Female Sexual Dysfunction and Lower Urinary Tract Symptoms – What Urologists must know
Alexandre Fornari, Paulo Roberto Sogari
Urology Department, Mãe de Deus Hospital - Porto Alegre, Brazil
It is generally known that at least 30% to 50% of American women present some symptom of sexual dysfunction, and that these numbers rise with age . Other factors that cause a significant increase in the rate of sexual dysfunction are those related to symptoms of diseases affecting the lower urinary tract. In this sense, the main ones are overactive bladder (OB), urinary incontinence and pelvic prolapse, besides hormone deficiencies.
There is some controversy concerning overactive bladder. In a review published by Salonia et al , the diagnosis of OB negatively affects the quality of life and sexual function of women. Patel et al  did not verify this in the study. However, it is known that the quality of life of people who have an OB is significantly affected at different levels, and it is quite likely that sexual function is also affected. In clinical practice it is perceived that the possibility of urinary incontinence during sexual intercourse, often associated with OB, worries women with this problem, at the same time as they fear intercourse and feel ashamed in the relationship with their partner. In addition, 70% of the female patients with OB do not undergo any treatment  showing the potential extent of compromised sexual function in women with this pathology.
Concerning effort-related urinary incontinence, Hilton  showed that one in every four women assessed at an urogynecology clinic have a sexual dysfunction (SD) caused by urinary incontinence. In an elegant review by Barber et al.  there was a greater incidence of sexual dysfunction in women who were incontinent or had lower urinary tract symptoms (LUTS), compared to the general population, and it is necessary to assess sexual function in this group of patients. However, besides the already extensively demonstrated association between LUTS and SD, a cause/effect relationship was suggested. In a study by Moller et al , it was shown that SD might increase the occurrence of LUTS in women with this problem, while increased sexual activity may reduce the occurrence of LUTS. This is possibly related to exercise or inactivity of the pelvic floor muscles. Another significant factor compromising the sexual function as regards lower urinary tract symptoms is the presence of chronic pelvic pain. In a recent study by Nickel et al. , patients with chronic pelvic pain presented a significantly compromised quality of life and sexual function.
Childbirth, whether cesarean or normal delivery, widely discussed in the lay literature regarding sexual function, should also be considered. As to the development of stress urinary incontinence and pelvic prolapse, vaginal delivery appears to be an additional risk factor . However, this positive effect of cesarean section does not appear to be reflected in sexual function, despite the scarce evidence available. In a review published by Weber , the indices of return to sexual function after 3 months, dyspareunia and satisfaction at sexual activity were similar among the patients who underwent cesarean section or normal delivery.
Hormonal factors appear to be related to estrogen and testosterone deficiency that appear after menopause, especially when it is a consequence of surgical procedures (bilateral oophorectomy). This deficiency, leading to atrophy and dryness of the vaginal mucosa, may produce symptoms of the lower urinary tract. Testosterone plays a major role in sexual desire, in the feeling of general well being and fatigue, emotional changes and sleep disorders, and its deficiency is associated with a reduction in sexual activity. In a recent review  it was found that testosterone replacement, when appropriate, confers a significant improvement of all aspects of sex life studied.
Thus, there is a close, probably multifactorial relationship between DS and LUTS, with several different pathophysiological mechanisms interacting simultaneously. Further knowledge concerning this interaction provides a promising horizon in terms of conjugated treatments and improved quality of life for these patients.
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