developed through a literature review, consultations, and a validation process. A total of 75 articles were included in the review. Twelve physiotherapists and four health professionals reviewed the CPG. Physiotherapists should address the following in their assessment: relationships; assistance required during sexual activity; urinary, vaginal, or anorectal symptoms; erectile dysfunction; pain; fatigue; and the impact of the NMD on sexuality. Interventions can target physical activity, positioning, muscle weakness, fatigue, decreased range of motion, erectile dysfunction, sensitivity disorders, lubrication, pain, incontinence, and cardiorespiratory implications.

Conclusions:

The CPG promotes the importance of addressing sexuality and proposes different interventions that physiotherapists should integrate into their practice.

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review

Female sexual dysfunctions represent a real widespread problem, usually faced from a psychological point of view; however, millions of women worldwide are impacted by pelvic floor dysfunction, personal shame and social taboos, however, continue to inhibit free conversation on the subject. Women's quality of life is considerably improved by screening, diagnosing, and controlling urogenital and sexual issues. This review aims to provide a critical perspective of urogenital conditions and common disturbances in female sexual function associated with these issues. It also includes a discussion of postpartum pelvic dysfunction.

Sexual health and wellbeing among female pelvic cancer survivors following individualized interventions in a nurse-led clinic

PURPOSE

Treatment-induced sexual and intestinal dysfunctions coexist among women after pelvic radiotherapy. We aimed to explore if sexual health and wellbeing may be improved after radiotherapy following nurse-led interventions and if an association exists between improved intestinal health and sexual health.

METHODS

A population-based cohort of women treated with pelvic radiotherapy underwent interventions at a nurse-led clinic at Sahlgrenska University Hospital, Sweden, from 2011 to 2017. Self-reported questionnaires were used, pre- and post-intervention, to compare self-reported changes in sexual health and wellbeing. A regression model was performed to explore the association between intestinal and wellbeing variables.

RESULTS

Among the 260 female pelvic cancer survivors included in the study, more women reported increased than decreased satisfaction with overall sexual health post-intervention (26.0% vs. 15.3%, p = 0.035). They also reported significantly reduced superficial genital pain (25.8% vs. 13.1%, p ≤ 0.025), reduced deep genital pain (23.1% vs. 8.0%, p ≤ 0.001), increased QoL (42.7% vs. 22.4%, p < 0.001), and reduced levels of depression (43.1% vs. 28.0%, p = 0.003) or anxiety (45.9% vs. 24.4%, p < 0.001) post-intervention. We found a significant association between reduced urgency to defecate and improved satisfaction with overall sexual health (RR 3.12, CI 1.27-7.68, p = 0.004) and between reduced urgency to defecate with fecal leakage and reduced anxious mode (RR 1.56, CI 1.04-2.33, p = 0.021).

CONCLUSION

Sexual health and wellbeing can be improved by interventions provided in a nurse-led clinic focusing on physical treatment-induced late effects. Further research to optimize treatment strategies in female pelvic cancer survivors is needed.

Randomized controlled trial of home biofeedback therapy versus office biofeedback therapy for fecal incontinence

BACKGROUND

Biofeedback therapy is useful for treatment of fecal incontinence (FI), but is not widely available and labor intensive. We investigated if home biofeedback therapy (HBT) is non-inferior to office biofeedback therapy (OBT).

METHODS

Patients with FI (≥1 episode/week) were randomized to HBT or OBT for 6 weeks. HBT was performed daily using novel device that provided resistance training and electrical stimulation with voice-guided instructions. OBT consisted of six weekly sessions. Both methods involved anal strength, endurance, and coordination training. Primary outcome was change in weekly FI episodes. FI improvement was assessed with stool diaries, validated instruments (FISI, FISS, and ICIQ-B), and anorectal manometry using intention-to-treat analysis.

KEY RESULTS

Thirty (F/M = 26/4) FI patients (20 in HBT, 10 in OBT) participated. Weekly FI episodes decreased significantly after HBT (Δ ± 95% confidence interval: 4.7 ± 1.8, compared with baseline, p = 0.003) and OBT (3.7 ± 1.6, p = 0.0003) and HBT was non-inferior to OBT (p = 0.2). The FISI and FISS scores improved significantly in HBT group (p < 0.02). Bowel pattern, bowel control, and quality of life (QOL) domains (ICIQ-B) improved significantly in HBT arm (p < 0.023). Resting and maximum squeeze sphincter pressures significantly improved in both HBT and OBT groups and sustained squeeze pressure in HBT, without group differences.

CONCLUSIONS & INFERENCES

Home biofeedback therapy is non-inferior to OBT for FI treatment. Home biofeedback is safe, effective, improves QOL, and through increased access could facilitate improved management of FI.

Long-term results of dynamic graciloplasty for severe fecal incontinence

BACKGROUND

Fecal incontinence is a common complaint. In the presence of extensive sphincter deterioration, after anorectal trauma, or failure of non-invasive surgical procedures, a sphincter reconstruction with dynamic graciloplasty can be proposed. The aim of our study was to evaluate the long-term results of dynamic graciloplasty.

METHODS

A retrospective study was conducted on all the patients who underwent dynamic graciloplasty between 1997 and 2019 in one French tertiary referral center for severe fecal incontinence after previous unsuccessful treatments. Only patients with available long-term results (≥ 1 year) were included.

RESULTS

Among 40 patients who underwent dynamic graciloplasty, 31 patients [77% women, median age = 57 years (range 17-74 years)] were included with a mean long-term follow-up of 11 ± 6 years. The mean duration of fecal incontinence was 8 ± 7.9 years and the mean Wexner score was 16 ± 3. Fecal incontinence was adult-acquired in 88% of patients. 74% of patients underwent previously unsuccessful surgical procedures. A diverting colostomy was present in 7 patients (23%). Postoperative overall, surgical and major morbidity occurred in 20 (64%), 17 (55%) and 7 (23%) patients, respectively. At the end of follow-up, 18 patients still used their stimulation device (58%), and 4 patients required a permanent colostomy (12.5%). Long-term efficacy of dynamic graciloplasty was reported by 17 patients (55%).

CONCLUSION

The efficacy of dynamic graciloplasty is conserved in 55% of patients after a mean follow-up of 11 years. This procedure needs to be kept in the surgical armamentarium for persistent and severe fecal incontinence after previous surgical interventions or in the presence of large perineal defects, before the ultimate step of permanent stoma.

The severity of symptoms is insufficient to predict major alterations to quality of life of patients with fecal incontinence or chronic constipation

PURPOSE

Evaluate the impact of fecal incontinence (FI) and chronic constipation (CC) on the quality of life (QoL) in a large population and determine if a threshold of symptom scores was associated with alterations to QoL.

METHODS

A total of 422 outpatients with FI (n = 186), CC (n = 186), and mixed FI-CC (n = 50) referred for anorectal manometry were included prospectively. All patients completed a set of questionnaires to evaluate the severity of FI and CC (respectively Jorge and Wexner and KESS scores) and their impact on QoL (Gastrointestinal Quality of Life Index (GIQLI)).

RESULTS

The study population included 81.8% women. The QoL was altered to the same degree for both FI and CC, with significant more marked impairments in patients with mixed FI-CC (median GIQLI: 91 (71-108) vs. 91 (73-108) vs. 81 (57-97) respectively, p = 0.05). The symptom severity significantly but weekly correlated with the GIQLI score (r² = - 0.454 for FI and r² = - 0.483 for CC, p < 0.001). Thus, the large dispersion of the data flawed the identification of a threshold for symptom severity that could predict major impairment to QoL.

CONCLUSION

The QoL was equally altered for FI and CC. Although the symptom score severity was slightly but significantly associated with alterations to QoL, it was not possible to determine a threshold for symptom scores that predict an alteration to QoL. Therefore, the evaluation of QoL in parallel to the assessment of the symptom score is required to endorse the entire spectrum of the severity of CC or FI.

Impact of bowel and stoma dysfunction on female sexuality after treatment for rectal cancer

AIM

The aim of this study was to measure the impact of bowel dysfunction and a poorly functioning stoma on the risk of sexual inactivity and sexual dysfunction in female patients.

METHOD

In a population-based cross-sectional study, Danish rectal cancer patients diagnosed between 2001 and 2014 were invited to answer a comprehensive questionnaire regarding cancer- and treatment-related late side effects after rectal cancer treatment. Bowel function was assessed using the Low Anterior Resection score and stoma function using the Colostomy Impact score. Female sexuality was measured by sexual activity, overall sexual dysfunction (the Rectal Cancer Female Sexuality score) and by different domains of sexual dysfunction (Sexual Vaginal Changes questionnaire).

RESULTS

Eight-hundred and thirteen female patients completed the questionnaire (response rate 49.2%). Major bowel dysfunction did not significantly increase the risk of sexual inactivity (OR 1.39, 95% CI 0.93-2.07) but clearly increased the risk of sexual dysfunction (OR 3.03, 95% CI 1.67-5.51). The most distinct problems were dyspareunia and inability to complete intercourse. On the contrary, poor stoma function increased the risk sexual inactivity (OR 2.26, 95% CI 1.16-4.40) but not the risk of sexual dysfunction (OR 0.74, 95% CI 0.27-1.99). The most distinct problem was dissatisfaction with own physical appearance.

CONCLUSIONS

Both bowel dysfunction and stoma dysfunction negatively, but differently, affect sexuality. After restorative surgery, bowel dysfunction was primarily associated with sexual dysfunction while poor stoma function after abdominoperineal excision was associated with sexual inactivity.

Pelvic Floor Dysfunction And Its Effect On Quality Of Sexual Life

INTRODUCTION

Pelvic floor disorders (PFD) are extremely common; 1 in 3 parous women will experience urinary incontinence, 1 in 2 will develop pelvic organ prolapse, whereas 1 in 10 experience fecal incontinence. PFD are often associated with a significant reduction in women's psychological, social, and sexual well-being.

AIM

To review the current literature on sexual dysfunction related to PFD.

METHODS

A literature search was conducted using PubMed and key words including sexual dysfunction, prolapse, incontinence, pelvic floor dysfunction, and surgical repair.

MAIN OUTCOME MEASURE

The outcome was to identify the nature and severity of sexual dysfunction in women with PFD.

RESULTS

The prevalence of sexual dysfunction is estimated to be around 30-50% in the general population, whereas in women with PFD, the reported incidence rises to 50-83%. The leading factors cited for the reduction in a woman's sexual experience included worries about the image of their vagina for women with pelvic organ prolapse, dyspareunia and coital incontinence in women with urinary incontinence, and fear of soiling when dealing with anal incontinence. Pelvic floor muscle training has been associated with an improvement in sexual function. 11% of parous women will have surgery for pelvic organ prolapse, yet limited data are available on the impact of surgical intervention on sexual function. Native tissue repair of pelvic organ prolapse is associated with an improvement in sexual function, whereas posterior repair with levatorplasty and vaginal mesh repair can increase the risk of postsurgical dyspareunia. Subtotal hysterectomy is not associated with improved sexual function compared with traditional total hysterectomy.

CONCLUSION

It is clear there is an urgent need for further research on the effects of surgery for PFD on sexual function. To date, most studies have focused on anatomic rather than functional outcomes. Verbeek M, Hayward L. Pelvic Floor Dysfunction and Its Effect on Quality of Sexual Life. Sex Med Rev 2019;7:559-564.

A review of the effect of faecal incontinence and constipation on sexual function

AIM

Faecal incontinence and constipation are common conditions which may adversely affect quality of life. They may have an adverse effect on sexual function.

METHOD

This review of the published literature aimed to assess the published evidence.

RESULTS

Only seven published studies have reported the effect of these conditions on sexual function. Four reported on those with faecal incontinence. Two reported on those with faecal incontinence and constipation and one reported solely on constipation. All were questionnaire-based studies or retrospective reviews of institutional databases. A heterogenous mix of different measures of sexual function were applied. Conflicting findings were reported. Some studies suggested that those with faecal incontinence and constipation may have adverse sexual experiences. Others suggest that these pelvic floor disorders have no significant effect.

CONCLUSION

Further work is needed to investigate this. Large questionnaire studies with normal subject controls and adjustment for confounding factors are likely to be needed.

Sacral neuromodulation and sexual function: a systematic review and meta-analysis of the literature

INTRODUCTION AND HYPOTHESIS

Sexual function is being increasingly recognized as an important patient-reported outcome. Sacral neuromodulation (SNM) is a treatment with an expanding list of indications. The effect of sacral neuromodulation on sexual function has been examined in a number of studies with variable results. In this review, we aim to systematically review the literature and pool the data if appropriate.

METHODS

The literature search was conducted primarily on the Healthcare Databases Advanced Search (HDAS) platform using the Medline, EMBASE and CINHAL search engines. Of 196 initial citations, 17 articles met our predefined inclusion criteria. Thirteen studies reported enough information to be included in our meta-analysis. RevMan5 software was used for analysis.

RESULTS

Eight of 17 studies reported a positive effect of SNM on sexual function. Pooled analysis of data from 11 studies involving 573 patients before SNM and 438 patients after SNM showed significant improvement in sexual function (SMD = -0.39; 95% CI: -0.58 to -0.19; p = 0.0001). The results remained significant in most subgroup analyses except in patients suffering from fecal incontinence.

CONCLUSIONS

SNM in women with pelvic floor disorders, especially bladder dysfunction, seems to have a positive effect on sexual function. This needs to be verified in adequately powered primary research using sexual function as the primary outcome.

Supervised pelvic floor muscle training versus attention-control massage treatment in patients with faecal incontinence: Statistical analysis plan for a randomised controlled trial

Introduction

Faecal incontinence affects approximately 8–9% of the adult population. The condition is surrounded by taboo; it can have a devastating impact on quality of life and lead to major limitations in daily life. Pelvic floor muscle training in combination with information and fibre supplements is recommended as first-line treatment for faecal incontinence. Despite this, the effect of pelvic floor muscle training for faecal incontinence is unclear. No previous trials have investigated the efficacy of supervised pelvic floor muscle training in combination with conservative treatment and compared this to an attention-control massage treatment including conservative treatment. The aim of this trial is to investigate if 16 weeks of supervised pelvic floor muscle training in combination with conservative treatment is superior to attention-control massage treatment and conservative treatment in patients with faecal incontinence.

Design

Randomised, controlled, superiority trial with two parallel arms.

Methods

100 participants with faecal incontinence will be randomised to either (1) individually supervised pelvic floor muscle training and conservative treatment or (2) attention-control massage treatment and conservative treatment. The primary outcome is participants' rating of symptom changes after 16 weeks of treatment using the Patient Global Impression of Improvement Scale. Secondary outcomes are the Vaizey Incontinence Score, the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, a 14-day bowel diary, anorectal manometry and rectal capacity measurements. Follow-up assessment at 36 months will be conducted.

Discussion

This paper describes and discusses the rationale, the methods and in particular the statistical analysis plan of this trial.

Long term effect of vaginal delivery and cesarean section on female sexual function in primipara mothers

Introduction

Pregnancy and birth giving are two of the most important and common effective factors influencing female sexual function. Sexual dysfunction can affect women’s quality of life and marriage. This research tried to determine the relation between labor type and long term sexual function in primipara women of Sabzevar, Iran.

Methods

This cross-sectional study took place in Sabzevar healthcare system in 2014. Study population was chosen by random sampling from every primipara woman who had delivered 2 years ago, in Sabzevar Hospitals. A total number of 177 primipara women were enrolled in this study after signing an informed contest. Sexual function of mothers was determined by validated Persian version of female sexual function index (FSFI). SPSS statistical software version 19 and descriptive and inferential statistics such as percentage, mean, standard deviation, Chi square, student t-test and fisher exact test were used to analyze data.

Results

Among the study population, 69.5% had natural vaginal delivery (NVD) and 30.5% had caesarean section (C/S). The overall FSFI score was not significantly different in women undergoing NVD or C/S (p=0.23). Also, no significant relation was found between delivery method and urinary (p=0.07) and fecal incontinency (p=0.6). Female sexual function was prominent in women with urinary (p=0.015) and fecal incontinency (p=0.018).

Conclusion

The results of present study showed that delivery method has no long-term effect on female sexual function and appropriate education about the sexual issues after delivery and effect of birth giving on sexual function are necessary for this group of society.

Fecal Incontinence: Epidemiology, Impact, and Treatment

Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. FI has a considerable psychosocial and financial impact on patients and their families. A variety of treatment modalities are available for FI including behavioral and dietary modifications, pharmacotherapy, pelvic floor physical therapy, bulking agents, anal sphincteroplasty, sacral nerve stimulation, artificial sphincters, magnetic sphincters, posterior anal sling, and colostomy.

Anal Intercourse and Fecal Incontinence: Evidence from the 2009-2010 National Health and Nutrition Examination Survey

OBJECTIVES

The aim of this study was to assess the prevalence and associations between anal intercourse and fecal incontinence.

METHODS

Analyses were based on data from 6,150 adults (≥20 years) from the 2009-2010 cycle of the National Health and Nutrition Examination Surveys. Fecal incontinence was defined as the loss of liquid, solid, or mucus stool occurring at least monthly on a validated questionnaire. A gender-specific sexual behavior questionnaire assessed any anal intercourse via an audio computer-assisted personal interview. Co-variables included: age, race, education, poverty income ratio, body mass index, chronic illnesses, depression, loose stool consistency (Bristol Stool Scale types 6 or 7), and reproductive variables in women. Prevalence estimates and prevalence odds ratios (PORs) were analyzed in adjusted multivariable models using appropriate sampling weights.

RESULTS

Overall, 4,170 adults aged 20-69 years (2,070 women and 2,100 men) completed sexual behavior questionnaires and responded to fecal incontinence questions. Anal intercourse was higher among women (37.3%) than men (4.5%), P<0.001. Fecal incontinence rates were higher among women (9.9 vs. 7.4%, P=0.05) and men (11.6 vs. 5.3%, P=0.03) reporting anal intercourse compared with those not reporting anal intercourse. After multivariable adjustment for other factors associated with fecal incontinence, anal intercourse remained a predictor of fecal incontinence among women (POR: 1.5; 95% confidence interval (CI): 1.0-2.0) and men (POR: 2.8; 95% CI: 1.6-5.0).

CONCLUSIONS

The findings support the assessment of anal intercourse as a factor contributing to fecal incontinence in adults, especially among men.

Impact of fecal incontinence and its treatment on quality of life in women

Fecal incontinence (FI) is a physically and psychosocially debilitating disorder which negatively impacts quality of life (QOL). It bears a significant burden not only on patients but also on their families, caretakers as well as society as a whole. Even though it is considered a somewhat common condition, especially as women age, the prevalence is often underestimated due to patients' reluctance to report symptoms or seek care. The evaluation and treatment of FI can be also hindered by lack of understanding of the current management options among healthcare providers and how they impact on QOL. This article provides a comprehensive review on the impact of FI and its treatment on QOL in women.

Faecal incontinence: a life-course approach

Faecal incontinence is under-reported and under-diagnosed. It is associated with negative social and psychological sequelae and reduced quality of life. Timely intervention potentially reduces its adverse impact throughout the life-course as most cases are potentially treatable. This review provides a summary of pre-disposing factors. It offers an overview of preventative and treatment options within the community setting, with signposting to further reading and a call to further research into this area of women's health.

Written versus oral disclosure of fecal and urinary incontinence in women with dual incontinence

INTRODUCTION AND HYPOTHESIS

To compare fecal incontinence (FI) and urinary incontinence (UI) disclosure in women with dual incontinence (DI), and to assess UI disclosure in DI subjects compared with women with UI alone. We hypothesized that women with DI would be less likely to disclose FI in comparison to UI and as likely to disclose UI as women with UI alone.

METHODS

We performed a retrospective chart review of new patient visits to an academic urogynecology clinic from 2007 to 2011. Clinical records were reviewed; demographic data and responses to the Incontinence Severity Index (ISI) and Wexner scales were recorded. Patients' written responses to the ISI and Wexner were compared with the diagnoses obtained from the oral history by the physician.

RESULTS

Of 1,899 women in the database, 557 women were diagnosed with DI and 447 women were diagnosed with UI alone. Women with DI were less likely to orally disclose FI than UI (135 out of 557 [23 %], vs 485 out of 557 [87 %], p < 0.001), but were as likely as women with UI alone to disclose UI (385 out of 447 [86 %] vs 485 out of 557 [87 %], p = 0.66). In the multivariate analysis, DI subjects had greater odds of disclosing FI to their physicians if they had private insurance (OR 1.9, 95 %CI 1.2, 3.0) or Wexner score >7 (OR 9.0, 95 % CI 5.4,14.8) and lower ISI score (OR 1.5, CI 1.4, 1.6).

CONCLUSIONS

Women with DI were less likely to report FI in comparison to UI. Patients were more likely to orally report FI when the symptoms were severe.

Anal incontinence and Quality of Life in late pregnancy: a cross-sectional study

OBJECTIVE

To evaluate the association between different types of anal incontinence (AI) and Quality of Life (QoL) in late pregnancy.

DESIGN

Cross-sectional study.

SETTING

Two maternity units in Norway 2009-2010.

POPULATION

Primiparae aged 18 or over.

METHODS

Participants answered questions about AI during the last 4 weeks of pregnancy on the St. Mark's score and impact of QoL in the Fecal Incontinence QoL score. Socioeconomic data were obtained from hospital records.

MAIN OUTCOME MEASURES

Self-reported AI and impact on QoL.

RESULTS

1571 primiparae responded; 573 (37%) had experienced AI during the last 4 weeks of pregnancy. One third of the incontinent women reported reduced QoL in the domain 'Coping'. 'Women experiencing urgency alone reported markedly better QoL compared to any other AI symptoms. AI appeared to have the strongest impact on the domains 'Coping' and 'Embarrassment'. Depression was only associated with experiencing the combination of all three symptoms [odds ratio (OR) 13; 95%confidence interval (CI) 3.2-51]. Experiencing flatus alone weekly or more was associated with the highest impact on 'Embarrassment' (OR 20; 95%CI 6.4-61) compared with all other symptoms or combination of AI symptoms, except the combination of all three AI symptoms.

CONCLUSIONS

Between 3 and 10% of the primiparae in this material experienced AI to such a extent that it affected QoL. The greatest impact was seen in the QoL domain 'Coping'. These findings highlight the importance of an increased awareness of AI in late pregnancy among health professionals and the need to implement routine discussions about AI with expectant and new mothers.

Childbirth and female sexual function later in life

OBJECTIVE

To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life.

METHODS

Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health.

RESULTS

Among 1,094 participants, mean (standard deviation) age was 56.3 (±8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83).

CONCLUSIONS

Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life.

LEVEL OF EVIDENCE

II.

The association between fecal incontinence and sexual activity and function in women attending a tertiary referral center

INTRODUCTION AND HYPOTHESIS

To determine whether fecal incontinence (FI) is associated with sexual activity and to compare sexual function in women with and without FI.

METHODS

We conducted a retrospective chart review of all new patients seen in an academic urogynecology clinic. Women who reported fecal incontinence, as defined by loss of fecal material on the Wexner scale, were compared with those without fecal incontinence. We compared sexual activity and Pelvic Organ Prolapse Incontinence Sexual Questionnaire-12 (PISQ-12) scores between groups.

RESULTS

In our population of women with pelvic floor disorder, 588 women reported FI compared with 527 who did not. On multivariate analysis, FI was not associated with sexual activity status, but was associated with worsened PISQ-12 scores (p < 0.001). PISQ-12 item analysis found that women with FI reported more dyspareunia, fear, and avoidance of sexual activity with greater partner problems (all p <0.05) than women without FI.

CONCLUSIONS

Women with FI were as likely to engage in sexual relations as women without FI; however, sexually active women with FI had poorer sexual function than those without FI.