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ORIGINAL ARTICLE
Pelvic floor muscle training improves sexual function
of women with stress urinary incontinence
Athanasios G. Zahariou &Maria V. Karamouti &
Polyanthi D. Papaioannou
Received: 20 February 2007 /Accepted: 19 August 2007 / Published online: 18 September 2007
#International Urogynecology Journal 2007
Abstract The aim of this study was to assess the effect of a
program of supervised pelvic floor muscle training (PFMT)
on sexual function, in a group of women with urodynami-
cally diagnosed stress urinary incontinence (SUI), using a
validated questionnaire. Incontinence episodes frequency
and continence pads used per week were measured before
and after treatment using a 7-day bladder diary. Improve-
ments in sexual function were assessed using the Female
Sexual Function Index (FSFI). Seventy women completed
the 12-month program of supervised PFMT successfully. At
the end of the study, incontinence episode frequency
decreased by 38.1%, and patients required 39% less pads
per week. All domains of the FSFI were also significantly
improved with median total FSFI scores increasing from
20.3 to 26.8. This is one of the few studies to quantify,
using a validated questionnaire, the improvement in sexual
function of women with SUI, undergoing successfully a
12-month supervised PFMT program.
Keywords Pelvic floor muscle training .Sexual function .
Urinary incontinence
Introduction
Problems of sexual function in women with urinary
incontinence (UI) are common possibly because of ana-
tomical and physiological abnormalities, as well as psy-
chological and emotional factors. Although the impact of
UI on women’s sexual life has been underestimated in the
medical literature for a long time, some recent studies
underline the negative effect of UI on women’s sexual
function [1–4]. Women with UI suffer very often from
leakage during intercourse, wetness at night and odor,
recurrent vaginitis and cystitis, accompanied by vaginal
dryness and atrophy, as well as dyspareunia and pain during
intercourse. Such symptoms have been associated with a
decrease in the frequency of coitus and sexual quietus, in
almost 50% of women with UI [5].
Surgery, drugs, and behavioral interventions are the
offered alternatives for patients with UI [6]. Based on the
principle that the least invasive, repeatable method with
the fewest side effects should be the first choice when
treating stress UI (SUI), PFMT has been recommended as
the first step of conservative management of SUI [7]. The
exact mechanism by which pelvic floor muscle training
(PFMT) improves incontinence is unknown; however, the
aim of therapy is to improve the strength and efficacy of
pelvic floor contraction.
Although the pelvic floor rehabilitation holds a very
important place among the treatment options of UI, until
now, little has been known about the sexual function of the
women we treat; our ability to evaluate the outcome of
intervention and rehabilitation is thus limited.
There are only two studies available concerning the
effect of PFMT as far as it concerns some aspects of sexual
function of women with SUI [8–10]. The first one by Beji
et al. [8] did not use a validated questionnaire for the
Int Urogynecol J (2008) 19:401–406
DOI 10.1007/s00192-007-0452-3
A. G. Zahariou :M. V. Karamouti :P. D. Papaioannou
Urologynecology Group, Elpis Hospital,
Volos, Greece
A. G. Zahariou (*)
Urology Department, Elpis Hospital,
3 Spyridi Street,
Volos 38221, Greece
e-mail: zahariou@otenet.gr
evaluation of sexual life but histories based on individual
interviews. The second one by Bo et al. [9] focused on the
other hand on the effect of PFMT on the quality of life and
studied only some general aspects of sexual function, such
as sex-life disorder by UI, pain during intercourse, and
incontinence episodes during intercourse.
The aim of this study is to evaluate the effect of a
12-month pelvic floor rehabilitation program on sexual
dysfunction variables of women with SUI, based on a
validated questionnaire for sexual dysfunction.
Materials and methods
This is a nonrandomized, convenient-sample, single-center
prospective study aiming to assess the effectiveness of
PFMT on female sexual function in women suffering from
SUI. The protocol for the research project was approved by
the Ethics Committee of the hospital, and all patients have
signed informed consent.
During the last 3 years 229 consecutive women
complaining for stress incontinence were screened at our
Uro-gynecological unit. The study sample was recruited
based on the following inclusion criteria: (a) age more
than 21, (b) being in a sexually active stable relationship,
(c) being sexually active the last 4 weeks, (d) having a uro-
dynamically proven diagnosis of SUI, (e) strict adherence—
completion—to a 12-month standardized PFMT program,
and (f) improvement of SUI after the PFMT program, based
on pad test and incontinence episodes per week.
Women reporting depression and other psychological
disorders associated with female sexual dysfunction were
excluded as: (a) Because depression can contribute to
female sexual dysfunction and female sexual dysfunction
can contribute to depression, specific questionnaires need to
be administered [10]; unfortunately no validated and/or
linguistically adapted version of these questionnaires was
available; (b) the aim of the study was to explore the
relationship between genuine stress incontinence and sexual
function, as well as possible effects of successful PFMT
program on sexual function but not the role of PFMT in
treating depression related sexual dysfunctions; therefore,
exclusion of women reporting depression or other psycho-
logical disorders made the study sample more homogenous:
Only women without reporting depression or other mood
disorders, but reporting sexual problems were included [11].
All women were examined employing the pelvic organ
prolapse staging system recommended by the International
Continence Society to quantify loss of pelvic organ support
[12]. Women with more than stage I pelvic organ prolapse,
women who had previously undergone incontinence or
prolapse surgery, or those with neurological diseases or
current urinary tract infection were excluded, as literature
reveals that these factors are implicated in sexual dysfunc-
tion pathophysiology [3,13].
The protocol required an interview in relation to
micturition problems and a pad test to measure urine loss.
The pad test was used to verify incontinence and to
quantify the degree of urine loss. A 1-h pad test was used,
as recommended by the International Continence Society
[14]. The pads were weighed on digital scales before and
after each test, and the weight gained was calculated. A
patient was classified as being incontinent if there was a
gain in pad weight of more than 2 g for the 1-h test. The
pad test was repeated for three consecutive times.
The sexual function of patients, both before and after
12 months of treatment, was evaluated with Female Sexual
Function Index (FSFI), which contains 19 questions and
categorizes sexual dysfunction in the domains of (a) desire,
(b) arousal, (c) lubrication, (d) orgasm, (e) satisfaction, and
(f) pain and evaluates the four phases of female sexual
function [15]. A scoring system is developed to obtain
individual domain scores, where higher scores indicate a
more healthful condition. Wiegel et al. [16] found a FSFI
total score of 26.5 to be the optimal cut score for
differentiating between women with and those without
sexual dysfunction.
Individual domain scores are obtained by adding the
scores of the individual items that comprise the domain and
multiplying the sum by the domain factor. The full-scale
score is obtained by adding the six domains scores. The
minimum domain score is 0 and the maximum 6.0, the full-
scale score ranges from 2.0 to 36.0. FSFI was selected
because it is a psychometrically sounded instrument, easy
to administer, and has demonstrated an ability to discrim-
inate between clinical and nonclinical populations [17].
The PFMT consisted of four office biofeedback sessions
and home therapy [18].Thehomeexerciseregimen
consisted of a progressive increase in the number of muscle
contractions. The exercise sets included two sets of five
quick and ten sustained contractions with a 10-s rest period.
The number of sustained contractions increased progres-
sively to a final regimen of five quick and 20 sustained
contractions twice daily. Trained nurses conducted all the
implementation and evaluation of PFMT. All women
attended weekly office visits for the first 12 weeks and
mailed in monthly urinary diaries for the remaining period.
Training was reinforced with monthly 30-min biofeedback
sessions and regular contact with the registered nurses.
During the PFMT, there was not an electromyogram
evaluation.
The observation that many women performing pelvic
floor muscle exercises incorrectly armored the need for
individual PFMT with a skilled practitioner. Vaginal
palpation and observation of inward movement were used
in all patients to assess the ability to contract the pelvic
402 Int Urogynecol J (2008) 19:401–406
floor muscles [19]. The incontinent women were weak on
manual muscle testing and had short pelvic floor muscle
endurance. There were only eight patients that demon-
strated a greater degree of bladder neck elevation than the
rest of the incontinent women.
Improvements in pelvic muscle strength were measured
with the Peritron precision perineometer. The probe directly
measures the pressure produced by muscular contractions
and is used for objective assessment of the strength and
endurance of pelvic floor muscle contractions and for
teaching and measuring the progress of regular pelvic floor
exercises. The Peritron perineometer has been tested and
found to be a reliable tool for clinical trials [20].
The independent-sample two-tailed ttest was used to
compare the domain FSFI scores before and after PFMT. p
values less than 0.05 were considered statistically signifi-
cant. Statistical analysis was performed using the computer
statistical package SPSS/12.0 (SPSS, Chicago, IL). Data are
presented as the mean±standard deviation (range).
Results
Our study population included 58 women (58 of 229,
25.32%), with mean age 43±6.2 years (range 21–52 years.
Forty-four women (75.86%) were premenopausal, and 14
women (24.14%) were postmenopausal.
Patients experienced SUI for a mean of 6.1 ± 5.0 years
(range 1–12 years). All completed a 7-day urinary diary and
reported a mean of 14.2 ± 12 (range 1–42) incontinence
episodes and used 8±7 (range 0–22) continence pads per
week.
The pretreatment FSFI score 20.3 ± 2.3. More specifical-
ly, at the baseline, it was recorded a desire score 2.6± 0.3,
an arousal score 3.5±0.4, a lubrication score 3.5 ± 0.3, an
orgasm score 4.2±0.5, a satisfaction score 3.4±0.4, and a
pain score 3.1±0.4 (mean± standard deviation; Table 1).
The urine leakage episodes during sexual intercourse
were 2±1.
The patients completed their follow-up urinary diary
reports and were in close collaboration with registered
nurses. Twenty-nine women (50%) reported that they were
total dry after the PFMT program. Before PFMT, the
average pelvic muscle strength of the patients was 21.7 ±
10.8. The post-treatment average pelvic muscle strength of
women was 39.2±14.2 cm H
2
O and was statistically
significantly improved (p<0.001). Patients with PFMT
experienced a significant reduction of about 38.1% in the
number of incontinence episodes per week (before treat-
ment 14.1±11, after treatment 8.7±8, p<0.005). There was
also a 39% reduction in continence pads used per week
(before treatment 10± 8, after treatment 6.1 ± 5 pads, p<
0.001). According to the pad test, there was a reduction in
urine loss from 42.1 g (pretreatment median value) to
22.8 g (post-treatment median value, p< 0.001).
At the end of 12 months of successful and continuous
PFMT and a significant improvement of SUI, women had a
mean value±standard deviation for desire 3.8 ± 0.5, arousal
4.5±0.5, lubrication 4.6 ± 0.4, orgasm 4.7 ± 0.5, satisfaction
4.4±0.4, and pain 4.8±0.5, according to the FSFI (Table 1).
The urinary leakage episodes were also significantly
improved during sexual contact (before treatment 2 ± 1,
after treatment 0.4±0.5, p<0.005).
The median FSFI total score was 20.3 before treatment
and after 12 months of successful PFMT was significantly
improved to 26.8 (p<0.001). A correlational analysis was
undertaken between the FSFI total score improvement and
the pelvic floor muscle strength (Fig. 1). The plot reveals a
strong positive relationship and the Pearson’sr=0.74
(p<0.005). The same analysis was undertaken between
the FSFI total score improvement and UI results measured
as incontinence episodes per week. There is a strong
positive relationship with lower values of Pearson’sr=
0.68 (p<0.005).
Discussion
Women sexual dysfunction is multifactorial and involves
physical, social, and psychological dimensions. Sexual
function can be described as a sequence of four phases/
domains: sexual desire, arousal, orgasm, and satisfaction
[15]. Dysfunction can affect any of these areas and can be
organic, psychological, mixed, or of uncertain etiology.
The aim of this study was to assess the effect of a
successful program of supervised PFMT on sexual function
of women with urodynamically diagnosed SUI, using a
validated questionnaire. What is really difficult concerning
the study of women’s sexual function is the determination
of the parameters that can be objectively studied and
evaluated. We used the FSFI, a brief, valid, and reliable
Table 1 Pre- and post-treatment evaluation of sexual function of
women with stress incontinence
Pretreatment
evaluation
After PFMT
evaluation
Paired ttest
(pvalue)
Desire 2.6± 0.3 3.8± 0.5 <0.001
Arousal 3.5± 0.4 4.5± 0.5 <0.001
Lubrication 3.5± 0.3 4.6± 0.4 <0.001
Orgasm 4.2± 0.5 4.7± 0.5 <0.001
Satisfaction 3.4± 0.4 4.4± 0.4 <0.001
Pain 3.1± 0.4 4.8± 0.5 <0.05
Total score 20.3± 2.3 26.8± 2.8 <0.001
Data are shown as mean±standard deviations.
PFMT Pelvic floor muscle training
Int Urogynecol J (2008) 19:401–406 403
self-report measure of female sexual function, which was
easily administered to women across a wide age range. The
FSFI is a useful tool for the evaluation of treatment
outcome in clinical trials [17] as it was designed to be a
clinical trials assessment instrument that addresses the
multidimensional nature of female sexual function. Wiegel
et al. found a FSFI total score of 26.5 to be the optimal
cutoff score for differentiating between women with and
those without sexual problems [16]. Based on FSFI, our
results revealed that while PFMT led to substantial
improvements in sexual function, in most cases, the FSFI
score did not reach values over the proposed cutoff point.
Using as a cutoff score the value of 26.5 [16], in the
overall screened population (229 women with urodynamic
SUI that attended our Uro-gynecological unit), more than
34% of the women were found to have some kind of sexual
problems. This is in accordance with the results from other
researchers [3,4,21,22]. Urinary leakage seems to reflect a
main cause, as one out of four incontinent women report
that urinary leakage impairs their ability to have sexual
relations [13] and that UI may adversely affect the quality
of their sexual life [3,4]. However, controversy still exists,
as other studies observed that none of the women included
felt differently about themselves sexually because of UI
[23], while neither the magnitude of the leakage nor the
duration of the UI influenced the women’s sexual experi-
ences significantly [24].
In our study, however, the most frequently reported
sexual problems were lack of desire and pain; those two
symptoms may be interrelated, as UI and the fear of leakage
during intercourse [25,26] progressively may lead to loss
of confidence and self-esteem, frustration, and depression,
feelings that abolish sexual desire and enhance sexual
aversion. Low sexual desire and arousal and poor sexual
satisfaction probably arise from psychological and emo-
tional rather than anatomical factors. It is postulated that the
positive impact of PFMT on sexual function is primarily
attributable to relief from this distressing condition;
however, the possible positive impact of PFMT on sexual
function or dysfunction needs further exploration.
The pathophysiology of incontinence during intercourse
is unclear, but it has been supported by some urodynamic
studies that during orgasm, simultaneous bladder contrac-
tion and urethral relaxation have been recorded [27]. The
strengthening of the pelvic floor muscles in combination
with the spontaneous precontraction of pelvic floor muscles
before and during physical stress—penetration, orgasm—
often termed “counterbracing”[28], contribute to the
reduction in leakage episodes during intercourse. In our
study, women, who reported urinary leakage during sexual
contact, all significantly improved by the PFMT program.
According to our study, women with weak muscles who
receive PFMT strengthen the muscles in this region and
notice a positive effect on their sexual life. Pelvic floor
muscle contraction plays an important role in the female
orgasmic response. Furthermore, the strength of pelvic floor
muscles probably affects the anatomical position of clitoral
erectile tissue with consequences to sexual stimulation [29].
Muscle training, except for changing muscle morphology
by increasing cross-sectional diameter, also improves
neuromuscular function by increasing activated motor
neurons and their frequency of excitation [30], neurons
that participate except for pelvic muscle contraction to
sexual arousals [31].
The improvement of sexual pain and lubrication after the
treatment with PFMT was also significant. A possible
explanation is that the loss of urine affects the normal acidic
pH of the vagina, disturbing the normal flora and leading to
vaginal dryness and dysfunctional vagina lubrication,
leading to difficulty and pain during intercourse. These
results are in accordance with the only other available and
proportional study of Beji et al. [9], while Bo et al. [10]
used a different questionnaire and studied only the urine
leakage and dyspareunia of women with UI.
The importance of the positive effect of PFMT on
incontinent women sexual function is more apparent if we
take into account the ambiguous results of the rest of
available incontinence treatment methods. Some studies
claim that there is no improvement in sexuality after
surgery for UI or genital prolapse [31]. Small series
evaluating the sexual well-being before and after tension-
free vaginal tape placement have showed conflicting
results, with a reported deterioration of sexual function
after surgery ranging from 3 to 20% [3,32]. Another study
Fig. 1 The scatter plot shows FSFI total score improvement as a
result of pelvic floor muscle strength for 58 women with urodynami-
cally diagnosed SUI. The plot reveals a strong positive relationship,
Pearson’sr=0.74
404 Int Urogynecol J (2008) 19:401–406
evaluating the change in sexual function 1 year after pelvic
organ prolapse surgery with allograft, using the Pelvic
Organ Prolapse/Urinary Incontinence Sexual Questionnaire
12, seems to demonstrate that after surgery, sexual function
might improve, especially dyspareunia [33].
Sexuality is a complex function, and the pathophysiol-
ogy of women arousal, satisfaction, and orgasm is an
obscure field. The limitations of these studies are the
objective estimation of sexuality parameters, the isolation
of the psychological part that hold a significant position in
women’s sexual function, and the differentiation between
the female and male perception of sexual life problems. In
our interventional study, the lack of randomization and the
convenient sample used did not allow any suggestion on
the mechanism of PFMT positive effect on women
sexuality. The absence of any detail of the hormonal milieu
has to be raised as an extra limitation of the current study,
as we did not use menopausal status as criteria for the study
group stratification.
We believe that advanced studies with larger study
populations in combination with an appropriate control
group would be useful and would probably clarify the
interaction between UI and sexual function and dysfunction.
In conclusion, the present study indicates a strong
positive effect of the PFTM program on both SUI and
sexual function; a randomized control trial is needed to find
the effect size and hence put indications for such programs.
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