Original Research
Effect of Surgery for Stress Incontinence on
Female Sexual Function
Stephanie M. Glass Clark, MD, Qi Huang, MS, Adam P. Sima,
OBJECTIVE: To evaluate the effects of four different
surgical interventions for stress urinary incontinence
(SUI) on 2-year postoperative sexual function.
METHODS: This is a combined secondary analysis of
Downloaded from http://journals.lww.com/greenjournal by BhDMf5ePHKbH4TTImqenVOm0oSGVjfT8AkWoBMgJPNob0Tyfv4ENdncBXo1U0rFXdb3Oz90n62g= on 01/26/2020
SISTEr (Stress Incontinence Surgical Treatment Efficacy Trial)
and TOMUS (Trial of Mid-Urethral Slings). Women in the
original trials were randomized to receive surgical treat-
From the Department of Obstetrics and Gynecology and the Division of Female
Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and
Gynecology, Virginia Commonwealth University Health System, and the Depart-
ment of Biostatistics, Virginia Commonwealth University, Richmond, Virginia.
This secondary analysis study received no outside sources of funding. The Stress
Incontinence Surgical Treatment Efficacy Trial was conducted by the Urinary
Incontinence Treatment Network Investigators and was supported by cooperative
agreements with the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), and by the National Institute of Child Health and Human
Development (NICHD) and Office of Research in Women’s Health of the
National Institutes of Health (NIH). The Trial of Mid-Urethral Slings was
conducted by the Urinary Incontinence Treatment Network Investigators and
was supported by the NIDDK and NICHD. The data from both trials reported
in this study were supplied by the NIDDK Central Repositories. Statistical
analysis was supported by the Biostatistics Consulting Laboratory, which is
partially supported by award No. UL1TR002649 from the National Institutes
of Health’s National Center for Advancing Translational Science. Both the Stress
Incontinence Surgical Treatment Efficacy Trial and Trial of Mid-Urethral Slings
were conducted by the Urinary Incontinence Treatment Network Investigators and
supported by the National Institute of Diabetes and Digestive and Kidney Dis-
eases (NIDDK). The data were acquired for this study by accessing the National
Institute of Diabetes and Digestive and Kidney Diseases Central Repository. The
manuscript was not prepared in collaboration with the Investigators of the Stress
Incontinence Surgical Treatment Efficacy Trial or Trial of Mid-Urethral Slings,
and does not necessarily reflect the opinions or views of the Stress Incontinence
Surgical Treatment Efficacy Trial, Trial of Mid-Urethral Slings, the NIDDK
Central Repositories or the NIDDK.
Presented at the Society of Gynecologic Surgeons’ 45th Annual Scientific Meeting,
March 31–April 3, 2019, Tucson, Arizona.
Each author has confirmed compliance with the journal’s requirements for
authorship.
Corresponding author: Stephanie M. Glass Clark, MD, Department of Obstetrics
and Gynecology, Virginia Commonwealth University, Richmond, VA; email:
stephanie.glass3@gmail.com.
Financial Disclosure
Stephanie M. Glass Clark reports receiving a travel stipend from an award from
the Society of Gynecological Surgeons, sponsored by OB-STATS. The other
authors did not report any potential conflicts of interest.
© 2020 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/20
352 VOL. 135, NO. 2, FEBRUARY 2020
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
PhD, and Lauren N. Siff, MD
ment for SUI with an autologous fascial sling or Burch
colposuspension (SISTEr), or a retropubic or transobturator
midurethral sling (TOMUS). Sexual function (assessed by
the short version of the PISQ-12 [Pelvic Organ Prolapse/
Urinary Incontinence Sexual Questionnaire]) was com-
pared between groups at baseline, 12 and 24 months.
Secondarily, the effects of subjective and objective surgical
cure rates and the effect of concomitant surgical proce-
dures on 24-month sexual function was explored.
RESULTS: Nine hundred twenty-four women were
included in this study: 249 (26.9%) had an autologous
fascial sling, 239 (25.9%) underwent Burch colposuspension,
216 (23.3%) had a retropubic midurethral sling placed, and
220 (23.8%) had transobturator midurethral sling placed.
Baseline characteristics (including PISQ-12 scores) were
similar between the four treatment arms, with notable
exceptions including race–ethnicity, prolapse stage, con-
comitant surgery, and number of vaginal deliveries. After
adjustment for differences between the groups, there was
a clinically important improvement in PISQ-12 scores over
the 24-month postoperative period for all treatment
groups, with no significant differences attributed to the type
of anti-incontinence procedure (baseline PISQ-12: 32.6,
33.1, 31.9, 31.4; 24-month PISQ-12: 37.7, 37.8, 36.9, 37.1,
P,.01). There was no significant difference in mean PISQ-
12 scores between 12 months and 24 months (12-month
PISQ-12: 37.7, 37.8, 36.9, 37.1; 24 months as above, P5.97).
Multivariable analysis showed independent associations
between objective and subjective cure rates as well as con-
comitant procedures with a 24-month PISQ-12 score.
CONCLUSION: Women undergoing anti-incontinence
surgery show overall improvement in sexual function
from baseline to 24 months postoperatively, without
significant differences based on surgical procedure per-
formed. The majority of this improvement occurs in the
first 12 months and is maintained over 24 months.
(Obstet Gynecol 2020;135:352–60)
DOI: 10.1097/AOG.0000000000003648
U
rinary incontinence is a common problem in
adult women, affecting as much as 28–55% of
the population.1 Female sexual dysfunction is shown
OBSTETRICS & GYNECOLOGY
to have a direct relation to the severity of stress uri-
nary incontinence (SUI).2 Patients often cite numer-
ous reasons for urinary incontinence contributing to
sexual dissatisfaction, including embarrassment, psy-
chological distress, fear of coital incontinence, loss of
self-esteem, and dyspareunia.3
There is a growing body of literature concerning
female sexual function after treatment for urinary
incontinence. Pelvic floor muscle therapy has been
shown to improve sexual function as well as urinary
incontinence symptoms.4,5 Surgical treatment, on the
other hand, has had unclear effects on sexual function.
Several studies have shown an improvement in sexual
function after surgical correction.6–8 Though even in
studies that show an overall improvement in sexual
function, de novo dyspareunia may occur.8 A system-
atic review and meta-analysis of surgery for SUI
showed that coital incontinence improves after inter-
vention, but the authors did not observe an improve-
ment or deterioration in overall female sexual
function.9 The relationship between surgical treat-
ment and improvement in sexual function has yet to
be fully elucidated.
This study evaluates four of the standard surgical
interventions for SUI (Burch colposuspension, autol-
ogous fascial sling, retropubic and transobturator
polypropylene midurethral slings) and their relation-
ship to postoperative sexual function. Each of these
methods is shown to be highly effective for SUI
treatment, with the autologous fascial pubovaginal
sling and the retropubic midurethral sling being
slightly more effective in each of the individual studies
from this secondary analysis.10,11 Although the four
surgical approaches are all effective for resolving
symptoms of SUI, there may be important differences
between them regarding their effect on sexual func-
tion. Our primary aim was to determine whether
there was a difference in 24-month postoperative sex-
ual function between treatment groups. Secondarily,
we sought to explore the effects of subjective and
objective surgical cure rates and concomitant surgical
procedures on 24-month sexual function. We hypoth-
esized that women with SUI who were undergoing
surgical treatment would experience an overall
improvement in sexual function from baseline to 24
months and that there would be no significant differ-
ence between surgical treatment options.
METHODS
This is a secondary analysis of the SISTEr (Stress
Incontinence Surgical Treatment Efficacy Trial) and
TOMUS (Trial of Mid-Urethral Slings). Both were
multicenter randomized trials that compared Burch
VOL. 135, NO. 2, FEBRUARY 2020 Glass Clark et al
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
colposuspension to autologous fascial sling and retro-
pubic to transobturator midurethral slings. The SIS-
TEr study was conducted from February 2002
through June 2006. The TOMUS study was con-
ducted from April 2006 through June 2010. The data
were obtained by accessing the Central Repository for
the National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK). This study was classified
as exempt by the Virginia Commonwealth University
Institutional Review Board (IRB HM20012510)
because these are both publicly available data sets.
The specifics of the designs and inclusion and
exclusion criteria for both trials have been published
previously.12,13 In brief, the inclusion criteria for the
original studies included adult women older than age
21 years who had stress-predominant urinary inconti-
nence for at least 3 months and were planning on
surgical intervention for SUI. We included women
who reported they were sexually active in the preced-
ing 6 months at any of the study visits (baseline study
visit, 12 months or 24 months postoperative study
visit [Fig. 1]). To be included in the analysis, patients
needed to report sexual activity at any of the study
visits and complete a short form of the PISQ-12 (Pel-
vic Organ Prolapse/Urinary Incontinence Sexual
Questionnaire) questionnaire at one of the included
study visits.
The primary aim of this study was to assess the
effect of surgical intervention for SUI on 2-year
postoperative condition specific sexual function and
to determine whether type of anti-incontinence surgi-
cal procedure affects postoperative sexual function. In
both trials, female sexual function information was
collected at study visits using the short version of the
PISQ-12 PISQ-12.14 Each of the 12 items in PISQ-12
has a score range of 0–4, with higher scores indicating
better sexual function. The PISQ-12 scores of each
patient was obtained at baseline, 12-month postoper-
ative visit, and 24-month postoperative visit. Only
participants who had been sexually active in the 6
months before the visit were eligible to answer the
PISQ-12. The PISQ-12 scores were compared at each
timepoint between treatment groups. There is
no minimum important difference established for
the PISQ-12; thus, we used one half the baseline stan-
dard deviation to determine clinical significance.15
Secondary aims of the study were to evaluate whether
subjective failure rate, objective failure rate, or other
concomitant procedures at the time of anti-
incontinence surgery were related to postoperative
sexual function.
Variables collected include baseline character-
istics and sociodemographic factors (age, body mass
Sexual Function After Stress Incontinence Surgery 353
 Fig. 1. Eligibility and exclusions for
analysis. Eligible from TOMUS
(Trial of Mid-Urethral Slings) (A)
and SISTEr (Stress Incontinence
Surgical Treatment Efficacy Trial)
(B). PISQ-12, Pelvic Organ Pro-
lapse/Urinary Incontinence Sexual
Questionnaire.
Glass Clark. Sexual Function After Stress
Incontinence Surgery. Obstet Gynecol
2020.

index, race–ethnicity, marital or partner status, preg-
nancy history, smoking status, menopausal status,
prior hormone therapy, prior incontinence treatment
including prior surgical treatment, prolapse severity,
and concomitant surgery at time of procedure), sur-
gical factors (type of procedure performed; subjective
failure, defined by negative results from Medical,
Epidemiological and Social Aspects of Aging Ques-
tionnaire; 3-day void diary; and no retreatment for
stress incontinence [behavioral, pharmacologic, or
surgical]), and objective failure, defined by negative
results from both provocative stress test and 24-hour
pad test as well as having received no retreatment for
stress incontinence.12,13 Sexual function data included
total PISQ-12 score at baseline,12 and 24 month post-
operative study visits, and sexual domain specific re-
sponses (behavioral and emotive, physical, partner).14
Differences in baseline characteristics of the
women across treatments were assessed with Pearson
x2 or one-way analysis of variance. To account for
excluding women without PISQ-12 data, we evalu-
ated the rates of sexual activity for patients within
each treatment group and the change therein across
treatment groups using cross classification with treat-
ments. A linear mixed effect model was used to pre-
dict the PISQ-12 scores using time (baseline, 12
month follow-up, 24 month follow-up), treatment
group, and other baseline or treatment variables
related to the outcome. This model both allows for
the assessment of predictors of continuous outcome

Table 1. Sexual Inactivity Changes Across the Study Period by Procedure Type

Transobturator Sling Retropubic Sling Burch Procedure Fascial Sling P

Baseline 94/297 (31.7) 96/296 (32.4) 104/326 (31.9) 95/323 (29.4) .85
12 mo postoperative 92/263 (35.0) 87/263 (33.1) 82/252 (32.5) 75/257 (29.2) .56
24 mo postoperative 93/241 (38.6) 75/227 (33.0) 81/238 (34.0) 81/249 (32.5) .49
Data are n/N (%) of patients who were not sexually active at each study timepoint, unless otherwise specified.

354 Glass Clark et al Sexual Function After Stress Incontinence Surgery OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 2. Selected Characteristics of Patients

Transobturator Retropubic Sling Burch Procedure Fascial Sling

Characteristic Sling (n5220) (n5216) (n5239) (n5249) P

Age (y) 50.0610.1 50.669.7 49.669.8 49.169.2 .40

BMI (kg/m2) 29.666.4 29.866.6 29.266.2 29.865.9 .69
No. of pregnancies 3.161.6 3.261.7 3.361.7 3.461.7 .32
No. of vaginal deliveries 2.361.4 2.361.3 2.661.5 2.661.5 .04*
Race ethnic group ,.01*
Hispanic 29 (13.2) 28 (13.0) 17 (7.1) 31 (12.5)
Non-Hispanic white 170 (77.2) 170 (79.1) 181 (76.1) 179 (71.9)
Non-Hispanic black 7 (3.2) 5 (2.3) 12 (5.0) 20 (8.0)
Other 14 (6.4) 12 (5.6) 28 (11.8) 19 (7.6)
Marital or partner status .51
Not married 41 (18.6) 46 (21.3) 43 (18.0) 57 (22.9)
Married or living with partner 179 (81.4) 170 (78.7) 196 (82.0) 192 (77.1)
Current smoking status .06
No 194 (88.2) 192 (88.9) 210 (87.9) 203 (81.5)
Yes 26 (11.8) 24 (11.1) 28 (12.1) 46 (18.5)
Prior UI surgery .79
No 193 (87.7) 193 (89.4) 206 (86.2) 218 (87.5)
Yes 27 (12.3) 23 (10.6) 33 (13.8) 31 (12.5)
Prior UI treatment .10
No 104 (47.3) 105 (48.6) 133 (55.6) 141 (56.6)
Yes 116 (52.7) 111 (51.4) 106 (44.4) 108 (43.4)
Prolapse stage ,.01*
No prolapse 18 (8.1) 19 (8.8) 13 (5.4) 9 (3.6)
1 89 (40.5) 74 (34.3) 46 (19.2) 43 (17.3)
2 100 (45.5) 108 (50.0) 144 (60.3) 158 (63.4)
3 9 (4.1) 10 (4.6) 31 (13.0) 30 (12.0)
4 4 (1.8) 5 (2.3) 5 (2.1) 9 (3.6)
Menopausal status .75
Premenopausal 84 (38.2) 78 (36.1) 82 (34.3) 95 (38.2)
Postmenopausal 87 (39.5) 82 (38.0) 97 (40.6) 83 (33.3)
Somewhere in between 38 (17.3) 48 (22.2) 51 (21.3) 60 (24.1)
Not sure 11 (5.0) 8 (3.7) 9 (3.8) 11 (4.4)
Hormone therapy .23
No 78 (35.5) 90 (41.6) 81 (33.9) 80 (32.3)
Yes 58 (26.3) 48 (22.2) 76 (31.8) 73 (29.4)
No, premenopausal 84 (38.2) 78 (36.1) 82 (34.3) 95 (38.3)
Concomitant surgery ,.01*
No 169 (76.8) 167 (77.3) 105 (44.0) 98 (39.4)
Yes 51 (23.2) 49 (22.7) 134 (56.0) 151 (60.6)
Objective failure .17
No 167 (75.9) 171 (79.2) 173 (73.6) 202 (81.5)
Yes 53 (24.1) 45 (20.8) 62 (26.4) 46 (18.5)
Subjective failure .39
No 112 (50.9) 125 (57.9) 123 (52.3) 141 (56.9)
Yes 108 (49.1) 91 (42.1) 112 (47.7) 107 (43.1)
BMI, body mass index; UI, urinary incontinence.
Data are mean6SD or n (%) unless otherwise specified. P-values for continuous variables were obtained with analysis of variance. For
categorical variables, P-values were calculated using the Pearson x2 test for two-way tables.
* P,.05.

and is able to account for longitudinal measurements.
A parsimonious set of baseline and treatment varia-
bles were obtained from a backward selection proce-
dure that always included time, treatment, and the
interaction of treatment and time. A first-order auto-
regressive error structure was assumed. Because the
final model indicated no interaction, mean changes
between timepoints were calculated averaging over
the treatment groups.
Generalized linear regression models were then
created to evaluate the 24-month PISQ-12 score as
a factor of subjective and objective failure rates of the

VOL. 135, NO. 2, FEBRUARY 2020 Glass Clark et al Sexual Function After Stress Incontinence Surgery 355

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.

Fig. 2. Mean PISQ-12 (Pelvic Organ Prolapse/Urinary
Incontinence Sexual Questionnaire) score at each included
study visit (baseline, 12-month postoperative, 24-month
postoperative). Error bars correspond to 95% CIs. Graph
shows the improvement in mean sexual function, as mea-
sured by PISQ-12, over the study period and the mainte-
nance of the improvement from 12 to 24 months.
Glass Clark. Sexual Function After Stress Incontinence Surgery.
Obstet Gynecol 2020.
surgical procedure as well as a factor of a concomitant
surgery. These models adjusted for baseline PISQ-12
score, as well as any baseline differences between
treatment groups identified. A one-way analysis of
variance was then used to evaluate differences in
individual responses to the PISQ-12 questions as well
as the sexual domains (behavioral or emotive, phys-
ical, partner) between treatment groups.
All statistical analyses were performed in SAS 9.4
or JMP Pro 14.0.0, and graphical results were
generated using R. An a priori alpha of 0.05 was
used to determine statistical significance.
RESULTS
Nine hundred twenty-four women met inclusion crite-
ria (Fig. 1). Before proceeding with analysis of the
included patients, an additional analysis was performed
of women who were sexually active and inactive; there
was no difference or significant change in the number
of sexually active women across the four treatment
groups (baseline visit P5.85, 12-month postoperative
P5.56, 24-month postoperative P5.49) (Table 1). Of
the 1,252 patients from the original studies, 924 were
sexually active and completed PISQ-12 questionnaires
at either baseline or at 12 month or 24 month follow up
visits, and were included in the final analyses (Fig. 1).
Of the 924 total women included in final analy-
ses: 249 (26.9%) had an autologous fascial sling, 239
(25.9%) underwent Burch colposuspension, 216
(23.3%) had a retropubic midurethral sling placed
and 220 (23.8%) had transobturator midurethral sling
placed. Baseline characteristics among all four treat-
ment groups were similar overall (Table 2). Excep-
tions to this were differences observed in race–
ethnic group (P,.01), the number of vaginal deliver-
ies (P5.04), prolapse stage (P,.01), and concomitant
prolapse repair surgery (P,.01).
There were no significant differences in mean PISQ-
12 scores between the four treatment groups at the time of
baseline (P5.07), the 12 month visit (P5.42), and the 24-
month visit (P5.50). Patients in the two studies exhibited
an overall improvement in sexual function over the 24-
month study period (Fig. 2 and Table 3). Specifically,
sexual function scores were higher at 12 month and 24
month follow-up time periods compared with baseline
after adjusting for baseline differences (baseline PISQ-
12: 32.6, 33.1, 31.9, 31.4; 12-month PISQ-12: 37.7,
37.8, 36.9, 37.1; 24-month PISQ-12: 37.7, 37.8, 36.9,
37.1). The majority of the improvement in sexual function
was observed at the first 12 months after surgery visit and
was maintained over the second postoperative year. There
was no significant difference in mean PISQ-12 scores
between the 12-month follow-up and the 24-month
follow-up (P5.97). There is no published minimum
important difference for the PISQ-12, so we conserva-
tively estimated the minimum important difference as half
the standard deviation of the baseline score.15 The SD of
PISQ-12 at baseline is 7.08 for all surgical treatment
groups. The mean scores for each treatment improved
beyond this estimate for minimum important difference
regardless of treatment type (Table 3).

Table 3. Mean Change in Sexual Function Over the 2-Year Postoperative Period

Measure of Sexual Transobturator

Function Sling Retropubic Sling Burch Procedure Fascial Sling P

PISQ-12
Baseline 32.6 (31.6–33.5), 204 33.1 (32.1–34.0), 201 31.9 (31.0–32.8), 220 31.4 (30.4–32.3), 225 .07
At 12 mo 37.7 (36.8–38.5), 167 37.8 (37.0–38.6), 169 36.9 (36.1–37.8), 166 37.1 (36.2–38.0), 179 .42
At 24 mo 37.7 (36.7–38.7), 144 37.1 (36.1–38.0), 148 36.7 (35.8–37.6), 154 37.4 (36.5–38.3), 167 .50
Change, baseline–24 mo 4.7 (3.7–5.7), 135 3.4 (2.5–4.4), 138 4.3 (3.3–5.2), 142 5.1 (4.2–6.0), 142 .08
Data are mean (95% CI), n unless otherwise specified.

356 Glass Clark et al Sexual Function After Stress Incontinence Surgery OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 4. Individual Question Responses to PISQ-12

Transobturator Retropubic Burch Fascial

Sling Sling Procedure Sling P

Q1. How frequently do you feel sexual desire? This feeling may
include wanting to have sex, planning to have sex,
feeling frustrated due to lack of sex, etc.
Baseline 2.8660.95 2.9460.96 2.7360.97 2.7660.88 .09
12 mo postoperative 2.7560.99 2.7260.93 2.7760.96 2.6660.87 .72
24 mo postoperative 2.6660.95 2.8560.98 2.6960.95 2.6860.89 .27
Q2. Do you climax (have an orgasm) when having sexual
intercourse with your partner?
Baseline 2.7461.17 2.6161.12 2.6261.19 2.6861.13 .64
12 mo postoperative 2.5861.07 2.5261.13 2.6061.12 2.6761.18 .66
24 mo postoperative 2.5661.19 2.5561.14 2.6761.16 2.5161.05 .61
Q3. Do you feel sexually excited (turned on) when having
sexual activity with your partner?
Baseline 2.1961.06 2.1861.15 2.1360.99 2.1861.05 .94
12 mo postoperative 2.0961.00 2.1361.07 2.0260.92 2.0560.97 .76
24 mo postoperative 2.0561.08 2.1361.04 2.0860.98 2.0560.90 .90
Q4. How satisfied are you with the variety of sexual activities in
your current sex life?
Baseline 2.4461.17 2.3961.20 2.2761.06 2.4561.12 .33
12 mo postoperative 2.1161.06 2.2361.17 2.0660.96 2.1561.02 .47
24 mo postoperative 2.0761.13 2.2561.11 2.1161.00 2.1661.03 .49
Q5. Do you feel pain during sexual intercourse?
Baseline 3.7961.13 3.9161.12 3.6461.18 3.6361.19 .04*
12 mo postoperative 4.1461.00 4.1561.01 4.1261.00 4.1361.04 .99
24 mo postoperative 4.1661.06 4.1761.08 4.1261.08 4.1461.07 .98
Q6. Are you incontinent of urine (leak urine) with sexual
activity?
Baseline 3.4661.19 3.4761.25 3.2761.21 3.3261.24 .21
12 mo postoperative 4.7560.60 4.7160.64 4.6260.78 4.7260.65 .37
24 mo postoperative 4.6660.68 4.7460.59 4.5860.82 4.7060.71 .24
Q7. Does fear of incontinence (either stool or urine) restrict
your sexual activity?
Baseline 3.5461.34 3.7261.28 3.3561.26 3.4661.32 .03*
12 mo postoperative 4.7660.64 4.8160.54 4.6260.74 4.7660.66 .04*
24 mo postoperative 4.7660.66 4.7760.58 4.6160.82 4.7560.67 .12
Q8. Do you avoid sexual intercourse because of bulging in the
vagina (either the bladder, rectum or vagina falling out)?
Baseline 4.5161.00 4.6260.85 4.2561.16 4.3161.08 ,.01*
12 mo postoperative 4.9360.29 4.9460.26 4.8660.46 4.8960.49 .18
24 mo postoperative 4.8760.57 4.9960.11 4.8360.53 4.8960.48 .03*
Q9. When you have sex with your partner, do you have
negative emotional reactions such as fear, disgust, shame
or guilt?
Baseline 4.1361.19 4.1861.12 4.0261.13 3.8661.28 .02*
12 mo postoperative 4.7560.72 4.8460.46 4.6860.76 4.7660.74 .19
24 mo postoperative 4.7260.72 4.7260.74 4.6860.79 4.7960.67 .59
Q10. Does your partner have a problem with erections that
affects your sexual activity?
Baseline 4.3961.03 4.2161.12 4.2461.12 4.2261.08 .31
12 mo postoperative 4.4160.99 4.2661.11 4.1961.18 4.1961.08 .21
24 mo postoperative 4.4260.98 4.1861.16 4.1461.15 4.2761.02 .12
Q11. Does your partner have a problem with premature
ejaculations that affects your sexual activity?
Baseline 4.5560.90 4.4660.92 4.4660.89 4.3361.06 .14
12 mo postoperative 4.6560.78 4.5860.84 4.4560.93 4.4460.99 .08
24 mo postoperative 4.6260.80 4.4560.96 4.4760.92 4.4560.88 .28
(continued )

VOL. 135, NO. 2, FEBRUARY 2020 Glass Clark et al Sexual Function After Stress Incontinence Surgery 357

© 2020 by the American College of Obstetricians

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Unauthorized reproduction of this article is prohibited.
Table 4. Individual Question Responses to PISQ-12 (continued )
Transobturator Retropubic Burch Fascial
Sling Sling Procedure Sling P

Q12. Compared to orgasms you have had in the past, how

intense are the orgasms you have had in the past six
months?
Baseline 2.5860.87 2.5860.87 2.4960.93 2.3960.87 .15
12 mo postoperative 2.7760.86 2.8860.85 2.8560.87 2.7360.87 .39
24 mo postoperative 2.8260.94 2.7060.79 2.8460.95 2.8460.86 .45
Data are mean6SD unless otherwise specified.
*P,.05.

We found that postoperative objective failure and
subjective failure are significantly associated with lower
PISQ-12 scores in a generalized linear regression,
controlling for baseline differences (P,.01, P,.01).
Concomitant prolapse repair surgery is significantly
associated with higher PISQ-12 scores when control-
ling for baseline characteristic differences (P,.01).
We examined responses to all questions in the
PISQ-12 questionnaire. The mean score for individual
questions by surgical treatment group are shown at all
timepoints in Table 4. Interestingly, statistically signif-
icant differences were observed for pain (question 4)
and negative emotional reactions (question 9) with
sexual intercourse at baseline that were no longer seen
at 12 or 24 months postoperatively. Similarly, fear of
incontinence at baseline and 12 months (question 7)
and avoidance of sexual intercourse because of bulg-
ing in to the vagina (question 8) at baseline and 24
months were different between groups (Table 4). In
terms of domains, at baseline the physical and partner
domains showed significant differences between treat-
ment groups (Table 5), but these differences were no
longer detected postoperatively and no differences
were noted in the behavioral or emotive domain at
any timepoint.
Although the differences in sexual function do-
mains and individual condition-specific questions show
statistically significant differences, they are all less than
0.4 points different in mean scores between surgical
treatment groups, which is lower than the baseline
standard deviation for all questions and domains, and
therefore unlikely clinically meaningful (Tables 4 and
5). The greatest improvement from baseline to postop-
eratively in sexual function postoperatively was seen in
the specific questions 6 and 7 “are you incontinent of
urine with sexual activity” or “does fear of incontinence
restrict your sexual activity?” and was noted in the
physical domain, although improvements in all three
domains were apparent in these data.
DISCUSSION
The primary aim of this study was to identify the
effect of surgical intervention for SUI on 2-year
postoperative condition-specific sexual function and
to determine whether type of anti-incontinence surgi-
cal procedure affects postoperative sexual function.

Table 5. Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–Specific Domains Affected by

Incontinence

Domain Transobturator Sling Retropubic Sling Burch Procedure Fascial Sling P

Behavioral, Emotive
Baseline 9.77 (3.45) 9.91 (3.61) 10.24 (3.24) 9.93 (3.24) .52
12 mo postoperative 10.46 (3.35) 10.42 (3.66) 10.54 (3.13) 10.46 (3.35) .99
24 mo postoperative 10.67 (3.67) 10.25 (3.58) 10.47 (3.23) 10.60 (3.15) .72
Physical
Baseline 11.20 (3.42) 11.66 (3.39) 10.52 (3.42) 10.72 (3.27) ,.01*
12 mo postoperative 14.59 (1.75) 14.62 (1.64) 14.22 (2.02) 14.50 (1.96) .19
24 mo postoperative 14.44 (1.96) 14.67 (1.64) 14.14 (2.33) 14.48 (2.09) .15
Partner
Baseline 11.38 (2.66) 11.47 (2.51) 11.24 (2.37) 10.82 (2.64) .04*
12 mo postoperative 12.56 (2.18) 12.58 (2.06) 12.14 (2.26) 12.10 (2.33) .06
24 mo postoperative 12.58 (2.30) 12.06 (2.37) 12.15 (2.37) 12.35 (2.11) .21
Behavioral, Emotive domain5questions 1–4; Physical domain5questions 5–9; Partner domain5questions 10–12. Data are mean6SD
unless otherwise specified.
*P,.05.

358 Glass Clark et al Sexual Function After Stress Incontinence Surgery OBSTETRICS & GYNECOLOGY

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Unauthorized reproduction of this article is prohibited.
There is an overall clinically meaningful improve-
ment in sexual function 2 years after anti-incontinence
surgery, independent of the type of procedure per-
formed. This was true for overall sexual function as
well as condition-specific questions regarding recur-
rent incontinence, prolapse, pain or sexual function
domains (physical, behavioral or emotive, or partner).
This supported our hypothesis. Interestingly, we did
not find a significant difference in sexual function
between 12 and 24 months, which suggests that most
of the improvements in female sexual function as
measured by PISQ-12 had occurred within the first
12-month period after treatment for SUI. This is
a particularly salient point for care of and counseling
patients who are undergoing anti-incontinence proce-
dures that the improvements in sexual function
initially seen do not significantly decrease over time.
This study is strengthened by the data obtained
from the original SISTEr and TOMUS trials’ being
validated, condition-specific, and in a large random-
ized population. The PISQ-12 questionnaire is
a strength of this study because it addresses multiple
domains of sexual function for patients; the differen-
tiation of the domains helps demonstrate that the
greatest improvement in sexual function postopera-
tively derives from the physical domain in sexual
function as it relates to coital incontinence or fear of
coital incontinence. The study is also strengthened by
the number of patients with responses out to 24
months, which is reflective of more stable, long-term
quality of life metrics. However, the generalizability of
this study is limited by the low degree of diversity
among women in these trials.
Although the PISQ-12 is an excellent tool for
measuring sexual function in our study population,
there are limitations to its use. It does not address
sexual stimulation or nonpenetrative vaginal inter-
course. Additionally, it limits partner-related prob-
lems to erectile dysfunction and premature
ejaculation; some eligible participants may be
excluded secondary to sexual preferences given the
assumptions inherent to the questionnaire that the
partner is male. This does limit our ability to evaluate
important aspects of sexual function for our patients
such as self-stimulation, same sex partners and sexual
activity beyond vaginal penetration.
This was a secondary analysis comparing four
surgical intervention groups; thus, we do not have
a nonsurgical treatment or control group for compar-
ison. Because we excluded participants who did not
complete PISQ-12 survey, we limited the opportunity
to allow those patients to provide a free-text response
for why they were not sexually active, which may
VOL. 135, NO. 2, FEBRUARY 2020 Glass Clark et al
© 2020 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
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pertain to their SUI symptoms or may be completely
unrelated. Though in our study there were no differ-
ences in sexual activity compared with inactivity
between treatment groups. Additionally, the study is
limited by the decreasing response rates and loss to
follow up for patients over the 24 months study
period. This has a potential to bias our results and
overestimate improvement in sexual function over the
study period.
These data contribute to the growing body of
literature of postoperative sexual function after four
commonly performed anti-incontinence procedures.
This study and others demonstrate that sexual
function improves with surgical improvement of
stress incontinence which may suggest a possible
association of urinary incontinence and sexual dys-
function.3,16 As we continue to explore the complex
and multi-faceted problem of sexual dysfunction, fur-
ther evaluation of the effect of pelvic floor disorders—
and their treatments—will be important and necessary
research.
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PEER REVIEW HISTORY
Received August 26, 2019. Received in revised form October 11,
2019, and October 25, 2019. Accepted November 1, 2019. Peer
reviews and author correspondence are available at http://links.
lww.com/AOG/B698.

360 Glass Clark et al Sexual Function After Stress Incontinence Surgery OBSTETRICS & GYNECOLOGY

© 2020 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.