The Relationship Between Sexual Activity and Urinary Incontinence in Older Women.

Urinary incontinence (UI) occurs in 17% to 55% of older community-dwelling women, with variable but sometimes serious effects on quality of life and the ability to function physically and socially. An often-overlooked consequence of UI is potential interference with sexual activity. Population estimates of older women who are sexually active are 56% and 5% of married and unmarried women, respectively, with a mean prevalence of approximately 20%.

Sexually active women with UI report that it can deter sexual fulfillment in a number of ways, including low libido, fear of urine leakage during the sexual act, depression, or embarassment. Because UI is neither totally inevitable nor incurable in women of any age, treatment for UI would be expected to lessen or eliminate the negative effect UI has on sexual function, although results from studies examining the effect of behavioral and surgical treatments for UI on sexual function are conflicting, with some women showing improvements, the majority reporting no difference in the frequency of intercourse, and a few reporting occasional decrements in sexual function.

One explanation for these discrepant findings is the heterogeneous nature of these small intervention studies, with most women seeking treatment for severe symptoms of UI. Another possibility is that UI does not impair sexual activity per se but is associated with a number of factors that influence sexual activity, such as age and physical and mental health. Poor physical and mental health are known correlates of UI and may also explain lowered interest or energy for sexual activity. To provide women with a realistic notion of how treatment for UI can be expected to improve sexual function, the direct causal attribution of UI to sexual inactivity must be clearly understood. The purpose of this study was therefore to examine the association between continence status and sexual activity in a large population-based sample of older community-dwelling women, while taking into account factors related to both of these conditions, including age and physical and mental health.

DISCUSSION

Data from this large population-based survey show that older women remain sexually active as they age, regardless of continence status. Concomitant impairments in physical and mental health appear to confound negative causal associations between UI and sexual activity, with younger age favoring better health and increased sexual activity. Having a good body image was also related to being sexually active in multivariate models accounting for age in this sample. UI frequency did not influence sexual activity of incontinent women. Only the amount of urine loss and the presence of stress and nocturnal incontinence were shown to be related to sexual activity in women with UI.

These findings confirm results from one small clinical study indicating that increasing age is a stronger predictor of sexual inactivity than continence status. Although many previous studies reported significant negative relationships between UI and sexual activity, these studies did not consider the confounding effect of physical and mental health in their analyses.

Failure to consider the confounding or mediating effects of functional loss on outcomes has been a pitfall of other research studies examining associations between psychological health and other chronic conditions, including UI. One study was among the first to show that incontinent respondents being less healthy than continent respondents partly explained the relationship between severe UI and depression. As knowledge of geriatric syndromes evolves, this oversight will likely be corrected, and research on sexual activity in older women with and without incontinence will become more robust. In the meantime, studies showing decreased sexual activity as a consequence of UI must be interpreted with caution, because almost all of these studies examined younger groups of women, usually younger than 60, and used referral-based samples of women who may have had more physical or functional disabilities or who may have been more bothered by their symptoms than general community populations.

The data from the current study suggest that some subsets of women experiencing UI appear to be less likely to engage in sexual activity than others, even when age and health status are accounted for. These include women with nocturnal incontinence and those experiencing moderate to large amounts of urine loss. Urine loss due to stress and mixed incontinence, but not urge incontinence, has been reported to occur more frequently during orgasm and penetration in one small study of younger women attending a gynecological practice. Urine loss that occurs during the sexual act, as well as nocturnal symptoms and large volumes of urine loss, may affect women's desire to engage in sexual activities. However, mixed incontinence was not associated with decreased sexual activity in the current sample, and women with stress UI were more likely to report being sexually active.

Evidence from the current study that frequency of UI has no effect on restriction of sexual activity partially explains conflicting findings from intervention studies aimed at reducing UI to improve sexual function. When cessation of intercourse is causally related to involuntary loss of large amounts of urine or from bed-wetting at night, interventions that reduce or eliminate these episodes may be successful in rekindling sexual activity, although in cases where sexual dysfunction in incontinent women is due to factors unrelated to fear of urine loss during intercourse, sexual activity should not be expected to resume after continence is achieved.

These factors could include poor body image, loss of self-esteem, poor quality of the spousal relationship, or the presence of other comorbidities, such as severe arthritis, heart disease, or various neurological conditions. A detailed medical and psychosexual history should be obtained from every woman with sexual dysfunction who expresses interest in improving her sexual relations after undergoing treatment for UI, to avoid disappointment when UI is not the main deterrent to achieving a healthy sex life.

Although marital status, a proxy measure of having a sexually functional partner, emerged as the strongest predictor of sexual activity in the current study, there are limitations to the use of marital status as an indicator of partner availability that should be acknowledged. This variable does not capture single women, either divorced or widowed, who have access to regular partners or who engage in sexual activity with female partners. Furthermore, it does not differentiate between partners who themselves may have physical or emotional limitations that preclude sexual activity for the respondent.

Several other limitations must be acknowledged. The generalizability of these data is limited to cognitively intact, relatively healthy women who choose to answer postal surveys. The women who responded to this survey were slightly healthier than the average Canadian woman aged 65 and older. Because of sampling bias and low response rate (47%), frail, bed-bound, or sexually inhibited women likely would not have been captured in this survey. Nonetheless, the prevalence of sexually active women in the sample (27%) falls within prevalence ranges observed for older community women in other population-based samples. The diagnosis of type of UI is limited by the availability of questions in the International Consultation on Incontinence Questionnaire, as is any causal inference about UI and sexual activity due to the cross-sectional nature of the study and phrasing of the questions.

Another limitation is the possible bias attached to self-reported responses, especially on sensitive topics such as sexuality and incontinence, which might have caused an overestimation of sexual activity and an underestimation of UI problems in this study. The fact that the question used to obtain information on sexual activity was dichotomous might constitute yet another limitation, since it limited the ability to define levels or types of sexual activity. Because evaluating sexual activity was not the primary objective of this health survey, and sexual activity was not specifically defined, many respondents may have been participating in some forms of sexual expression or intimacy but may have answered “no” if they were not engaging in penetrative sexual intercourse. This limits interpretation of the findings with regard to the type of sexual activity engaged in by older women.

In conclusion, this large population-based survey on continence status and sexual habits of older community-dwelling women suggests that women remain sexually active regardless of continence status and that poor health is an important explanatory variable that may have confounded results from previous studies failing to show that improvements in UI lead to enhanced sexual function. These results provide direction to future researchers on the choice of variables to be included when studying UI and sexual activity. They can also serve to increase clinicians' awareness of the importance of discussing the myriad factors affecting aspects of sexuality in older women.