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

2. 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

3. Female Ejaculate
Squirting
Coital incontinence

4. 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

5. 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, ± 2.89; urea: ± mg/dL; creatinine: ± 4.16 mg/dL; uric acid: ± 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 Jul;10(7):

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

7. 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

8. JAMA. 1999;281:

9. 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
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

10. 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

11. 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

12. 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

13. (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

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

15. Why is the incidence different?

16. 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.

17. Why is there the coital incontinence?

18. 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

19. 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

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

21. 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 Nov;52(1):45-7.

22. 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

23. 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.

24. 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)

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

26. 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

27. 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

28. What are the risk factors?

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

30. Our experience: Higher age (>60 years; p=0.21) Smoking (p=0.30)
ClinicalTrials.gov Identifier:
NCT
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%: ), Caesarean delivery (OR:0.5, CI 95%: )
Previous anti-incontinence surgery (OR 0.56, CI 95% )
Previous hysterectomy (OR 2.73,CI 95%: )
Previous pelvic organ prolapse surgery (OR: 4.7, CI 95% : ) Previous vaginal delivery ( OR: 2.12, CI 95%: )

31. What is the treatment?

32. 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.

33. 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

34. 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.

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

37. Reasons why incontinence may lead to sexual dysfunction

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. Frequency of sexual life
Our experience:
ClinicalTrials.gov Identifier:
NCT
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)