Quality of life of Brazilian women with urinary incontinence and the impact on their sexual function

Quality

of

life

of

Brazilian

women

with

urinary

incontinence

and

the

impact

on

their

sexual

function

Sara

A.L.

Karbage

*,

Ze´lia

M.S.A.

Santos

,

Mirna

A.

Frota

,

Heber

J.

de

Moura

,

Camila

T.M.

Vasconcelos

,

Jose´ Ananias

Vasconcelos

Neto

,

Leonardo

R.P.S.

Bezerra

a_{Master’sinPublicHealth,UniversidadedeFortaleza(UNIFOR),Fortaleza,Ceara´,Brazil} b_{Master’sinAdministration,UniversidadedeFortaleza(UNIFOR),Fortaleza,Ceara´,Brazil} c_{NurseDepartment,UniversidadeFederaldoCeara´ (UFC),Fortaleza,Ceara´,Brazil} d_{UrogynecologyDepartment,UniversidadeFederaldoCeara´ (UFC),Fortaleza,Ceara´,Brazil} e_{UrogynecologyDepartment,HospitalGeraldeFortaleza,Brazil}

Introduction

The International Continence Society (ICS) defines urinary incontinence(UI)asacomplaintofanyinvoluntarylossofurine.UI isconsideredapublichealthproblemandaffectsthequalityoflife (QoL)ofthousandsofwomen[1,2].Otherpelvicfloordysfunctions (PFD),suchasanal incontinence(AI)and pelvicorganprolapse (POP),areusuallyassociatedwithUIcanadverselyaffectwomen’s QoL [3]. These debilitating conditions interfere with social wellbeing,psychological,occupationalanddomesticaspectsand arealsorelatedtosexualcomplaints[4].

According to the World Health Organization, female sexual dysfunction(FSD)isdefinedasaninabilitytoderivesatisfaction from the sexual act [5]. Up to 64% of sexually active women attendinganurogynecologyclinicsufferfromFSD[6].Theymaybe athigherriskofsexualcomplaintsformultiplesociodemographic reasons, advanced age and the presence of PFD [6]. Older publicationsexamining therelationship between FSDand PFD, aswellastheeffectsofitstreatment,havebeenlimitedbytheuse ofnonvalidatedandnon-condition-specificquestionnairesornot controlling for confounding variables including age and meno-pausalstatus[3].

We decided to investigate the impact of sociodemographic characteristicsinthesexualfunctionofBrazilianwomenwithUI. Firstwecomparedsociodemographiccharacteristicsinwomenwith UIwithandwithoutsexualactivity.Finally,weevaluatedsexual functionusingthePortugueseversionofshortformPelvicOrgan

ARTICLE INFO

Articlehistory:

Received13January2015

Receivedinrevisedform12January2016 Accepted17March2016

Keywords:

Urinaryincontinence Qualityoflife Sexualdysfunction Publichealth

ABSTRACT

Introductionandobjective:Sexualfunctionmaybeaffectedinwomenwithurinaryincontinence(UI),but dataregardingthisassociationarecontroversial.Theaimofthisstudywastoassesstheimpactof sociodemographiccharacteristicsinthesexualfunctionofBrazilianwomenwithUI.

Study design: Cross-sectional study with 251 women with UI in the period from April to June 2014.Firstly,sociodemographicand pelvicfloordysfunctions(PFD) characteristicswerecompared betweengroupsofwomenwithandwithoutsexualactivity.Secondly,wecomparedthevariablesabove withthetotalscoreofPelvicOrganProlapseand/orUrinaryIncontinenceSexualQuestionnaire (PISQ-12).Forcontinuous variables,we used theMann–Whitney or Kruskal–Wallistest; forcategorical variablesweusedthechi-squarestatisticconsideringthedifferenceofp< 0.05.

Results:Womenwithsexualactivitytendtobeyounger,tobepremenopausal,haveasteadypartnerand notbehypertensive.ThemeantotalscoreofPISQ-12was27.30.Womenwhoattendedelementary school,with coital UI, with moderate constipation and symptomatic prolapse have worse sexual function.Premenopausalwomenwithmixedurinaryincontinencehaveworsesexualfunctionthan thosewithstressurinaryincontinence.

Conclusion:TheassociationbetweensexualdysfunctionandUIdeservesspecialattentionfromhealth professionals.Thecareofthemaintenanceorrestorationofsexualwell-beingshouldbeofferedtoall women,regardlessofage,sinceUImayaffectsexuallifeandQoLofthesewomen.

ß2016ElsevierIrelandLtd.Allrightsreserved.

* Correspondingauthorat:RuaCe´sarFonseca,540apto501,Coco´,60192-260 Fortaleza,Ceara´,Brazil.Tel.:+558587789119.

E-mailaddress:sara_arcanjo@hotmail.com(SaraA.L.Karbage).

ContentslistsavailableatScienceDirect

European

Journal

of

Obstetrics

&

Gynecology

and

Reproductive

Biology

j o urn a l hom e pa ge : ww w. e l s e v i e r. c om/ l o ca t e / e j ogr b

http://dx.doi.org/10.1016/j.ejogrb.2016.03.025

Prolapse/UrinaryIncontinenceSexual Questionnaire (PISQ-12)in sexuallyactivewomen.

Materialsandmethods

Thiswasacross-sectionalstudyconductedinUrogynecology departments oftwo tertiary hospitalsin Fortaleza-Ceara´-Brazil, fromApril toJune 2014. The studywas approvedby thelocal ethical committee, and all participants gave informed consent beforeenrollmenttothestudy.

All womenwith complaintsof UI evaluated in this period were invited toparticipate in theresearch. Initially a total of 361 patients were found to be eligible for the study, but 54womendidnotreturntofillintheQoLquestionnaires.The POPquantificationsystemapprovedbyICSwasused toassess the degree of prolapse in each patient [2]. Then, 56 of the participantswereexcludedforhavingPOPgrade3or4,dueto their possible confounding QoL effects. Finally our sample consistedof251womenwithUI.

After providing a medical history and undergoing a general physicalexamination,allthepatientsunderwentathoroughpelvic examination and urodynamic assessment in the lithotomy position.Demographicinformation includedage,maritalstatus, schooling, income, social class, occupation, body mass index, medicalcomorbidities,medications,smoking,menopausalstatus, parity,weighofnewbornandsexualactivity.

Incontinencewasdividedintothreesubcategories,accordingto ICS terminology [2]: stress urinary incontinence (SUI), mixed urinary incontinence (MUI) and overactive bladder syndrome (OAB).SUIwasthecomplaintofinvoluntaryleakagewitheffort, exertion,sneezingorcoughing.OABwasdefinedascomplaintsof urgencyassociatedwithincontinence,frequencyornocturia,and MUIwasaninvoluntaryleakageassociatedwithurgencyandwith effort. Coital incontinence was defined when UI occurs during sexualintercourse.

Fecal incontinence was assessed with the Wexner Fecal Incontinence Scale (FIS), which records both type (gas, mucus, liquid, solid stool) and frequency of anal incontinence (AI) symptoms. Scores range from 0 to 12, with higher scores representingmoresevereAI[7,8].Constipationwasclassifiedas mild, moderate or severe according toCleveland Clinic Florida ConstipationScale[9].

Allsexuallyactivewomenduringthepast sixmonthswere asked to answer the Portuguese version of Pelvic Organ Prolapse/UrinaryIncontinenceSexual Questionnaire (PISQ-12). Privacyandconfidentialitywereassuredduringthestudy.The PISQ-12 is a self administered, validated, condition-specific, sexual health questionnaire that evaluates sexual function in womenwithUIand/orPOP[4,13].Thequestionnaireevaluates 3maindomains:emotive/behavioral(questions 1–4),physical (questions 5–9), and partner-related (questions 10–12). Responses are graded on a 5-point Likert scale from ‘‘never’’ to‘‘always’’.Eachquestionisscoredfrom0to4,foramaximum total score of 48, where higher scores indicate better sexual function. Participantsshould answer at least 10 questions for thetotalscorecalculation.

Data management and statistical analyses were performed using SPSS, version 20.0 (SPSS Inc., Chicago, IL, USA). Firstly, demographic and QoL comparisons between women with and without sexual activity were made. Then, response rates and demographicinformationwerecomparedwiththetotalscoreof PISQ-12insexuallyactivewomen.Forcontinuousvariables,we used Mann–Whitney or Kruskal–Wallis tests for two or more groups.Chi-squaretestwasusedtocomparecategoricalvariables, andSpearmantestwasusedtonumericalvariables,considering statisticaldifferenceofp<0.05.

Results

Thefirstpartconsistsofthecomparisonofsocialcharacteristics ofwomenwithandwithoutsexualactivity.InTable1,wefound thatthevariablesage,maritalstatus,hypertension,diabetesand menopausal status had statistical association between the two groupsofwomen(withorwithoutsexualactivity).

Most sexually active women with UIwere married(73.0%), werepre-menopausal(68.6%),werenothypertensive(73.8%)and were not diabetic (91.5%). Women with partner had 5.4 more chancestohavesexualactivitythanwomenwithoutpartner. Pre-menopausal women withUI had 12.62 more chances to have sexual activity than post-menopausal ones. Women without hypertension and without diabetes had 3.41 and 2.45 more chances to havesexual activitythan hypertensive and diabetic ones,respectively.

Table 2 contains PFD characteristics of women withUI and showsthatstageofPOP,AIandconstipationscores,typeofUIand urodynamic data do not seem to interfere with their sexual activity.

Thesecondpartconsistsoftheevaluationofsexualfunctionof women withUI using PISQ-12. From 176 women with sexual activity,161(91.4%)respondedcorrectlytheinstrument(atleast 10questions).Theaveragetotalscorewas27.308.67(range5– 47), and the average of each domain was as follow: emotive/ behavioral–8.754.39(0–16),physical–11.055.15(0–20),and partner-related–7.492.43(0–12).

Amongsexuallyactivewomen,48.3% referredcoital inconti-nence:68.3%withpenetration,27.0%withorgasm,and4.7%with both situations. Approximately 58% of respondent women answered that the fear of leakage interferes negatively during thesexualintercoursesometimes,usuallyoralways(question7). The first three questions of PISQ-12 also reveal that 23.3% of womenwithUIhavedesiredysfunction(seldomornever),35.2% have orgasm dysfunction (seldom or never), and 32.1% have arousaldysfunction(seldomornever).

There was statistical association between the variables schooling,coitalincontinence,constipationandsymptomofPOP withthetotalscoreofPISQ-12(Table3).Lowereducationallevelis associated with worse sexual function. Women with coital incontinence have worse sexualfunction than women without coital incontinence. Women with moderate constipation have worse sexual function than women with mild constipation. WomenwithsymptomaticPOPhaveworsesexualfunctionthan womenwithasymptomaticPOP.

TherewasnodifferenceinthetotalscoreofPISQ-12inwomen withSUI(28.849.03),MUI(26.329.03)orOAB(33.507.77). WomenwithMUIhadthelowestscore,butthisdifferencewasnot statistically significant (p=0.101). Similarly, urodynamic findings werenotstatisticallyassociatedwithPISQ-12scores.

However, evaluating separately pre and post-menopausal women, there was a difference in the total score of PISQ-12 betweenwomenwithSUIandMUIinthepre-menopausalgroup (p=0.004). Among pre-menopausal women, those with MUI (25.927.85) have worse sexual function than those with SUI (30.858.48). Among post-menopausal women, there were no differenceinthetotalscoreofPISQ-12betweenwomenwithMUI (26.2510.01)orSUI(25.658.47),p=0.821.

Comments

The association between sexual activity and maritalstatus was corroborated by Fashokun et al.[14]. Intheir study, the mostcommonreasoncitedforsexualinactivity givenbyboth cohorts (women with and without PFD) was the lack of a

partner; only six participants (<1%) with PFD reported their

bladder, bowel,or vaginal problems were a reason for sexual inactivity. Evaluating women from a private urogynecology practice, Pauls et al. detected that advanced age, menopause,

Table1

Comparisonofsocialcharacteristicsofwomenwithurinaryincontinencewithandwithoutsexualactivity.Fortaleza-Ceara´-Brazil,2014.n=251.

Socialcharacteristics Withsexualactivity(176/70.1%) Withoutsexualactivity(75/29.9%) p

Age(years),Mda

SDb _47.07

8.47 58.5210.47 0.000*

Yearsofstudy,Mda

SDb _7.13

4.23 6.994.30 0.813*

Income,Mda

SDb _1199.05

866.96 1116.90988.99 0.076*

Maritalstatus,n(%) 0.000**

Single,divorcedorwidowed 47(27.0) 50(66.7)

Married 127(73.0) 25(33.3)

Socialclass,n(%) 0.140**

A – –

B 25(14.5) 09(12.0)

C 98(57.0) 35(46.7)

D 48(27.9) 30(40.0)

E 01(0.6) 01(1.3)

BMIc_,Mda

SDb _29.05

4.72 28.754.89 0.208*

Numberofpregnancies,Mda

SDb _4.04

2.48 4.873.37 0.145*

Numberofbirths,Mda

SDb _3.47

2.19 4.093.04 0.240*

Numberofvaginaldeliveries,Mda

SDb _2.88

2.26 3.563.12 0.619*

Numberofcesareansections,Mda

SDb _0.47

0.71 0.350.58 0.319*

Weighofnewborn(g),Mda

SDb _3857.47

703.89 3720.85743.76 0.306*

Smoking,n(%) 0.072**

Never 97(60.2) 38(52.1)

Past 46(28.6) 31(42.5)

Present 18(11.2) 04(5.5)

Hypertension,n(%) 0.000**

Yes 43(26.2) 41(54.7)

No 121(73.8) 34(45.3)

Diabetes,n(%) 0.024**

Yes 14(8.5) 14(18.7)

No 150(91.5) 61(81.3)

Obesity,n(%) 0.368**

Yes 55(33.5) 20(26.7)

No 109(66.5) 55(73.3)

Menopausalstatus,n(%) 0.000**

Pre 107(68.6) 11(14.9)

Post 49(31.4) 63(85.1)

* _{Mann–Whitneytest.}

** _{Chi-squaretest.}

a_Median.

b _{Standarddeviation.}

c_{Bodymassindex.}

Table2

ComparisonofPFDcharacteristicsofwomenwithurinaryincontinencewithandwithoutsexualactivity.Fortaleza-Ceara´-Brazil,2014.n=251.

PFDa_{characteristics Withsexualactivity(176/70.1%) Withoutsexualactivity(75/29.9%) p}

StageofPOPb_,Mdc

SDd _1.68

0.62 1.590.70 0.360*

AIe_score,Mdc

SDd _1.21

2.34 1.492.86 0.799*

Constipationscore,Mdc

SDd _4.18

6.72 4.906.92 0.279*

TypeofUI,n(%) 0.361**

SUIf _{64(36.8) 23(29.9)}

MUIg _{107(61.5) 49(63.6)}

OABh _{03(1.7) 05(6.5)}

DOi_{(urodynamic),n(%) 0.867}**

Yes 16(11.7) 08(12.5)

No 121(88.3) 56(87.5)

VLPPj_{(urodynamic),Md}c

SDd _75.83

41.29 73.0149.26 0.435*

* _{Mann–Whitneytest.}

** _{Chi-squaretest.}

a_{Pelvicfloordysfunctions.}

b _{Pelvicorganprolapse.}

c_Median.

d _{Standarddeviation.}

e_{Analincontinence.}

f _{Stressurinaryincontinence.}

g _{Mixedurinaryincontinence.}

h_{Overactivebladdersyndrome.}

unmarried status, and presence of hypertension were signifi-cantlyassociatedwithsexual inactivity[6].

Olderageandpostmenopausalstatus,commoninwomenwith PFD,arealsoassociatedwithsexualdysfunction[3].Fashokunetal. found that the strongest predictor of both sexual activity and functionwasage[14].Similarly,RibeiroandRaimundoobserved thatsexualinactivitymaybemoreassociatedtoagethantoUI[15]. Thepercentageofsexuallyactivewomeninthisstudy(70.1%) wassimilartotheonefoundbyO¨ zeletal.(60.7%)[16].Fashokun etal.foundnodifferenceintheratesofsexualactivitybetween womenwithandwithoutPFD(75.0%61.6%)aftercontrolledfor age[14].

Thisstudyhasshownthatgeneral QoLofwomenwithUIis affected, especially in sexually inactive women. Jha et al. demonstratedthat overallQoL in womenwithUIwasstrongly correlatedtotheimpactofurinarysymptomsonsexlife[17].Other studyevaluatedwomenwithandwithoutUIandidentifiedworse generalQoLandworsesexualfunctioninincontinentwomen[18]. The average of the total score of PISQ-12 in our study (27.38.7)wassimilartotheonethatvalidatedthequestionnaire toPortuguese(27.89.3)[4].TurkishwomenwithPFDhadatotal scoreof23.68.4[19].ThereisnocutoffinthescoreofPISQ-12to classifywomenaccordingtotheirsexualfunction.However,these scoresarelowerthantheonesfoundinwomenwithoutPFD,which hadtheaverageof40andcouldpossiblybeconsideredavalueof normality[20].

ThisstudyalsodemonstratesthatUIin womenisassociated withlowsexualarousalandinfrequentorgasm.Handaetal.found similarresultsandconcludedthatincreasingage,loweducational attainmentandmenopausewereassociatedwithinfrequentsexual desire,decreasedsexualarousal,andinfrequentorgasm[21].

Theprevalenceofcoitalincontinenceinoursampleofwomen (48.3%)wassimilartotheonefoundbyRogersetal.(45%)[22].On theotherhand,theprevalencewas60%and66%in thestudies ofJhaetal.andElAzabetal.,respectively[17,23].Themodeof administrationofthequestionnairemayinfluenceintheserates, sincewomencanbetooembarrassedquestioningfacetoface,and prevalence is underestimated. In this case, self-administration orelectronicquestionnaireswouldbepreferable[17,21].Despite therealprevalence,womenwithcoitalincontinencehaveworse sexualfunction.

AmongwomenwithPOPstagesIandII,approximatelyhealth ofthemweresymptomatic,whatrevealedtobeassociatedwith

lowerscoresofPISQ-12,whichis worsesexualfunction.Handa et al.alsofoundthat thephysicalpresenceof stageIIprolapse alonewasnotassociatedwithsexualdysfunction[21].Incontrast, womenwithprolapsesymptomsweremuchmorelikelytoreport sexualcomplaints.

Urodynamic findingsarenotgoodpredictorstoevaluatethe impactofUIinsexualfunctionofwomen.Jhaetal.alsodispelsthe belieftraditionallyheldinrelationtocoitalincontinenceandfound that urodynamic diagnosis is not linked to underlying sexual problems[17].OurstudyconsideredclinicaldiagnosticofUI,not urodynamicfindings.

The results of the studies that compare sexual function of womenaccordingtotheirtypeofUIareconflicting.Coksueretal. observedthatpre-menopausalwomenwithurodynamicMUIhad lowermeanPISQ-12scores[24].Ontheotherhand,Asogluetal. foundlowerscoresinwomenwithSUI[25].Wefounddifferencein thesexualfunctionbetweenwomenwithSUIandMUIonlyinthe pre-menopausalgroup,whichrepresentwomenwithmoresexual activity.

Conclusion

Olderandpost-menopausalwomenwithurinaryincontinence, withhypertensionanddiabeteshavelesssexualactivity;andthe presence of coital incontinence, constipation and symptomatic pelvicorganprolapseworsentheirsexualfunction.

The qualityof thestudiesvariessignificantly, andnearly all studies exclude women who are not sexually active. Sexual functionisanimportantdimension ofnormaladultlifeandyet very little is known about the relationships between female sexualityandchronichealthconditions,includingPFD. Further-more,FSDmustbeevaluatedinthecontextofage,maritalstatus, and general health status of the woman. The care of the maintenanceorrestorationofsexualwell-beingshouldbeoffered toallwomen,regardlessofage,sinceUImayaffectsexuallifeand QoLofthesewomen.

References

[1]AbramsP,CardozoL,FallM,etal.Thestandardisationofterminologyoflower urinarytractfunction:reportfromtheStandardisationSub-committeeofthe InternationalContinenceSociety.NeurourolUrodyn2002;21:137–78. [2]HaylenBT,RidderD,FreemanRM,etal.AnInternationalUrogynecological

Association(IUGA)/InternationalContinenceSociety(ICS)jointreportonthe terminologyforfemalepelvicfloordysfunction.NeurourolUrodyn2010;29: 4–20.

[3]Kammerer-DoakD.Assessmentofsexualfunctioninwomenwithpelvicfloor dysfunction.IntUrogynecolJ2009;20(Suppl.1):S45–50.

[4]SantanaGWRM,AokiT,AugeAPF.Assessmentofsexualfunctioninwomen withandwithouturinaryincontinenceandpelvicorganprolapse,usingthe PortugueseversionofthePISQ-12questionnaire.IntJMedMedSci2012;2(1): 59–62.

[5]AbdoCHN,OliveiraJrWM,MoreiraED,FittipaldiJAS.Perfilsexualda popu-lac¸a˜obrasileira:resultadosdoEstudodoComportamentoSexual(ECOS)do Brasileiro.RevBrasMed2002;59(4):250–7.

[6]Pauls RN,Segal JL,Silva WA,Kleeman SD,KarramMM. Sexualfunction in patients presenting to aurogynecology practice. Int Urogynecol J 2006;17:576–80.

[7]JorgeJM,WexnerSD.Etiologyandmanagementoffecalincontinence.Dis ColonRectum1993;36:77–97.

[8]RockwoodT,ChurchJ,FleshmanJW,etal.Patientandsurgeonrankingofthe severityofsymptomsassociatedwithfecalincontinence:thefecal inconti-nenceseverityindex.DisColonRectum1999;42:1525–31.

[9]AgachanF,ChenT,PfeifferJ,ReissmanP,WexnerSD.Aconstipationscoring systemtosimplifyevaluationandmanagementofconstipatedpatients.Dis ColonRectum1996;39:681–5.

[13]RogersRG,CoatesKW,Kammerer-DoakD,KhalsaS,QuallsC.Ashortformof thePelvicOrganProlapse/UrinaryIncontinenceSexualQuestionnaire (PISQ-12).IntUrogynecolJ2003;14:164–8.

[14] FashokunTBO,HarvieHS,SchimpfMO,etal.Sexualactivityandfunctionin womenwithandwithoutpelvicfloordisorders.IntUrogynecolJ2013;24: 91–7.

[15]RibeiroJP,RaimundoA.Satisfac¸a˜osexualepercepc¸a˜odesau´deemmulheres comincontineˆnciaurina´ria.Ana´lisePsicolo´gica2005;3(XXIII):305–14. Table3

TotalscoreofPISQ-12insexuallyactivewomen accordingtotheirsocialand clinicalcharacteristics.Fortaleza-Ceara´-Brazil,2014.n=161.

Socialandclinicalcharacteristics PISQ-12 Mda

SDb

p

Schooling Analfabeta 24.945.87 0.015**

EnsinoFundamental in

completo

25.279.71

EnsinoFundamental completo

26.048.57a

EnsinoMe´dio 31.227.93b EnsinoSuperior 31.505.97

Coitalincontinence Yes 25.428.44 0.001*

No 30.298.37

Constipation Mild 32.316.24c 0.025**

Moderate 25.419.27d

Severe 22.607.02

SymptomaticPOP Yes 25.488.45 0.003*

No 29.798.65

* _{Mann–Whitneytest.}

** _{Kruskal–Wallistest.a < b;c > d.}

a _Median.

[16]O¨ zelB,WhiteT,Urwitz-LaneR,MinagliaS.Theimpactofpelvicorganprolapse onsexualfunctioninwomenwithurinaryincontinence.IntUrogynecolJ 2005;17:14–7.

[17]JhaS,StrelleyK,RadleyS.Incontinenceduringintercourse:mythsunravelled. IntUrogynecolJ2012;23:633–7.

[18]Faria K,PedrosaLAK.Avaliac¸a˜odaqualidadedevidaefunc¸a˜osexualde mulheres com e sem incontineˆncia urina´ria. Rev Eletr Enf 2012;14(2): 366–73.

[19]CamC,SancakP,KarahanN,SancakA,CelikC,KaratekeA.Validationofthe shortformofthePelvicOrganProlapse/UrinaryIncontinenceSexual Ques-tionnaire(PISQ-12)inaTurkishpopulation.EurJObstetGynecolReprodBiol 2009;146:104–7.

[20]AschkenziSO,BotrosSM,BeaumontJ,MillerJJ,GambleT,SandPK.Useofthe ShortPelvicOrganProlapse/UrinaryIncontinenceSexualQuestionnairefor

FemaleSexualDysfunctioninageneralpopulation.ObstetGynecol2008;111: 4S–10S.

[21]HandaVL,CundiffG,ChangHH,HelzlsouerKJ.Femalesexualfunctionand pelvicfloordisorders.ObstetGynecol2008;111(5):1045–52.

[22]RogersGR,VillarrealA,Kammerer-DoakD,QuallsC.Sexualfunctioninwomen withand withouturinaryincontinence and/orpelvic organprolapse.Int UrogynecolJ2001;12(6):361–5.

[23]ElAzabAS,YousefHA,SeifeldeinGS.Coitalincontinence:relationtodetrusor overactivityandstressincontinence.NeurourolUrodyn2011;30(4):520–4. [24]CoksuerH,ErcanCM,Halilog˘luB,etal.Doesurinaryincontinencesubtypes