Laxity Disorders, Incontinence and Female Sexuality

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Susan Kellogg-Spadt, PhD, CRNP

A major class of disorders encountered in a urologic/urogynecologic setting is associated with weakness and laxity of the pelvic floor muscles. Predominant symptoms associated with this laxity and weakness are pelvic organ prolapse and urinary and/or fecal incontinence.

Contents 1 Urinary incontinence 2 Fecal incontinence 3 Strategies for managing sexuality with incontinence 4 Conclusion

Urinary incontinence

An incidence of involuntary loss of urine is experienced by about 95% of women during their lifetime, with an estimated 1 in 4 women having leakage before the age of 59. Approximately 50% of all women in nursing homes are incontinent. Urinary incontinence can be broadly classified in three ways urge incontinence (UUI), related to sensory urgency (see previous section on hypersensitivity disorders); stress incontinence (SUI), which occurs with increased intra-abdominal pressure that occurs with maneuvers such as sneezing, coughing and straining; or mixed incontinence (SUI + UUI). Abnormalities in urethral closure and poor pelvic muscle support are the primary mechanisms underlying stress incontinence. Factors predisposing a woman to SUI include age, genetics, vaginal birth trauma, previous pelvic/vaginal surgery, history of radiation therapy, menopausal status, lifestyle factors such as strenuous lifting, and chronic medical conditions including obstructive pulmonary disease, obesity, and constipation. Assessment strategies for incontinence include evaluation of voiding diaries, urinalysis, cytology, and urodynamic testing. Incontinence can be improved in 8 out of 10 women by treatment options that include nonsurgical and surgical strategies. Nonsurgical strategies include behavioral bladder retraining, pelvic floor muscle strengthening (Kegel exercises), pessary placement, and urethral plugs. Surgical procedures provide cure rates as high as 95% when performed on appropriate candidates.

Fecal incontinence

Fecal incontinence, or involuntary leakage of solid, liquid or gaseous stool from the rectum, affects 5.5 or more million Americans. It is more common in women and in the elderly. Muscle damage is involved in most cases of fecal incontinence. In women, this damage commonly occurs during childbirth, especially after difficult vaginal delivery that involves forceps and/or an episiotomy. Studies suggest that 3-25% of woman experience some degree of fecal incontinence after childbirth. Damage to sensory and motor nerves is also a common cause of fecal incontinence. Nerve injury can occur during childbirth, with severe and prolonged straining for stool or in association with chronic medical conditions such as diabetes, spinal cord tumors, and multiple sclerosis. Muscle damage can also occur during rectal surgery. It may also occur in people with inflammatory bowel disease or a history of abscess in the perirectal area. Fecal incontinence is often associated with a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgency for a bowel movement. Surgery, radiation injury, and history of inflammatory bowel disease are associated with poor elasticity of the rectum. Medical evaluation includes physical examination and ultrasonography and other tests that measure anal pressure, elasticity and sensation. The treatment of fecal incontinence varies and depends upon the etiology of the incontinence. Behavioral strategies include dietary modification which eliminates irritants and adds fiber; bowel retraining strategies to prevent diarrhea and enhance formation of regular bowel movements; Kegel exercises; and anorectal biofeedback. Pelvic floor reconstructive surgery can be an effective treatment for structural defects.

Strategies for managing sexuality with incontinence

Data from several recent studies suggest that women with mild to moderate incontinence self-report commensurate levels of sexual activity, comfort and enjoyment with sex as do women without incontinence. Mild to moderate prolapse did not usually interfere with sexual intercourse as the herniated tissues tend to be pushed into the vagina with penile penetration and thrusting. Prolapse pressure was considered less bothersome during intercourse because of being in a recumbent position. Studies indicate that when incontinence and prolapse are severe, however, symptoms are a source of anxiety and interfere with the overall sense of sexual satisfaction. Interestingly, studies suggest that women under age 65 report being incontinent during intercourse at higher rates than women over age 65. The reasons for the findings are unclear and may be related to more frequent and/or more vigorous sexplay among the younger age group. The younger women may have had greater UUI, which is harder to control during sexplay than SUI. Women who experience urinary incontinence during intercourse express concern about feeling unclean, undesirable, and “unsexy”. They fear embarrassment, rejection and possible subsequent vaginal or urinary tract infection. Encouraging a woman to be open and communicative with her partner about incontinence will often decrease anxiety by bringing the issue into the forefront rather than being veiled in secrecy. Educating the woman with urinary leakage that urine is sterile and poses little health threat will often decrease fear associated with unavoidable leakage. Other strategies for women who experience any type of incontinence during sexual activity include daily performance 30-60 Kegel exercises (PFM exercises); use of biofeedback or an electrical stimulation home unit 30 minutes before intimacy; emptying the bladder or colon before sexual activity; avoiding ingestion of fluids for one hour before lovemaking; and coital positioning to decrease leakage, e.g. female in superior or side-lying position. Use of a water-soluble lubricant or vaginal estrogen before penetration may decrease urethral trauma and facilitate comfortable entry. For women with fecal incontinence the threat of being sexually active is accompanied by increased fear of odor, self- or partner infection, and partner disgust. Practical suggestions for women include honesty with the partner about the risk of soiling; accommodating for soiling by placement of disposable pads; use of an antidiarrheal medication 1-2 hours before sex play; use of a tapwater enema 60 minutes before sex play; and limiting food intake for 4-6 hours before lovemaking. Coital positioning with minimal depth thrusting in female superior position is generally best tolerated.

Conclusion

When managing incontinence and sexuality, it is important for couples to communicate openly and honestly, and to be flexible in adapting their sexual behaviors to their physical needs and restrictions. Clearly incontinence and intimacy need not be mutually exclusive terms. A woman’s sense of well-being is closely tied to the quality of her affiliative relationships, including her intimate physical relationships. Creativity, combined with behavioral and pharmaceutical techniques, can assist women with chronic genitourinary and colorectal disorders to reclaim a sense of themselves as competent women capable of intimacy, rather than “sexually dysfunctional.”

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Editor’s Note: Susan Kellogg-Spadt, PhD, CRNP is the co-founder of The Pelvic & Sexual Health Institute at Graduate Hospital in Philadelphia where she has been The Director of Sexual Medicine.

Women’s Sexual Health Journal, Vol X, October, 2006 4-8