Japanese women

ORIGINAL ARTICLE

Impact of overactive bladder and lower urinary tract symptoms on sexual health in Japanese women

Tomoko Sako &Miyabi Inoue &Toyohiko Watanabe &Ayano Ishii &Teruhiko Yokoyama &Hiromi Kumon

Received:8March 2010/Accepted:4August 2010/Published online:27August 2010#The International Urogynecological Association 2010

Abstract

Introduction and hypothesis This study aims to assess whether lower urinary tract symptoms (LUTS)affect sexual function in Japanese females.

Methods A multi-component questionnaire was mailed to 576female hospital workers.It contained the Female Sexual Function Index (FSFI)and a self-administered questionnaire pertaining to LUTS.

Results Of the 276responses (overall response rate,47.9%),146questionnaires were evaluable.LUTS had been experienced by 72(49.3%)of the respondents,17(11.6%)had urge urinary incontinence,and 35(24.0%)had stress urinary incontinence (SUI).The mean overall FSFI score was 22.4±9.0.The mean FSFI score was not significantly different between women with LUTS and women without LUTS (23.2±9.3and 21.6±8.8,respec-tively;P =0.057).However,the mean FSFI score of women with SUI was significantly lower than that of women without it (P =0.04).No other symptoms showed significant differences in FSFI scores.

Conclusions Our results suggest that sexual dysfunction is related to SUI.

Keywords Female sexual dysfunction (FSD).Female Sexual Function Index (FSFI).Lower urinary tract symptoms (LUTS).Stress urinary incontinence (SUI).

Female sexual arousal disorder (FSAD).Overactive bladder (OAB)

Introduction

The preferred terminology to describe a constellation of symptoms that may be caused by multiple pathologic conditions,such as detrusor overactivity,is lower urinary tract symptoms (LUTS).LUTS is a common health problem,not only in men,but also in women.An evaluation of urinary symptoms in a sample of Japanese patients (N =5,729)that compared men and women (age range,21to 83years)showed that the prevalence of urinary problems was similar in both sexes [1].Urinary problems deteriorate the quality of life of many women.Urinary incontinence has also been implicated to have an unfavor-able effect on female sexuality [2–7].Some studies have evaluated sexual function in women with LUTS and overactive bladder (OAB)[8–10],and some questionnaires exist to evaluate female sexual function [11];the FSFI is a questionnaire used worldwide to evaluate female sexual function [12].

Salonia et al.reported the FSFI score of 227women (mean age,52years;range,19–66years)in Italy who complained of urinary incontinence and/or LUTS and 102controls (mean age,54years;range,19–63years).They concluded that women reporting urinary incontinence or LUTS also complained of sexual dysfunction significantly more frequently than women in a general,healthy female population who did not complain of urinary symptoms [13].Sen et al.reported the FSFI score of 153incontinent Turkish women and 89controls.The mean age of subjects with urinary incontinence was 46.63±9.93years (range,26–81years)and that of control subjects was 45.34±

T.Sako :M.Inoue (*):T.Watanabe :A.Ishii :H.Kumon Department of Urology,Okayama University Hospital,2-5-1Shikatacho,

Okayama 700-8558,Japan e-mail:uromiya@https://www.wendangku.net/doc/e84752007.html,

T.Yokoyama

Department of Urology,Kawasaki Medical School Hospital,Matsushima Kurashiki,Okayama 701-0192,Japan

Int Urogynecol J (2011)22:165–169DOI 10.1007/s00192-010-1250-x

6.29years(range,32–64years),and the mean total FSFI score was20.48±6.20and22.97±6.95,respectively.The scores of all domains were significantly lower in inconti-nent women than in control subjects,and mixed urinary incontinence had a significant impact on sexual function when compared with other types of incontinence[14].

Other reports have indicated that every type of inconti-nence lowers the FSFI score[15].In the present study,the mean FSFI score of women with SUI was significantly lower than that of women without it,and there was a significant improvement in FSFI score after surgery to treat SUI[16–18].

However,in Japan,there is a paucity of epidemiological data regarding the incidence and prevalence of female sexual dysfunction.We assessed the effect of urinary incontinence and female LUTS on sexual activity and sexual quality of life in sexually active women in Japan. The objectives of this research were to describe the sexuality of women with and without female LUTS in Japan and to assess a relationship between female LUTS and sexual dysfunction.

Methods

A multi-component questionnaire was mailed to576women working in a hospital.It contained the Female Sexual Function Index(FSFI)[11]and a self-administered question-naire pertaining to LUTS[19].Female sexual function was evaluated with the FSFI.Women who agreed to participate in this study replied to a questionnaire and sent it back to us.

The FSFI is a validated and reliable measure of female sexual function[12].It has19questions that assess six domains of sexual function,including desire,arousal, lubrication,orgasm,satisfaction,and pain.Score ranges for items3–14and17–19are0–5,and for items1,2,15, and16are1–5.The composite score is determined by the sum of domains multiplied by the domain factor.The full-scale score range is from2to36,with higher scores associated with a lesser degree of sexual dysfunction[12].

The questionnaire pertaining to LUTS is a validated questionnaire that was developed by members of the Japan Neurogenic Bladder Society Committee,and it covered demographic characteristics and LUTS[19].The descrip-tions of the symptoms were consistent with International Continence Society terminology.Demographic character-istics collected were age,marital status,parity,menopausal status,and general health condition(very good,good,fair, bad,or very bad).Nine LUTS were assessed:daytime micturitions,nocturia,weak urine flow,sensation of residual urine,bladder pain,urinary urgency,urgency urinary incontinence,stress urinary incontinence,and use of incontinence pads[19].

Questionnaires that contained responses to all items were evaluated.Questionnaires with blanks were excluded from evaluation.

The LUTS group included those women who answered that they have a urinary symptom(urinary urgency,urgency urinary incontinence,or stress urinary incontinence)less than once per week.The group reporting no urinary symptoms was the control group.Differences in mean FSFI scores were compared between the LUTS group and the control group.

The Mann–Whitney U test was used for comparison of scores within the groups.Differences in the mean FSFI score among age groups were analyzed with a Kruskal–Wallis test. Statistical significance was considered as P<0.05for all statistical analyses.All analyses were performed with SPSS software(SPSS,Chicago,IL,USA).

Results

Of the576women who were sent questionnaires,276 responded(overall response rate,47.9%),and146of the respondents filled out the questionnaire adequately for proper evaluation.In this evaluable population,the mean age was32.2years(range,21–56years),62(42.5%)were married,82(56.2%)were single,2(1.4%)were divorced, and123(84.2%)had a sex partner.The mean FSFI score was22.4±9.0.By age group,the mean FSFI score was 23.9±8.2in women20–29years;21.4±9.3in women30–39years;19.8±10.3in women40–49years;and20.1±9.9 in women50–59years.There was no significant difference in the total mean score among age groups.The scores for each sexual function domain are shown in Table1.In each domain,a significant difference was observed among age groups in the score for desire,arousal,and lubrication (P<0.05).

The mean frequency of sexual activity was46.7±58.8 times per year(Fig.1).

Seventy-two(49.3%)of the respondents had experienced LUTS.Overall,27(18.5%)of the respondents had difficulty,24(16.4%)had an incomplete emptying feeling, 18(12.3%)had bladder pain,18(12.3%)had urgency,17 (11.6%)had urge urinary incontinence,and35(24.0%)had stress urinary incontinence(SUI).The mean age of subjects with LUTS was33.7±8.9years(range,23–56years)and the mean age of controls was30.7±8.5years(range,21–56years).Age was significantly higher in women with LUTS than without LUTS(P=0.04),and the mean age of subjects with SUI was significantly higher than those without SUI(P=0.001).

The mean FSFI score was23.2±9.3(range,2–35.4)in women with LUTS and21.6±8.8(range,2–36)in women without LUTS;there was no significant difference between

these groups (P =0.057)(Table 2).When FSFI scores were analyzed by symptoms,the FSFI score of women with SUI was significantly lower than that of women without it (P =0.04).With regard to domain scores in the group with SUI,there was a significant relationship with desire (P =0.034),arousal (P =0.001),and lubrication (P =0.001).However,there was no significant relationship with the other domains (Table 2).

No other symptoms showed significant differences in FSFI scores (Fig.2).

Discussion

Several studies have reported a correlation between sexual function and LUTS [8–10].In Asia,Kim et al.reported that sexual activity was reduced significantly in OAB and urinary incontinence versus an asymptomatic group [20].They investigated 3,372women (mean age,26.4±4.8years)enrolled via a multicenter internet survey.The prevalence of OAB syndrome and urinary incontinence was 12.7%and 21.0%,respectively,in their study.

There are few reports about female sexual function in Japanese women,and a correlation of female sexual function with LUTS in Japan had not been reported prior to this study.

In this study,sexual dysfunction was related to stress urinary incontinence in Japanese women.With regard to the scores of each domain in the group with SUI,there was a significant relationship with desire,arousal,and lubrication.The low score of FSFI in women with SUI may come from fear of incontinence during intercourse and embarrassment.Leakage during penetration is linked to SUI,and leakage during orgasm is also linked to urodynamic overactive detrusor function or mixed incontinence.The pathophsio-logic explanation of leakage during penetration is un-known;it could be caused by displacement of the bladder neck or anterior vaginal wall or by decreased tension in the pelvic floor muscle [21].Possibly,it is affected by other factors related with SUI.The mean age of subjects with SUI was significantly higher than that of those without SUI (P =0.001).Bang-Ping Jiann et al.reported that the age group of 50–67years had significantly lower mean scores in all domains than the groups of 20–34and 35–49years,and they had more problems in the areas of desire,arousal,and lubrication [22].In our study,there was no significant difference in the total mean score among age groups,but in each domain,a significant difference was observed among age groups in the score for desire,arousal,and lubrication.Thus,there may be a bias of background.It is necessary to assess and investigate both groups on the same background in the future.

Detrusor overactivity or OAB was reported to be more related to sexual problems than SUI [20,22],but we did not find a significant relationship between the FSFI score and urge urinary incontinence and LUTS in our study.This result may be caused by the small number of women with urgency and urge incontinence.In this study,we sent the questionnaires to 576women,but only 146

women

Fig.1Frequency of sexual activity in Japanese women

Table 1FSFI scores of Japanese women by sexual function domain Domains

Mean age group score ±SD P value

Mean total score ±SD

20–29years

30–39years 40–49years 50–59years Number of patients 78

34

25

9

146Desire 3.2±1.0 2.8±1.1 2.6±0.7 2.6±0.60.004* 3.0±1.0Arousal 3.7±1.6 3.1±1.7 2.9±1.9 2.6±1.50.011* 3.3±1.7Lubrication 4.6±1.9 4.1±2.2 3.6±2.4 3.8±2.20.022* 4.3±2.1Orgasm 3.6±1.8 3.2±1.9 3.2±2.3 3.3±2.20.361 3.4±1.9Satisfaction 4.3±1.5 3.9±1.5 3.8±1.4 3.7±1.60.061 4.1±1.5Pain 4.5±2.1 4.2±2.3 3.7±2.7 4.1±2.70.145 4.3±2.3Overall

23.9±8.2

21.4±9.3

19.8±10.3

20.1±9.9

0.166

22.4±9.0

*P <0.05(Kruskal –Wallis test)

answered completely.Most women answered the question of urinary symptoms but did not answer the question of sexual function.Japanese women are not willing to answer the questions of sexual function because they hesitate to talk about their sexual life to other persons and they want to make it a secret (especially in older women than young women).Furthermore,questionnaire respondents were healthy women working in a hospital.They were young women with few urinary symptoms (SUI or LUTS).Even if they had symptoms,their symptoms were comparatively moderate and slight.The LUTS group included women who answered that they had a urinary symptom (urinary urgency,urgency urinary incontinence,or stress urinary incontinence)less than once per week.There were few

women who reported having urinary symptoms more than once per week.A limitation of this study is that the sample was not put together under our strict inclusion and exclusion criteria.We could not investigate the correlation between sexual function and the severity of LUTS.We should assess and evaluate the sexual function of patients with severe LUTS in the future.

When Rosen et al.first presented the FSFI,they assessed the sexual function of women in the USA.In their report,they compared the female sexual arousal disorder group (FSAD group;N =128)with a control group (N =131).The mean ages of the FSAD group and the control group were 40.5±12.98years (range,21–69years)and 39.7±13.15years (range,21–68years),respectively.The total FSFI score was 19.2±6.63in the FSAD group and 30.5±5.29in the control group [12].

Our study also demonstrates lower FSFI scores in Japanese women compared with women in Turkey (27.29)and in the USA [23].

The FSFI score in Japan was close to that in Italy (23.6),but the mean age of the control group in Italy was higher than in other studies [13].

The reason why Japanese women ’s sexual functions at all ages are low is uncertain.One possibility is that Japanese women may not attach importance to their sex life.Actually,few females with sexual dysfunction consult a physician at a hospital.In addition,talking about sex is very shameful for a woman and is thought to be a taboo in Japan.However,it seems that research on female sexual dysfunction is necessary,and the number of women diagnosed with female sexual dysfunction is likely to increase in Japan in the future.

Sexual dysfunction is a distressing problem in women with SUI.Nevertheless,it has received little attention,which may result from the shame of the women afflicted with SUI.We should pay more attention to this problem in Japan.Its assessment and management,as part of a routine evaluation,should be considered in women presenting with urinary

symptoms.

Fig.2Relationship between FSFI score and LUTS

LUTS (+)

LUTS (?)P value

SUI (+)SUI (?)P value

Number of patients 72

74

35

111

Age 33.7±8.930.7±8.50.040*38.7±9.230.1±7.70.001*Desire 3.0±1.0 3.0±1.00.597 2.7±1.1 3.1±1.00.034*Arousal 3.1±1.7 3.5±1.70.072 2.5±1.7 3.6±1.70.001*Lubrication 4.1±2.1 4.5±2.10.110 3.4±2.2 4.6±2.00.001*Orgasm 3.3±1.9 3.6±2.00.243 3.0±2.0 3.6±1.90.133Satisfaction 4.0±1.5 4.2±1.50.279 4.0±1.2 4.1±1.50.559Pain 4.1±2.3 4.4±2.20.435 3.7±2.6 4.5±2.10.146Overall

21.6±8.8

23.2±9.3

0.05719.4±8.7

23.3±8.9

0.004*

Table 2FSFI scores of women with and without LUTS and with and without SUI

*P <0.05(Mann-Whitney U analysis)

Conclusion

This is the first study in Japan to investigate the relationship between female sexual function and LUTS.Our results suggest that sexual dysfunction is related to SUI.Sexual dysfunction may be a prevalent and distressing problem in Japanese women with urinary incontinence,affecting sexual quality of life.Sexual and urinary dysfunction should be evaluated routinely,and we should care for female sexual dysfunction in the same way as we care for urinary dysfunction.

Conflicts of interest None.

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