The Impact of Urinary Incontinence on Sexual Health in Older Adults.

“Therefore my age is as a lusty winter, frosty but kindly.” In William Shakespeare's comedy about romantic love, As You Like It (Act II, Scene 3), Adam, the elderly manservant, speaks these lines as he contemplates his aging and tries to underscore that his spirit and abilities remain robust. These words ring true today as many people hope for a similar fate with their own journey through the aging process. For many older adults, maintaining a satisfying level of sexual activity is an important part of sustaining a high quality of life. Clinical research and practice have clearly demonstrated that, although a person may be elderly, it does not mean that they are necessarily asexual. In fact, studies of residents in long-term care facilities have revealed that many of these individuals remain interested in sex and that some remain sexually active in this environment.

The availability of a regular partner certainly influences the degree to which elderly individuals remain sexually active. Many older adults want to continue to experience the full range of sexual activities they enjoyed in younger years for as long as possible, but forms of sexual expression may also change with advancing age. For some older adults, masturbation may become a primary sexual outlet. In many cases, the simple acts of touch and physical intimacy may supplant penetrative sexual intercourse as highly meaningful and satisfying forms of sexual expression.

Many factors can negatively influence sexual function in older adults. Significant comorbid conditions such as diabetes mellitus, hypertension, and peripheral vascular disease may limit genital blood flow. Impaired circulation may in turn lead to erectile dysfunction in men and diminished sensation or orgasmic dysfunction in women. Osteoarthritis and neurological disorders may impair physical mobility during intercourse and make certain sexual positions difficult or uncomfortable for older adults. Atrophic vaginitis is a common condition in postmenopausal women that may be associated with dyspareunia and decreased sexual activity. Hormonal changes may lead to alterations in libido for both men and women. Clinicians must ask specifically about sexual function, because many older adults will not volunteer this information or raise questions themselves.

The study by Tannenbaum et al. in this issue examined the association between urinary incontinence and self-reported levels of sexual activity in a community-based postal survey of 5,000 Canadian women aged 55 and older. Particular strengths of this study were that it surveyed a broad range of women across the country and represented approximately 15% to 18% of the total female Canadian population. Data were available for 2,361 of the 5,000 women surveyed. The overall prevalence of urinary incontinence was 38%, and 27% of the women reported being sexually active. The authors found that continence status did not appear to influence participation in sexual activity for many older women. Age and marital status, a proxy measure for the availability of a sexual partner, were the strongest predictors of continued sexual activity. Although the frequency of incontinent episodes was not related to changes in sexual activity, overall physical and mental health did appear to influence this outcome. In addition, stress incontinence, nocturnal incontinence, and larger volumes of urine loss did appear to negatively affect sexual participation. The authors concluded that marital status and physical and mental health parameters must be considered in evaluating the results of intervention studies to improve sexual health in older incontinent women.

In addition to the community-based design, other strengths included the exploration of multiple predictor variables such as overall physical and mental health and body image. There were also several potential limitations that the authors recognized and discussed. The results were based on a self-reported postal survey that may have some inherent response biases. The question on sexual activity was dichotomous and thus may not have accounted for varying levels or forms of sexual expression. Sexual satisfaction was also not measured in this study. The use of marital status as a proxy measure for a regular sexual partner was also potentially biased. This variable will not capture single women who may have a regular sexual partner, married women whose partner suffers from significant sexual dysfunction, or women who engage in sexual activity with other women. The generalizability of the research findings are also limited to relatively healthy, community-dwelling adults.

Several other studies have examined the relationship between urinary incontinence, pelvic organ prolapse, and decreased sexual function in women. One demonstrated that urinary incontinence was significantly associated with decreased libido, vaginal dryness, and dyspareunia. These findings were independent of subject age. Another found that women with incontinence and prolapse were less sexually active than women without these problems. It also found that women who feared being incontinent during sexual intercourse had lower levels of sexual participation. Some studies have reported that pelvic organ prolapse may be associated with a significant reduction in sexual activity, but other studies have been less conclusive. The etiology of incontinence during sexual intercourse is most likely multifactorial. Mechanical and nonmechanical factors may be involved. Some women only experience urinary incontinence at the time of orgasm. Studies have shown that women with incontinence during sexual activity report less overall satisfaction with the sexual act itself and lower health-related quality of life than women who do not leak urine.

The associations between urinary incontinence and low levels of sexual activity in women appear to cross multiple ethnic and cultural boundaries. Studies of women in Europe, Asia, and the Middle East have also revealed relationships between urinary incontinence, decreased sexual activity, and diminished quality of life.

Although similar studies in men have been limited, there is evidence to suggest that men with urinary incontinence may also decrease their level of sexual activity. Anecdotally, many prostate cancer survivors who suffer from postprostatectomy urinary incontinence describe limiting their sexual activity. Even if they are able to achieve and maintain an adequate erection, they may avoid sexual activity for fear of leaking on their partner. In some cases, use of a condom to catch the urine may be helpful. However, in patients with large volume leakage, this would not be an adequate solution.

Studies examining the effect of therapies to improve continence status on sexual health in women have yielded mixed results. Some have demonstrated an associated improvement in sexual function, whereas others have shown little or no improvement after surgical correction of prolapse or incontinence. Nevertheless, Tannenbaum et al. correctly noted that partner availability is often not measured in these studies of older women. Additional research will be needed to further elucidate the effects of incontinence and pelvic organ prolapse on sexual function in older adult women. Because partner availability is such a strong predictor of sexual activity in this population, this variable must be taken into account in epidemiological research and studies designed to examine targeted intervention outcomes.

Depictions of human sexuality are pervasive in modern popular culture. This imagery is used to sell everything from automobiles to soda pop, but it is rare to see depictions of sexuality in the elderly population and then almost never in a positive light. There have been occasional exceptions, such as the television program The Golden Girls, which originally aired from 1985 to 1992. This program depicted four vibrant older women, all of whom were sexually active at some point during the series. Yet their continence status was unknown. Perhaps urinary incontinence is one of the last taboo topics for the mainstream media? The younger members of the Baby Boom generation came of age in the 1960s during the height of the sexual revolution in the United States. As this population cohort ages, they will likely be more open to discussing matters of sexuality and sexual health and the associated effects of age and comorbid conditions such as urinary incontinence.

There is a critical need for additional research on normative sexual behavior in older adults, particularly with regard to female sexual function. The role of the living environment must also be considered. The sexual activity of community-dwelling older people may be quite different from those in assisted living or long-term care because of availability of privacy for sexual activity. Increasing numbers of older adults are living with family members, and this may be a limiting factor for sexual activity for some people. Despite the recent wave of research and clinical interest in treatment of erectile dysfunction in men, there are limited available data on the overall degree of sexual satisfaction experienced by elderly people. There has also been almost no published research on the relationship between quality of life and alternate forms of sexual expression including masturbation and simple physical intimacy in older adults.

Additional scholarly work in the areas of urinary incontinence and geriatric sexuality will help to better clarify the complex relationships between these conditions. This enhanced knowledge may aid in the development of future therapies for sexual dysfunction for men and women. These could have profound effects on sexual health and its overall effect on quality of life.