Coital incontinence: un problema sessuale misconosciuto Dott.ssa Ester Illiano Università di Perugia

Definition Coital incontinence is defined as “complaint of involuntary loss of urine during coitus” according to the International Urogynecological Association and the International Continence Society in 2010

Female Ejaculate Squirting Coital incontinence

Non Urinary Origin –female ejaculation Grafenberg in ‘50 postulates the existence of an ejaculate of non urine fluid during orgasm .  Grafenberg E. The role of the urethra in female orgasm. Int J Sexology 1950;3:145-8 Addiego ’81 finds a higher level of prostatic acid phospahtase and also coins the Term “G Spot” Addiego F, et al Female ejaculation: a case study. J Sex Res 1981;17:1-13 Skene’s Gland or ducts analagous to the male prostate

Female ejaculation orgasm manifests as either a female ejaculation of a smaller quantity of whitish secretions from the female prostate or a squirting of a larger amount of diluted and changed urine Squirting: diluted urines (density: 1,001.67 ± 2.89; urea: 417.0 ± 42.88 mg/dL; creatinine: 21.37 ± 4.16 mg/dL; uric acid: 10.37 ± 1.48 mg/dL) Female ejaculation: is biochemically comparable to some components of male semen (prostate-specific antigen: 3.99 ± 0.60 × 103 ng/mL). J Sex Med. 2013 Jul;10(7):1682-91

Is it an Unknown problem? Coital incontinence: Is it an Unknown problem?

In 1979… Sutherst and Brown reported that 43% of women affected by urinary incontinence referred that their urinary problems had adversely affected their sexual life BJOG 1979;86:387

JAMA. 1999;281:537-544

Hypoactive sexual desire in accordance with the WSD classification proposed by the International Consensus Development Conference on Female Sexual Dysfunction Stress incontinence Urgency incontinence Sexual disorder 22% 9% Arousal 47% 21% Hypoactive sexual desire 18% 5% Sexual pain 27% 46% Orgasmic phase disorders 1998-2002 227 consecutive women (mean age 52; age range 19–66) with: UI and/or recurrent or persistent LUTS were considered for this study. European Urology 45 (2004) 642–648

Overactive bladder (OAB), with or without UUI, affects women’s sexual health, reducing sexual desire and ability to achieve orgasm J Sex Med 2007;4:656–666

From the previous data, it is quite evident how urinary leakage occurring during intercourse (i.e., coital urinary incontinence) can be considered a common although underreported symptom, affecting sexually active women with pelvic floor dysfunction

From 1970 to 2008 The incidence of coital incontinence in incontinent women can vary between 10% and 27% BJOG 1988;95:377–81 J Obstet Gynecol 1999;19:286–8. Am J Obstet Gynecol 2004;190:1030–3

(9%) patients voluntarily reported this A total of 281 (56%) women answered affirmatively having experienced coital incontinence, and 224 (44%) did not (9%) patients voluntarily reported this condition Plos oneMay 24, 2017

Our experience: ClinicalTrials.gov Identifier: NCT02306655 International multicentre study 1041 sexually active incontinent women 53.8% women had coital urinary incontinence

Why is the incidence different?

This symptom is difficult to diagnose, because women rarely refer it spontaneously as shown by Bachman et al. on more than 900 women, with only 3% of them self-reporting sexual disturbances (including coital urinary incontinence) and increasing to 20% after direct questioning in an outpatient setting Obstet Gynecol 1989;73:425–7.

Why is there the coital incontinence?

Incontinence at penetration Incontinence during orgasm 324 were sexually active Coital urinary incontinence is traditionally divided into two forms on the basis of the timing of occurrence during intercourse: Incontinence at penetration Incontinence during orgasm British Journal of Obstetrics and Gynaecology April 1988, Vol. 95, pp. 377-381

Several of those experiencing incontinence on orgasm during sexual intercourse also had urine leakage occurring during masturbation to orgasm, whereas none of those with incontinence on penetration had had urine leakage with other forms of sexual activity British Journal of Obstetrics and Gynaecology April 1988, Vol. 95, pp. 377-381

The problem may be found in patients with all urodynamic diagnoses British Journal of Obstetrics and Gynaecology April 1988, Vol. 95, pp. 377-381

The authors concluded that coital They could not find any correlation between different forms of coital incontinence and urodynamic diagnoses The authors concluded that coital incontinence can occur regardless of any Urodynamic diagnosis, and that the pathophysiology of this symptom is probably multifactorial. Eur J Obstet Gynecol Reprod Biol. 1993 Nov;52(1):45-7.

sphincter incompetence, also when it occurs exclusively during orgasm A retrospective report on 228 women complaining of urinary leakage during intercourse USI was by far the most frequent (>80%) diagnosis in all the forms of coital incontinence (incontinence at penetration, incontinence during orgasm, and mixed forms) The finding of DO was extremely uncommon. The coital incontinence is almost invariably a symptom of USI with urethral sphincter incompetence, also when it occurs exclusively during orgasm J Obstet Gynecol 1999;19:286–8

132 women with coital urinary incontinence: 49 (37.1%) predominantly during orgasm 83 (62.9%) predominantly at penetration Women with incontinence during orgasm showed a significantly higher rate of DO (69%) compared with women with incontinence at penetration (29%) (P<0.0001) J Sex Med 2009;6:40–48.

Coital incontinence showed significant positive correlation The prevalence of coital incontinence was significantly higher among women with SUI (89.4%) compared to those with detrusor overactivity (33.3%) (P =0.000) and but significantly higher from subjects with mixed incontinence MI (78.9%); (P =0.281) Coital incontinence showed significant positive correlation with the severity of SUI as reported by the patients (P = 0.05) Neurourology and Urodynamics 30:520–524 (2011)

Our experience: ClinicalTrials.gov Identifier: NCT02306655 International multicentre study 1041 sexually active incontinent women 53.8% women had coital urinary incontinence

Our experience: ClinicalTrials.gov Identifier: NCT02306655 p value Odds 95% C.I.for Odds Coital incontinence (a) Lower Upper Mxed urinary incontinence 0.0001 6.063 4.504 8.162 Mixed Urinary incontinence predominant stress 2.948 2.262 3.843 Mixed Urinary incontinence predominant urgency 0.27 1.368 1.036 1.807 Prevoius pelvic organ prolpase surgery 1.887 1.354 2.629 Coital incontinence during penetration (b) Stress urinary incontinence 0.23 1.47 1.056 2.056 Mixed urinary incontinence 3.005 1.984 4.550 0.10 1.514 1.102 2.080 1.634 1.126 2.372 Coital incontinence during intercourse (c) 3.536 2.619 4.773 3.598 2.757 4.696 1.859 1.351 2.558 Coital incontinence during orgasm (d) Urgency urinary incontinence 1.884 1.364 2.602 Mixed Urinary incontinence 2.994 2.062 4.348

The orgasm is considered as a trigger Urine leakage during penetration is explained by the lowering of the bladder fundus and the urethra during an increase in the intraabdominal pressure and a change in the position of the bladder neck during penetration The orgasm is considered as a trigger for involuntary detrusor contractions and incontinence at orgasm is a severe form of detrusor overactivity

What are the risk factors?

Urethral function plays an important role in maintaining continence during coitus Plos oneMay 24, 2017

Our experience: Higher age (>60 years; p=0.21) Smoking (p=0.30) ClinicalTrials.gov Identifier: NCT02306655 Higher age (>60 years; p=0.21) Smoking (p=0.30) Postmenopausal phase (p=0.3) Hormone therapy (p=0.56) Multiparous (p=0.23) Lower body mass index (BMI<25 kg/m2; OR 0.72, CI 95%:0.53-0.97), Caesarean delivery (OR:0.5, CI 95%: 0.42-0.65) Previous anti-incontinence surgery (OR 0.56, CI 95% 0.42-0.83) Previous hysterectomy (OR 2.73,CI 95%:1.96-3.84) Previous pelvic organ prolapse surgery (OR: 4.7, CI 95% : 1-41- 10.11) Previous vaginal delivery ( OR: 2.12, CI 95%: 1.52-4.31)

What is the treatment?

Pelvic Floor Muscle Training In both articles, the authors reported a statistically significant improvement of women’s sexuality and a reduction of the episodes of incontinence during intercourse Acta Obstet Gynecol Scand 2000;79:598–603 Int Urogynecol J Pelvic Floor Dysfunct 2008;19:401–6.

Pharmacological Treatment Oxybutinin improved sexual function in their population, the impact of pharmacological therapy on coital urinary incontinence was unsatisfactory: of the 569 patients affected by urinary incontinence during intercourse at baseline, only 23% were cured, whereas 438 (77%) did not respond to the treatment Sand et al.2005 Tolterodina 4 mg impact of pharmacological therapy on coital urinary incontinence was unsatisfactory: of the 34 patients affected by urinary incontinence during orgasm and urodynamically proven pure DO at baseline, only 58 % were cured Serati et al.2008 It could be hypothesized that CI at orgasm may be a marker of a more severe form of DO . Another possible explanation is that in these form of DO, not only muscarinic but also trigonal vanilloid receptors may be involved

high cure rate also on coital incontinence in women affected by USI Surgical Treatment TVT has clearly demonstrated a very high efficacy in the treatment of urodynamic stress (and also mixed) incontinence and, when reported, a high cure rate also on coital incontinence in women affected by USI Sentilhes et al. and Pace and Vicentini in 2008 show that TOT have a cure rate ranging between 55% and 96% on the symptom of urinary leakage during intercourse.

What is the impact of coital incontinence on quality of sexual life?

Reasons why incontinence may lead to sexual dysfunction

A couple problem Urol Int. 2005;74(3):250–5. Embarrassment, guilt and anxiety about sexual activities are highly prevalent in this population Arousal can be also compromised, as patients with coital incontinence have significantly greater issues with lubrication Dyspareunia may be increased in women with coital incontinence compared to those without urinary complaints Among partners of women with coital incontinence, an association with increased ejaculation before reaching full erection was noted Urol Int. 2005;74(3):250–5.

Women with CI had a significantly lower QoL than the controls in all domains except Sleep/energy, although even in this domain the differences approached borderline statistical significance Int Urogynecol J (2017) 28:697–704

The Personal relationships domain of the KHQ included questions pertaining to personal and intimate life, such as: ‘Does your bladder problem affect your relationship with your partner?’ ‘Does your bladder problem affect your sex life?’ ‘Does your bladder problem affect your family life?’ CI had a substantial influence on the answers selected. Int Urogynecol J (2017) 28:697–704

The PISQ Physical domain score was significantly lower in women with CI (p = 0.001), and the PISQ total score revealed reduced quality of sexual function, but the difference between the groups was not significant (p > 0.05). Int Urogynecol J (2017) 28:697–704

Women with mixed incontinence had the worst sexual quality of life (p = 0.001) and incontinence-related symptom distress (p = 0.014) Plos oneMay 24, 2017

Factors affecting sexual desire in women with overactive bladder (OAB), mixed urinary incontinence (MUI) and stress urinary incontinence (SUI). Acta Obstetricia et Gynecologica Scandinavica (2011) 621–628

Factors affecting satisfaction with sexual life in women with overactive bladder (OAB), mixed urinary incontinence (MUI) and stress urinary incontinence (SUI). Acta Obstetricia et Gynecologica Scandinavica (2011) 621–628

Frequency of sexual life Our experience: ClinicalTrials.gov Identifier: NCT02306655 Quality of sexual life p 1 2 3 4 <0.0001 Coital urinary incontinence No 265 99 38 75   ,8% 55,1% 20,6% 7,9% 15,6% Yes 85 237 139 0,0% 15,2% 17,7% 42,3% 24,8% Frequency of sexual life P P<0.0001 22 249 86 63 61 4,6% 51,8% 17,9% 13,1% 12,7% 6 144 214 110 1,1% 15,4% 25,7% 38,2% 19,6% The International Consultation on Incontinence Questionnaire (ICIQ-UI) and the Patient Perception of Bladder Condition (PPBC)