==== Front Rev Bras Ginecol Obstet Rev Bras Ginecol Obstet 10.1055/s-00030576 RBGO Gynecology & Obstetrics 0100-7203 1806-9339 Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil 32898914 10.1055/s-0040-1713805 190267 Original Article Sexuality Factors Associated with Sexual Activity for Women with Pelvic Floor Dysfunction - A Cross-Sectional Study Fatores associados à atividade sexual de mulheres com distúrbios do assoalho pélvico - Um estudo transversalhttp://orcid.org/0000-0002-0060-6999 Macêdo Sandra Rebouças 1 http://orcid.org/0000-0001-6784-5970 Vasconcelos Neto José Ananias 2 http://orcid.org/0000-0001-7582-3915 Tamanini José Tadeu Nunes 3 http://orcid.org/0000-0003-0878-2943 Bezerra Leonardo 4 http://orcid.org/0000-0002-0959-7363 Castro Rodrigo Aquino 5 1 Department of the Physiotherapy Course, Centro Universitário Unichristus, Fortaleza, CE, Brazil 2 Department of Urogynecology, Universidade Federal de São Carlos, São Carlos, SP, Brazil 3 Department of Medicine, Hospital Geral de Fortaleza, Fortaleza, CE, Brazil 4 Department of Maternal and Child Health, Universidade Federal do Ceará, Fortaleza, CE, Brazil 5 Department of Gynecology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil Address for correspondence Sandra Rebouças Macêdo, Master Rua Adolfo Gurgel 133, 60.192-345. Cocó, Fortaleza, CEBrazilsandrarmacedo@yahoo.com.br 08 9 2020 8 2020 1 9 2020 42 8 493500 13 9 2019 07 5 2020 The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ). 2020 The Author(s). https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective  To examine women with pelvic floor dysfunction (PFDs) and identify factors associated with sexual activity (SA) status that impacts quality of life (QoL). Methods  We conducted a cross-sectional study that included women > 18 years old who presented with at least one PFD symptom (urinary incontinence [UI] and/or pelvic organ prolapse [POP]), in outpatient clinics specializing in urogynecology and PFD in Fortaleza, state of Ceará, Brazil, using a service evaluation form and QoL questionnaires. Results  The analysis of 659 women with PFD included 286 SA (43.4%) women and 373 non-sexually active (NSA) (56.6%) women, with a mean age of 54.7 (±12) years old. The results revealed that age (odds ratio [OR] = 1.07, 95% confidence interval [CI] 1.03–1.12) and post-menopausal status (OR = 2.28, 95% CI 1.08–4.8) were negatively associated with SA. Being married (OR = 0.43, 95% CI 0.21–0.88) was associated with SA. Pelvic organ prolapse (OR = 1.16, 95% CI 0.81–1.68) and UI (OR = 0.17, 95% CI 0.08–0.36) did not prevent SA. SF-36 Health Survey results indicated that only the domain functional capacity was significantly worse in NSA women ( p  = 0.012). Two King's Health Questionnaire domains in NSA women, impact of UI ( p  = 0.005) and personal relationships ( p  < 0.001), were significantly associated factors. Data from the Prolapse Quality-of-life Questionnaire indicated that NSA women exhibited compromised QoL. Conclusion  Postmenopausal status and age negatively affected SA. Being married facilitated SA. Presence of POP and UI did not affect SA. However, NSA women with POP exhibited compromised QoL. Resumo Objetivo  Examinar mulheres com disfunções do assoalho pélvico (DAP) e identificar fatores associados ao status de atividade sexual (AS) e impacto na qualidade de vida (QV). Métodos  Realizamos um estudo transversal, no qual participaram mulheres > 18 anos, que apresentaram pelo menos um sintoma de DAP (incontinência urinária [UI] e/ou prolapso de órgão pélvico [POP]), em ambulatórios especializados em uroginecologia e DAP em Fortaleza, CE, Brasil, utilizando um formulário de avaliação de serviço e questionários de QV. Resultados  A análise de 659 mulheres com DAP incluiu 286 mulheres sexualmente ativas (SA) (43,4%) e 373 mulheres não sexualmente ativas (NSA) (56,6%), com idade média de 54,7 (±12) anos. Os resultados revelaram que idade (odds ratio [OR] = 1,07; intervalo de confiança [IC] 95%: 1,03–1,12) e status pós-menopausa (OR = 2,28; IC 95% 1,08–4,8) foram negativamente associados à atividade sexual. O casamento (OR = 0,43; IC 95% 0,21–0,88) foi associado à AS. Por outro lado, POP (OR = 1,16; IC 95% 0,81–1,68) e IU (OR = 0,17; IC 95% 0,08–0,36) não impediram a AS. Os resultados do SF-36 Health Survey indicaram que apenas a capacidade funcional do domínio ( p  = 0,012) foi significativamente pior em mulheres NSA. Dois domínios King's Health Questionnaire (KHQ, na sigla em inglês) em mulheres NSA, impacto da IU ( p  = 0,005) e relacionamento pessoal ( p  < 0,001), foram fatores significativamente associados. Os dados do Prolapse Quality-of-life Questionnaire (P-QoL, na sigla em inglês) indicaram que as mulheres NSA apresentavam QV comprometida. Conclusão  O status pós-menopausa e a idade afetaram negativamente a AS, enquanto o casamento facilitou a AS. A presença de POP e IU não afetou a AS. No entanto, as mulheres NSA com POP apresentaram QV comprometida. Keywords sexual activity pelvic floor dysfunction urinary incontinence pelvic organ prolapsed Palavras-chave atividade sexual disfunções do assoalho pélvico incontinência urinária prolapso do assoalho pélvico qualidade de vida quality of life ==== Body pmcIntroduction In the context of clinical practice, women who are sexually active (SA) and those who are non-sexually active (NSA) with satisfactory self-perception of their sexual function (SF) may also experience sexual problems related to pelvic floor dysfunction (PFD). 1 The reported prevalence of sexual activity in middle-aged and older women ranges from 53 to 79%, depending on the population studied. 2 Panman et al 3 reported that, among older women with PFD, increased age and lower levels of education were predictors of sexual inactivity. Sexual activity and SF rates have not been found to exhibit any differences between women with and without PFD, and women with PFD are as likely to be SA as those without PFD. 4 5 However, women with pelvic organ prolapse (POP) are reported to be more likely to avoid sexual activity compared with women with urinary incontinence (UI). 4 5 Previous studies have reported that PFD strongly affects perimenopausal and postmenopausal women. The demand for evaluation and treatment of these conditions has steadily increased in recent years, with increased life expectancy and efforts to promote quality of life (QoL). 4 5 Sexuality is a fundamental part of human life, and is an important parameter for health and QoL. 6 Thus, the current study sought to identify factors that affect sexual activity in women with PFD, and the impacts of QoL, according to sexual activity status. Methods Study Design and Inclusion/Exclusion Criteria We conducted a cross-sectional observational study, which was designed for outpatient clinics specializing in urogynecology and PFD in Fortaleza, state of Ceará, Brazil. The present study was approved by the Ethics and Research Committee of the Universidade Federal de São Paulo (UNIFESP, in the Portuguese acronym), of the Hospital Geral Cesar Cals and of the Hospital Geral de Fortaleza, through the Brazil Platform (CAAE 15961313.6.0000.5505). Patients who participated in the study signed the Free Informed Consent Terms prepared according to Resolution 466/2012 of the National Health Council. In the present study, 659 women with PFD were examined between September 2013 and November 2016. The eligibility criteria included women > 18 years old who presented with at least one symptom of PFD (UI and/or POP). The exclusion criteria included severe cognitive impairment, psychiatric and neurological diseases and pelvic cancer. Independent Variables and Dependent Variables Data were collected during outpatient follow-up of participants using a standardized form collecting sociodemographic data, clinical features and physical examinations. We administered questionnaires that have been translated into Portuguese and validated, including the QoL general questionnaire SF36 Health Survey (SF-36), 7 as well as condition-specific questionnaires such as King's Health Questionnaire (KHQ) 8 and the Prolapse Quality-of-life Questionnaire (P-QoL). 9 Medical evaluation was performed using a standardized anamnesis and physical gynecological examination standardized with Pelvic Organ Prolapse Quantification (POP-Q) proposed by the International Continence Society (ICS), classifying the point of greatest prolapse with reference to the hymenal caruncle in stages from zero to four. 10 In relation to POP, women were classified as POP stage < II or stage ≥ II. The diagnosis of UI type was based on clinical complaints, according to the standardization developed by the ICS. The condition was then classified according to the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) total score, as slight (1–5), moderate (6–12), severe (13–18) or very severe (19–21). 11 12 Perineal sensitivity and anal reflex were tested to investigate the integrity of the motor component of the pudendal nerve: bulbocavernosus cough and anocutaneous reflexes. Evaluation of the muscular function of the pelvic floor muscles (PFMs) was performed using the Perfect-Oxford Scheme (modified), on a scale of 0 to 5 13 and muscle strength. Power (P) and endurance (E) were analyzed as components. Fecal incontinence and chronic pelvic pain were not analyzed in the current study, as the number of cases was too small to have sufficient statistical power. Statistical Analysis For the variables, the data were presented as means and standard deviations (SDs), or medians, with 25th and 75th percentiles. For categorical variables, the participants were exposed to frequency to investigate associations between factors related to sexual activity. In the analysis of the characteristics of the groups, the Mann-Whitney U-test was used because the data did not adhere to the Gaussian distribution, indicating non-normality in the sample distribution. A significance level of 5% was adopted. The Pearson chi-squared test and the Fisher exact test were used for categorical variables to investigate the associations between the variables. Logistic regression analysis was used to verify the factors influencing sexual activity status. Variables that exhibited p  < 0.20 in the univariate model were included in the multiple logistic regression model. Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp., Armonk, NY, USA) and the R 3.3.1 (The R Foundation, Vienna, Austria) software. Results The results of the present study were based on an analysis of 659 women with PFD, categorized into 2 main groups: 286 SA women (43.4%) and 373 NSA women (56.6%) with PFD. To describe the clinical diagnoses of PFD of the women and examine the relationships with sexual activity, the variables were divided into UI and POP. Urinary incontinence was classified as mild, moderate, severe and very severe according to the ICIQ-SF final score classification. Pelvic organ prolapse was classified according to the POP-Q system as stage < II or stage ≥ II. The results were organized into blocks of data from women with SA and NSA status with PFD regarding: a) clinical and demographic characteristics ( Table 1 ); b) characteristics according to the type of PFD ( Table 2 ); c) characteristics according to the physical examination ( Table 3 ); d) logistic regression analyses related to the association between clinical, demographic and PFD characteristics ( Table 4 ); and e) to QoL scores ( Table 5 ). Table 1 Distribution of clinical and demographic characteristics of women with pelvic floor disorder according to sexual activity Demographic and clinical characteristics of patients Sexually active Non-sexually active p-value Age (Md ± SD) ( n  = 642) 47 ± 9 61 ± 12 < 0.00 aa Marital status, n (%) ( n  = 627) < 0.00 bb Single 37 (38.1) 60 (61.9) Married 215 (57.5) 159 (42.5) Divorced 22 (35.5) 40 (64.5) Widowed 9 (9.6) 85 (90.4) Education b (Md ± SD) ( n  = 608) 7 ± 4 6 ± 4 < 0.00 aa Family income (Md ± SD) ( n  = 519) 1.243 ± 812 1.293 ± 1365 0. 045 aa Number of deliveries (Md ± SD) ( n  = 647) 3 ± 2 5 ± 4 a < 0.001 aa Diabetes, n (%) ( n  = 659) 0.967 aa No 280 (43.4) 365 (56.5) Yes 6 (42.9) 8 (57.1) SAH, n (%) ( n  = 659) 0.021 aa No 257 (45.2) 312 (54.8) Yes 29 (32.2) 61 (67.8) Obesity, n (%) ( n  = 659) 0.004 aa No 251 (41.7) 351 (58.3) Yes 35 (61.4) 22 (38.6) BMI (Md ± SD) ( n  = 491) 29.5 ± 4.9 28.3 ± 5.1 c 0.007 bb Menopause, n (%) ( n  = 564) < 0.001 aa No 100 (66.1) 82 (33,9) Yes 82 (23.4) 268 (76.5) Do not know (Hysterectomized) 17 (53.1) 15 (46.9) Smoking, n (%) ( n  = 636) 0.003 aa Never smoked 174 (46.9) 197 (53.1) Previously smoked 67 (32.5) 139 (67.5) Currently smoking 28 (47.5) 31 (52.5) Abbreviations: BMI, Body mass index; Md ± SD, mean and standard deviation; SAH, systemic arterial hypertension. aa Mann-Whitney U test. b Years of study. bb Pearson's Chi-square test. Table 2 Distribution of characteristics according to the type of pelvic floor disorder and sexual activity status PFD Sexually active Non-sexually active p-value UI ( n  = 521) 239 (45.9) 282 (54.1) < 0.001 aa POP stage, n (%) ( n  = 640) < 0.001 aa POP stage