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1 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Irwin Goldstein MD Director, Sexual Medicine, Alvarado Hospital, San Diego, California Clinical Professor of Surgery, University of California, San Diego Editor-in-Chief, The Journal of Sexual Medicine Interim Editor-in-Chief, Sexual Medicine Reviews

2 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Association of incontinence to female sexual dysfunction Post-op Suburethral Sling Surgery Sexual Function and Orgasm Function Relevant Anatomy Hypothesis of Post-op Suburethral Sling Surgery Sexual Dysfunction and Plan to Intervene

3 Prevalence of Urinary Incontinence by Age group and severity Hannestad YS, et al. J Clin Epidemiol, 53: , 2000

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6 HSDD FSAD OD SPD 11/99 11% 23/99 23% 34/99 34% 44/99 44% FSD in women with LUTS or UI

7 FSFI

8 Sutherst JR, et al. Br J Obstet Gynaecol, 86: , 1979 Handa VL, et al. Am J Obstet Gynecol, 191: , 2004 Sand PK, et al. Am J Med, 119(3 Suppl 1):16-23, 2006

9 QUALITATIVE RESEARCH Distress Hear the actual words!!!!!!!!!!! Distress Distress

10 QUALITATIVE RESEARCH Distress Hear the actual words!!!!!!!!!!! Distress

11 Distress QUALITATIVE RESEARCH Hear the actual words!!!!!!!!!!! Distress Distress

12 Interpersonal Dimension: There is no such thing as an uninvolved partner in a marriage where sexual dysfunction Masters & Johnson, 1970 exists.

13 Effect of Urinary Leakage on Sexual Function during Sexual Intercourse When compared with women without any problem, women with urinary incontinence were: 4.7 times less satisfied with their sexual life their partners had ejaculation without full erection 3.1 times more Nezihe Kizilkaya Bejia et al Urologia Internationalis 2005;74:

14 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Association of incontinence to female sexual dysfunction Post-op Suburethral Sling Surgery Sexual Function and Orgasm Function Relevant Anatomy Hypothesis of Post-op Suburethral Sling Surgery Sexual Dysfunction and Plan to Intervene

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16 Of those sexually active, 31 (72%) reported no change in sexual function after surgery Two reported improvement Six (14%) reported sexual function worse - no partner and loss of libido main reason

17 Half of the patients cured of their incontinence during intercourse experienced a better sexual life

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20 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Urinary incontinence seems to be of great importance in connection with sexual satisfaction About half of the patients referred for suburethral sling operation for urinary stress incontinence experienced urinary incontinence during intercourse Those who experienced urinary incontinence during intercourse developed a better sexual life after the operation in about half of the cases

21 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Most post-op suburethral sling patients improve sexual function BUT some worsen sexual function, especially some experience orgasm dysfunction

22 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Association of incontinence to female sexual dysfunction Post-op Suburethral Sling Surgery Sexual Function and Orgasm Function Relevant Anatomy Hypothesis of Post-op Suburethral Sling Surgery Sexual Dysfunction and Plan to Intervene

23 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Orgasm types i) clitoral - rhythmic contractions of the vagina activated by clitoral stimulation ii) vaginal - rhythmic contractions of the vagina activated by anterior vaginal wall/periurethral tissue stimulation - squirter iii) uterine - buffeting and displacing cervix and causing it to rub against the peritoneal lining inducing pleasure accompanied by apnea and gasping iv) blended

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25 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: G - spot

26 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

27 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

28 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

29 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

30 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

31 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

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38 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Orgasm types i) clitoral - rhythmic contractions of the vagina activated by clitoral stimulation ii) vaginal - rhythmic contractions of the vagina activated by anterior vaginal wall/peri-urethral tissue stimulation - squirter iii) uterine - buffeting and displacing cervix and causing it to rub against the peritoneal lining inducing pleasure accompanied by apnea and gasping iv) blended Lowenstein L. Topographic relation of mid-urethral sling for stress incontinence to critical female genital structures. J Sex Med Nov;6(11):

39 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Orgasm types i) clitoral - rhythmic contractions of the vagina activated by clitoral stimulation ii) vaginal - rhythmic contractions of the vagina activated by anterior vaginal wall/peri-urethral tissue stimulation - squirter iii) uterine - buffeting and displacing cervix and causing it to rub against the peritoneal lining inducing pleasure accompanied by apnea and gasping iv) blended Lowenstein L. Topographic relation of mid-urethral sling for stress incontinence to critical female genital structures. J Sex Med Nov;6(11):

40 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Orgasm types i) clitoral - rhythmic contractions of the vagina activated by clitoral stimulation ii) vaginal - rhythmic contractions of the vagina activated by anterior vaginal wall/peri-urethral tissue stimulation - squirter iii) uterine - buffeting and displacing cervix and causing it to rub against the peritoneal lining inducing pleasure accompanied by apnea and gasping iv) blended Lowenstein L. Topographic relation of mid-urethral sling for stress incontinence to critical female genital structures. J Sex Med Nov;6(11):

41 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Association of incontinence to female sexual dysfunction Post-op Suburethral Sling Surgery Sexual Function and Orgasm Function Relevant Anatomy Hypothesis of Post-op Suburethral Sling Surgery Sexual Dysfunction and Plan to Intervene

42 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women:

43 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Most post-op patients improve sexual function BUT 14% 20% worsen sexual function Some post-op patients experience orgasm dysfunction this has not been heretofore emphasized

44 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Most post-op patients improve sexual function BUT 14% 20% worsen sexual function Some post-op patients experience orgasm dysfunction this has not been heretofore emphasized KEY IDENTIFY PATIENTS PRE-OP WHO HAVE A VAGINAL SQUIRTING ORGASM vaginal - rhythmic contractions of the vagina activated by anterior vaginal wall/peri-urethral tissue stimulation - squirter

45 KEY IDENTIFY PATIENTS PRE-OP WHO HAVE A VAGINAL SQUIRTING ORGASM DRAFT PRE-OP Questionnaire for patients undergoing Mid-Urethral Sling 1) Are you currently sexually active? (This includes intercourse, oral sex, and masturbation) 2) Are you still having periods or have your periods stopped? 3) If they have stopped how long ago was your last menstrual period? 4) Are you currently being treated with hormone replacement therapy? (Can include estrogen, progesterone, and testosterone) 5) If you are currently being treated with hormones which one(s)? 6) At what age did you experience your first orgasm? 7) On a scale of 1 to 5 with 1 being least and 5 being most how important is reaching orgasm during sexual activity?

46 KEY IDENTIFY PATIENTS PRE-OP WHO HAVE A VAGINAL SQUIRTING ORGASM DRAFT PRE-OP Questionnaire for patients undergoing Mid-Urethral Sling 8) Are you able to have an orgasm from vaginal penetration or from stimulation of your clitoris or both? 9) If the answer to the above question is yes, which method(s) allow you to orgasm? 10) If you are able to have an orgasm with either clitoral stimulation or vaginal penetration can you use one word to describe the feeling of each of those orgasms? 11) Are you a squirter? (NOT of urine) 12) If you classify yourself as a squirter at what age did you first begin to experience squirting? 13) On a scale of 1 to 5 with 1 being least and 5 being most how important is squirting in regards to your sexual function and satisfaction? 14) Does clitoral stimulation or vaginal penetration lead to squirting?

47 Sexual Side Aspects of Incontinence - Suburethral Sling Surgery - in Women: Most post-op suburethral sling patients improve sexual function BUT some worsen sexual function, especially some experience orgasm dysfunction

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