Abstract
No conclusions have been reached on whether female stress urinary incontinence (SUI) and related treatments affect male partners’ sexual function.
To assess the effects of female SUI and related treatments on male partners’ sexual function.
A comprehensive search of the PubMed, Embase, Web of Science, Cochrane, and Scopus databases was performed up to September 6, 2022. Studies were included that investigated the effect of female SUI and related treatments on male partners’ sexual function.
Male partners’ sexual function.
Of the 2294 citations identified, 18 studies with 1350 participants were included. Two studies assessed the effect of female SUI without treatment on male partners’ sexual function, finding that partners had more erectile dysfunction, more sexual dissatisfaction, and less sexual frequency than partners of women without urinary incontinence. Seven studies directly assessed the effect of female SUI treatments on male partners’ sexual function by surveying the male partners. Among these, 4 assessed transobturator suburethral tape (TOT) surgery; 1 assessed TOT and tension-free vaginal tape obturator surgery; and the remaining 2 assessed pulsed magnetic stimulation and laser treatment. Among the 4 TOT studies, 3 used the International Index of Erectile Function (IIEF). TOT surgery significantly improved the total IIEF score (mean difference [MD] = 9.74, P < .00001), along with erectile function (MD = 1.49, P < .00001), orgasmic function (MD = 0.35, P = .001), sexual desire (MD = 2.08, P < .00001), intercourse satisfaction (MD = 2.36, P < .00001), and overall satisfaction (MD = 3.46, P < .00001). However, the improvements in IIEF items may be of unclear clinical significance, as 4 points in the erectile function domain of the IIEF are typically defined as the minimal clinically important difference. In addition, 9 studies indirectly assessed the effect of female SUI surgery on male partners’ sexual function by surveying patients with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. The results demonstrated no significant differences in erectile function (MD = 0.08, P = .40) or premature ejaculation (MD = 0.07, P = .54).
The effects of female SUI and related treatments on male partners’ sexual function were summarized for the first time, providing a reference for future clinical practice and scientific research.
A limited number of studies that used various scales met the standardized eligibility criteria.
Female SUI may affect male partners’ sexual function, and female patients’ anti-incontinence surgery does not appear to have a clinically significant improvement on the sexual function of their partners.
Introduction
Urinary incontinence is a common health problem that significantly affects an individual’s quality of life.1 Urinary incontinence can be divided into many types according to the symptoms and etiology. Stress urinary incontinence (SUI) is one of the most common types. In Europe, the rate of SUI in women aged ≥40 years is 15.9%, which is significantly higher than that in men of the same age.2 In China, the rate of SUI in women of all ages is 18.9%, and it is 28.0% in women aged 50 to 59 years.3
Urine leakage can stimulate the vulvovaginal area and thereby lead to dyspareunia. Psychological harm caused by urine leakage during sexual intercourse may also decrease sexual interest and behavior. Thus, SUI has adverse effects not only on patients’ physical and mental health but also on their sexual function, at a rate of approximately 50%.4 The reported rate of coital incontinence in patients with SUI is between 28% and 70%, which can limit or even lead to complete abandonment of couples’ sex lives.5
Various approaches have been recommended for the treatment of SUI. Midurethral sling anti-incontinence surgery—including retropubic tension-free vaginal tape (TVT), transobturator suburethral tape (TOT), and TVT obturator (TVT-O)—has been recommended as a first-line intervention for SUI.6 In these procedures, the supportive periurethral tissue is strengthened by the tension-free tape to maintain the normal structure of the tissue that helps to control urination. In TOT surgery, the sling traverses the obturator foramen; in TVT surgery, the sling is placed behind the pubic bone adjacent to the urethra.
The impact of SUI surgery on sexual function has received attention in the medical literature, but studies have reached conflicting conclusions. Nevertheless, 2 meta-analyses7,8 found a positive effect of anti-incontinence surgery on the sexual function of female patients with SUI. The authors speculated that the remission of urine leakage during sexual intercourse was the main factor underlying the improvement in sexual function. However, concerns have been raised about the safety of SUI surgery due to the risk of neurovascular damage and dyspareunia.
A decrease in female sexual function may affect male partners’ sexual function. Several studies have assessed the effect of female SUI on male partners’ sexual function,9,10 but no definitive conclusion has been reached due to the limited sample sizes and differences among the studies. A small number of studies11-15 have assessed the effect of female SUI treatments on male partners’ sexual function by directly surveying the partners. However, the results of the studies are contradictory, which may be related to the different types of treatments investigated. There are no reviews summarizing the effects of female SUI or related treatments on male partners’ sexual function.
In this study, we aimed to summarize the impact of female SUI and related treatments on male partners’ sexual function for the first time to provide a reference for future clinical practice and scientific research.
Methods
The protocol for this systematic review was prospectively registered (CRD42022371469; PROSPERO). This review was based on the MOOSE guidelines (Meta-analysis of Observational Studies in Epidemiology)16 and the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-analyses).17
Data sources and searches
Five electronic databases (PubMed, Embase, Web of Science, Cochrane Library, and Scopus) were searched for relevant studies from database inception to September 6, 2022. The searches were based on the following keywords: “stress urinary incontinence,” “male partner,” and “sexual function.” The PubMed search strategy was as follows:
(“Urinary Incontinence, Stress”[MeSH] OR stress urinary incontinence OR stress incontinence OR stress incont* OR occult incontinence OR masked incontinence OR de novo incontinence) AND (“Sexual Partners”[MeSH] OR “Spouses”[MeSH] OR Partner OR Spouse OR Male OR Husband) AND (“Sexual Behavior”[MeSH] OR Sexual Behavior OR sexual function OR Sexual activity OR sex*).
Inclusion and exclusion criteria
Studies were included if they assessed the effect of female SUI and/or female SUI treatment on male partners’ sexual function by directly surveying male partners or surveying female patients with SUI with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ).
The exclusion criteria were as follows: nonoriginal articles (eg, commentaries, editorials, letters to editors, and reviews), case reports, and conference abstracts; irrelevant studies and animal studies; and lack of data required for analysis.
Study selection and data extraction
About 3 weeks later, once we finished the literature screening, we started the study selection process. The search data were exported to a reference management software program (Endnote X9), and duplicates were discarded. The titles and abstracts of the remaining articles were screened, followed by assessment of the relevant full texts for eligibility; this was conducted independently by the 2 primary reviewers (Z.T. and X.W.), with disagreements resolved by a third reviewer (L.F.). The following data were extracted: first author, publication year, country, study type, characteristics (outcome measure, intervention, and size), and outcomes.
Outcome measures
Nine studies directly assessed male partners
Two studies9,10 assessed the effect of female SUI without treatment on male partners’ sexual function by using the Golombok-Rust Inventory of Sexual Satisfaction (GRISS)18 (Table 2). The GRISS consists of 12 subscales: erectile dysfunction and premature ejaculation for males; vaginismus and anorgasmia for females; and nonsensuality, avoidance, dissatisfaction, sexual infrequency, and sexual noncommunication for both partners. The higher the score, the more serious the problem.
Four studies assessed the effect of TOT surgery on male partners’ sexual function. Among these, 3 studies11-13 used the International Index of Erectile Function–5 (IIEF-5) (Figure 2), and 1 study19 used the Male Sexual Health Questionnaire (MSHQ) (Table 3). The IIEF-5 assesses erectile function in terms of 5 items20: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. Each item is scored from 0 to 5. A higher score indicates better erectile function. The MSHQ21 assesses male sexual function in terms of 6 aspects: sexual relationship, quality of sex life, sex frequency, partner’s affection during sex, communication about sex, and other relationships. A higher score indicates better sexual function.
One study22 assessed the effect of TOT/TVT-O surgery on male partners’ sexual function via an informal questionnaire (Table 3).
Two studies assessed the effect of pulsed magnetic stimulation14 or laser treatment15 on male partners’ sexual function, with the former using GRISS and the latter an informal questionnaire (Table 3).
Nine studies indirectly assessed male partners by surveying female patients with SUI
Seven studies23-29 assessed the effect of female SUI surgery on male partners’ sexual function by using the short form of the PISQ (ie, the PISQ-12; Figure 3). The PISQ30 is a reliable and validated questionnaire that assesses sexual function in women with pelvic organ prolapse or SUI, and the PISQ-12 is one of the most common versions used in clinical practice. The PISQ-12 contains 12 items divided into 3 domains31: items 1 to 4, the behavioral/emotive domain; items 5 to 9, the physical domain; and items 10 to 12, the partner-related domain. A higher score indicates better sexual function. Regarding the partner-related domain, items 10 and 11 are more partner related, as they represent female patients’ views about their male partners’ erectile dysfunction or premature ejaculation, respectively, and item 12 represents the women’s views about their orgasms, which, although related to their male partners’ sexual function, are also influenced by their own sexual function.
Baseline characteristics of the studies.
| Study | Country | Study type | Scale | Invention | Size | Qualitya |
|---|---|---|---|---|---|---|
| Oğlak (2020)11 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 157 | 7/9 |
| Bekker (2010)10 | Netherlands | Cross-sectional | GRISS | With or without UI | 81 | 7/11 |
| Narin (2014)12 | Turkey | Cohort | IIEF-5 | 3 mo after TOT | 28 | 5/9 |
| Hsiao (2018)22 | China | Cohort | Questionnaire | 3 mo after TOT or TVT-O | 13 | 6/9 |
| Lim (2016)9 | Malaysia | Cross-sectional | GRISS | With or without SUI | 66 | 8/11 |
| Lim (2018)14 | Malaysia | Cohort | GRISS | 6 mo after magnetic stimulation | 48 | 6/9 |
| Tien (2017)15 | China | Cohort | Questionnaire | 3 and 6 mo after laser treatment | 30 | 7/9 |
| Turgut (2021)13 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 202 | 7/9 |
| Ko (2016)19 | Korea | Cohort | MSHQ | 3, 6 and 12 mo after TOT | 56 | 7/9 |
| Lau (2010)25 | China | Cohort | PISQ-12 | 6 mo after TVT-O | 56 | 7/9 |
| Liang (2012)26 | China | Cohort | PISQ-12 | 12 mo after TOT | 57 | 7/9 |
| Tang (2013)28 | China | Cohort | PISQ-12 | 6 and 12 mo after TVT-S | 28 | 7/9 |
| Glavind (2014)27 | Denmark | Cohort | PISQ-12 | 6 mo after TVT | 51 | 7/9 |
| Kizilkan (2020)23 | Turkey | Cohort | PISQ-12 | 6 mo after TOT | 117 | 7/9 |
| Latul (2022)32 | Netherlands | Cohort | PISQ-IR | 6 and 12 mo after MUS | 101 | 6/9 |
| Horosz (2020)33 | Poland | Cohort | PISQ-IR | 6 to 12 mo after TVT | 77 | 6/9 |
| Zhang (2020)24 | China | Cohort | PISQ-12 | 12 mo after TVT | 105 | 7/9 |
| Gümüş (2018)29 | Turkey | Cohort | PISQ-12 | 12 mo after TOT or L/S Burch | 77 | 7/9 |
| Study | Country | Study type | Scale | Invention | Size | Qualitya |
|---|---|---|---|---|---|---|
| Oğlak (2020)11 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 157 | 7/9 |
| Bekker (2010)10 | Netherlands | Cross-sectional | GRISS | With or without UI | 81 | 7/11 |
| Narin (2014)12 | Turkey | Cohort | IIEF-5 | 3 mo after TOT | 28 | 5/9 |
| Hsiao (2018)22 | China | Cohort | Questionnaire | 3 mo after TOT or TVT-O | 13 | 6/9 |
| Lim (2016)9 | Malaysia | Cross-sectional | GRISS | With or without SUI | 66 | 8/11 |
| Lim (2018)14 | Malaysia | Cohort | GRISS | 6 mo after magnetic stimulation | 48 | 6/9 |
| Tien (2017)15 | China | Cohort | Questionnaire | 3 and 6 mo after laser treatment | 30 | 7/9 |
| Turgut (2021)13 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 202 | 7/9 |
| Ko (2016)19 | Korea | Cohort | MSHQ | 3, 6 and 12 mo after TOT | 56 | 7/9 |
| Lau (2010)25 | China | Cohort | PISQ-12 | 6 mo after TVT-O | 56 | 7/9 |
| Liang (2012)26 | China | Cohort | PISQ-12 | 12 mo after TOT | 57 | 7/9 |
| Tang (2013)28 | China | Cohort | PISQ-12 | 6 and 12 mo after TVT-S | 28 | 7/9 |
| Glavind (2014)27 | Denmark | Cohort | PISQ-12 | 6 mo after TVT | 51 | 7/9 |
| Kizilkan (2020)23 | Turkey | Cohort | PISQ-12 | 6 mo after TOT | 117 | 7/9 |
| Latul (2022)32 | Netherlands | Cohort | PISQ-IR | 6 and 12 mo after MUS | 101 | 6/9 |
| Horosz (2020)33 | Poland | Cohort | PISQ-IR | 6 to 12 mo after TVT | 77 | 6/9 |
| Zhang (2020)24 | China | Cohort | PISQ-12 | 12 mo after TVT | 105 | 7/9 |
| Gümüş (2018)29 | Turkey | Cohort | PISQ-12 | 12 mo after TOT or L/S Burch | 77 | 7/9 |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; IIEF-5, International Index of Erectile Function–5; L/S Burch, laparoscopic Burch procedure; MSHQ, Male Sexual Health Questionnaire; MUS, midurethral sling; PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, short form; PISQ-IR, Prolapse/Urinary Incontinence Sexual Questionnaire–IUGA Revised; SUI, stress urinary incontinence; TOT, transobturator suburethral tape; TVT, tension-free vaginal tape; TVT-O, tension-free vaginal tape obturator; TVT-S, tension-free vaginal tape–SECUR; UI, urinary incontinence.
The quality of the cross-sectional studies was evaluated by the Agency for Healthcare Research and Quality Scale (maximum score, 11), and the other cohort studies were evaluated by the Newcastle-Ottawa Scale (maximum score, 9).
Baseline characteristics of the studies.
| Study | Country | Study type | Scale | Invention | Size | Qualitya |
|---|---|---|---|---|---|---|
| Oğlak (2020)11 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 157 | 7/9 |
| Bekker (2010)10 | Netherlands | Cross-sectional | GRISS | With or without UI | 81 | 7/11 |
| Narin (2014)12 | Turkey | Cohort | IIEF-5 | 3 mo after TOT | 28 | 5/9 |
| Hsiao (2018)22 | China | Cohort | Questionnaire | 3 mo after TOT or TVT-O | 13 | 6/9 |
| Lim (2016)9 | Malaysia | Cross-sectional | GRISS | With or without SUI | 66 | 8/11 |
| Lim (2018)14 | Malaysia | Cohort | GRISS | 6 mo after magnetic stimulation | 48 | 6/9 |
| Tien (2017)15 | China | Cohort | Questionnaire | 3 and 6 mo after laser treatment | 30 | 7/9 |
| Turgut (2021)13 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 202 | 7/9 |
| Ko (2016)19 | Korea | Cohort | MSHQ | 3, 6 and 12 mo after TOT | 56 | 7/9 |
| Lau (2010)25 | China | Cohort | PISQ-12 | 6 mo after TVT-O | 56 | 7/9 |
| Liang (2012)26 | China | Cohort | PISQ-12 | 12 mo after TOT | 57 | 7/9 |
| Tang (2013)28 | China | Cohort | PISQ-12 | 6 and 12 mo after TVT-S | 28 | 7/9 |
| Glavind (2014)27 | Denmark | Cohort | PISQ-12 | 6 mo after TVT | 51 | 7/9 |
| Kizilkan (2020)23 | Turkey | Cohort | PISQ-12 | 6 mo after TOT | 117 | 7/9 |
| Latul (2022)32 | Netherlands | Cohort | PISQ-IR | 6 and 12 mo after MUS | 101 | 6/9 |
| Horosz (2020)33 | Poland | Cohort | PISQ-IR | 6 to 12 mo after TVT | 77 | 6/9 |
| Zhang (2020)24 | China | Cohort | PISQ-12 | 12 mo after TVT | 105 | 7/9 |
| Gümüş (2018)29 | Turkey | Cohort | PISQ-12 | 12 mo after TOT or L/S Burch | 77 | 7/9 |
| Study | Country | Study type | Scale | Invention | Size | Qualitya |
|---|---|---|---|---|---|---|
| Oğlak (2020)11 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 157 | 7/9 |
| Bekker (2010)10 | Netherlands | Cross-sectional | GRISS | With or without UI | 81 | 7/11 |
| Narin (2014)12 | Turkey | Cohort | IIEF-5 | 3 mo after TOT | 28 | 5/9 |
| Hsiao (2018)22 | China | Cohort | Questionnaire | 3 mo after TOT or TVT-O | 13 | 6/9 |
| Lim (2016)9 | Malaysia | Cross-sectional | GRISS | With or without SUI | 66 | 8/11 |
| Lim (2018)14 | Malaysia | Cohort | GRISS | 6 mo after magnetic stimulation | 48 | 6/9 |
| Tien (2017)15 | China | Cohort | Questionnaire | 3 and 6 mo after laser treatment | 30 | 7/9 |
| Turgut (2021)13 | Turkey | Cohort | IIEF-5 | 6 mo after TOT | 202 | 7/9 |
| Ko (2016)19 | Korea | Cohort | MSHQ | 3, 6 and 12 mo after TOT | 56 | 7/9 |
| Lau (2010)25 | China | Cohort | PISQ-12 | 6 mo after TVT-O | 56 | 7/9 |
| Liang (2012)26 | China | Cohort | PISQ-12 | 12 mo after TOT | 57 | 7/9 |
| Tang (2013)28 | China | Cohort | PISQ-12 | 6 and 12 mo after TVT-S | 28 | 7/9 |
| Glavind (2014)27 | Denmark | Cohort | PISQ-12 | 6 mo after TVT | 51 | 7/9 |
| Kizilkan (2020)23 | Turkey | Cohort | PISQ-12 | 6 mo after TOT | 117 | 7/9 |
| Latul (2022)32 | Netherlands | Cohort | PISQ-IR | 6 and 12 mo after MUS | 101 | 6/9 |
| Horosz (2020)33 | Poland | Cohort | PISQ-IR | 6 to 12 mo after TVT | 77 | 6/9 |
| Zhang (2020)24 | China | Cohort | PISQ-12 | 12 mo after TVT | 105 | 7/9 |
| Gümüş (2018)29 | Turkey | Cohort | PISQ-12 | 12 mo after TOT or L/S Burch | 77 | 7/9 |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; IIEF-5, International Index of Erectile Function–5; L/S Burch, laparoscopic Burch procedure; MSHQ, Male Sexual Health Questionnaire; MUS, midurethral sling; PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, short form; PISQ-IR, Prolapse/Urinary Incontinence Sexual Questionnaire–IUGA Revised; SUI, stress urinary incontinence; TOT, transobturator suburethral tape; TVT, tension-free vaginal tape; TVT-O, tension-free vaginal tape obturator; TVT-S, tension-free vaginal tape–SECUR; UI, urinary incontinence.
The quality of the cross-sectional studies was evaluated by the Agency for Healthcare Research and Quality Scale (maximum score, 11), and the other cohort studies were evaluated by the Newcastle-Ottawa Scale (maximum score, 9).
Two studies32,33 assessed the effect of female SUI surgery on male partners’ sexual function with the International Urogynecological Association Revised PISQ (PISQ-IR),34 which is based on the PISQ-12 and assesses sexual function in sexually active and inactive women with pelvic floor dysfunction. A higher score indicates better sexual function.
Assessment of study quality
The 2 primary reviewers (Z.T. and X.W.) independently evaluated the quality of the studies. Sixteen studies were cohort studies, and we used the Newcastle-Ottawa Scale35 to evaluate their quality. Studies scoring ≥5 were eligible for inclusion in the meta-analysis, with those scoring ≥7 classified as high quality and the remainder as moderate quality. Two studies were cross-sectional, and we used the checklist recommended by the Agency for Healthcare Research and Quality36 to evaluate their quality. The maximum attainable score was 11, and studies scoring ≥8 were classified as high quality (Table 1).
Statistical analysis
RevMan 5.3 (Cochrane) and Stata 12.0 (StataCorp) were used for statistical analysis. I2 tests were used to assess heterogeneity,37 and the random effects model was used when there was heterogeneity. We conducted subgroup analyses based on the follow-up time, surgery type, and region. We also conducted a sensitivity analysis to evaluate the effect of each study by using “metaninf” in Stata 12.0 (Figure S2). The Begg test38 was used to evaluate potential publication bias.
Results
Literature search
Figure 1 shows the detailed literature search process. The initial search yielded 2294 articles, and 846 duplicates were deleted. The remaining 1448 articles were screened by their titles and abstracts, and 1375 were excluded. The remaining 73 articles were further evaluated for eligibility. Ultimately, 18 studies were included in this review.9-15,19,22-29,32,33
PRISMA study selection flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses.
Characteristics of included studies
A summary of the characteristics of the 18 studies (with 1350 participants) is shown in Table 1. Sixteen studies were prospective cohort studies and 2 studies9,10 were cross-sectional. Six studies were carried out in China,15,22,24-26,28 5 in Turkey,11-13,23,29 2 in Malaysia,9,14 and 2 in the Netherlands,10,32 with the remaining 3 in Korea,19 Denmark,27 and Poland.33
Nine studies directly assessed the effects on male sexual function by surveying the male partners themselves: 2 assessed the effect of female SUI without treatment (both used GRISS9,10); 5 assessed the effect of anti-incontinence surgery (3 used IIEF,11-13 1 used MSHQ,19 and 1 used an informal questionnaire22); and 2 assessed the effect of pulsed magnetic stimulation or laser treatment (1 used GRISS14 and 1 used an informal questionnaire15). Nine studies indirectly assessed the effects on male sexual function by surveying female patients with SUI (7 used the PISQ-1223-29 and 2 used the PISQ-IR32,33).
The quality assessments of the studies are presented in Table 1. Twelve studies9,11,13,15,19,23-29 were of high quality, and the remaining 6 studies10,12,14,15,32,33 were of moderate quality.
Primary results: direct assessment of female SUI on male partners’ sexual function
Female SUI without treatment
Bekker et al10 conducted the first study on the effect of female urinary incontinence (44.2% SUI, 10.4% urge, and 45.5% mixed) on male partners’ sexual function using the GRISS. The male partners whose female partners had urinary incontinence had significantly worse sexual function regarding erectile function (mean ± SD: 6.87 ± 3.23 vs 6.01 ± 2.28, P = .037), infrequency of intercourse (6.49 ± 1.96 vs 5.62 ± 2.00, P = .03), and sexual dissatisfaction (9.69 ± 3.63 vs 8.08 ± 2.79, P = .001) than those who had female partners without urinary incontinence, while no significant differences were found in communication, avoidance, nonsensuality, or premature ejaculation. Lim et al14 investigated the effect of female SUI on male partners’ sexual function and drew a similar conclusion, as male partners whose female partners had SUI had more erectile dysfunction (5.35 ± 2.50 vs 4.43 ± 2.63, P = .027), more sexual dissatisfaction (6.11 ± 3.48 vs 4.84 ± 2.24, P = .006), and a lower frequency of sexual intercourse (median [IQR]: 6 [4-7] vs 5 [3-6], P = .001) (Table 2) than those who had female partners without SUI.
Systematic review of the studies detecting the effect of female UI on the sexual function of male partners.
| Study | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Bekker (2010)10 | With or without UI (44.2% stress, 10.4% urge, 45.5% mixed) | GRISS | 81/108 | Partners of female patients with UI had more problems with erectile dysfunction (P = .037), sexual dissatisfaction (P = .001), and less frequent sexual intercourse (P = .03). |
| Lim (2016)9 | With or without SUI | GRISS | 66/95 | Partners of female patients with SUI had more problems with erectile dysfunction (P = .027), sexual dissatisfaction (P = .006), and less frequent sexual intercourse (P = .001). |
| Study | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Bekker (2010)10 | With or without UI (44.2% stress, 10.4% urge, 45.5% mixed) | GRISS | 81/108 | Partners of female patients with UI had more problems with erectile dysfunction (P = .037), sexual dissatisfaction (P = .001), and less frequent sexual intercourse (P = .03). |
| Lim (2016)9 | With or without SUI | GRISS | 66/95 | Partners of female patients with SUI had more problems with erectile dysfunction (P = .027), sexual dissatisfaction (P = .006), and less frequent sexual intercourse (P = .001). |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; SUI, stress urinary incontinence; UI, urinary incontinence.
Systematic review of the studies detecting the effect of female UI on the sexual function of male partners.
| Study | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Bekker (2010)10 | With or without UI (44.2% stress, 10.4% urge, 45.5% mixed) | GRISS | 81/108 | Partners of female patients with UI had more problems with erectile dysfunction (P = .037), sexual dissatisfaction (P = .001), and less frequent sexual intercourse (P = .03). |
| Lim (2016)9 | With or without SUI | GRISS | 66/95 | Partners of female patients with SUI had more problems with erectile dysfunction (P = .027), sexual dissatisfaction (P = .006), and less frequent sexual intercourse (P = .001). |
| Study | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Bekker (2010)10 | With or without UI (44.2% stress, 10.4% urge, 45.5% mixed) | GRISS | 81/108 | Partners of female patients with UI had more problems with erectile dysfunction (P = .037), sexual dissatisfaction (P = .001), and less frequent sexual intercourse (P = .03). |
| Lim (2016)9 | With or without SUI | GRISS | 66/95 | Partners of female patients with SUI had more problems with erectile dysfunction (P = .027), sexual dissatisfaction (P = .006), and less frequent sexual intercourse (P = .001). |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; SUI, stress urinary incontinence; UI, urinary incontinence.
Female SUI treatment
Five studies focused on TOT or TVT-O surgery. Three of these studies11-13 assessed the effect of TOT surgery via the IIEF. Surgery significantly improved male partners’ total IIEF scores (mean difference [MD] = 9.74; 95% CI, 8.59-10.89; P < .00001, I2 = 0%) and all IIEF items: erectile function (MD = 1.49; 95% CI, 1.08-1.89; P < .00001, I2 = 0%), orgasmic function (MD = 0.35; 95% CI, 0.13-0.56; P = .001, I2 = 0%), sexual desire (MD = 2.08; 95% CI, 1.27-2.89; P < .00001, I2 = 91%), intercourse satisfaction (MD = 2.36; 95% CI, 1.57-3.15; P < .00001, I2 = 83%), and overall satisfaction (MD = 3.46; 95% CI, 3.05-3.88; P < .00001, I2 = 68%) (Figure 2). Rosen et al39 reported that a change of 4 points in the erectile function item of the IIEF represents a minimal clinically important difference. Thus, although we found statistically significant improvements in all IIEF items, the improvements may be of unclear clinical significance.
Meta-analysis of studies on the effect of TOT surgery on male partners’ sexual function based on the IIEF-5 (direct assessment), including erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction items. IIEF-5, International Index of Erectile Function–5; TOT, transobturator suburethral tape.
One study investigated the effect of TOT surgery via the MSHQ,19 and significant improvements were observed regarding sexual relationship, quality of sex life, partner’s affection during sex, and communication about sex. Another study investigated the effect of TOT/TVT-O surgery through an informal questionnaire22 and reported that sexual intercourse improved for more than half the male partners (7/13) after surgery.
Two studies focused on pulsed magnetic stimulation14 and laser treatment15 (Table 3). Lim et al14 investigated the effect of pulsed magnetic stimulation using the GRISS. Although they did not statistically compare the results with the baseline data, the authors found that male partners’ sexual function improved immediately and 6 months after treatment with regard to erectile dysfunction, premature ejaculation, nonsensuality, dissatisfaction, infrequency, and total GRISS score. Tien et al15 investigated the effect of laser treatment using an informal questionnaire. They reported that sexual activity improved in 53.3% (16/30) of male partners 3 months after treatment and in 40% (12/30) 6 months after treatment.
Systematic review of studies detecting the effect of the treatment of female SUI on the sexual function of male partners.
| Studies | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Hsiao (2018)22 | 3 mo after TOT or TVT-O | Questionnaire | 13 | Sexual intercourse: 54% (7/13) improved and 46% (6/13) no change. Pain: no change in pain due to vaginal narrowing or dryness. Only 1 partner noticed the tape during intercourse |
| Lim (2018)14 | 6 mo after treatment with pulsed magnetic stimulation | GRISS | 48 | Mean scores decreased immediately and 6 mo after treatment with regard to erectile dysfunction, premature ejaculation, nonsensuality, dissatisfaction, infrequency, and overall GRISS score but no statistical analysis. |
| Tien (2017)15 | 3 and 6 mo after laser treatment | Questionnaire | 30 | Sexual activity: 53.3% (16/30) improved 3 mo after treatment and 40% (12/30) improved 6 mo after treatment |
| Ko (2016)19 | 3, 6, and 12 mo after TOT | MSHQ | 56 | Significant improvements were observed regarding sexual relationship, quality of sex life, partner’s affection, and communication about sex (P = .007, <.001, <.001, and <.001). |
| Studies | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Hsiao (2018)22 | 3 mo after TOT or TVT-O | Questionnaire | 13 | Sexual intercourse: 54% (7/13) improved and 46% (6/13) no change. Pain: no change in pain due to vaginal narrowing or dryness. Only 1 partner noticed the tape during intercourse |
| Lim (2018)14 | 6 mo after treatment with pulsed magnetic stimulation | GRISS | 48 | Mean scores decreased immediately and 6 mo after treatment with regard to erectile dysfunction, premature ejaculation, nonsensuality, dissatisfaction, infrequency, and overall GRISS score but no statistical analysis. |
| Tien (2017)15 | 3 and 6 mo after laser treatment | Questionnaire | 30 | Sexual activity: 53.3% (16/30) improved 3 mo after treatment and 40% (12/30) improved 6 mo after treatment |
| Ko (2016)19 | 3, 6, and 12 mo after TOT | MSHQ | 56 | Significant improvements were observed regarding sexual relationship, quality of sex life, partner’s affection, and communication about sex (P = .007, <.001, <.001, and <.001). |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; MSHQ, Male Sexual Health Questionnaire; TOT, transobturator suburethral tape; TVT-O, tension-free vaginal tape obturator.
Systematic review of studies detecting the effect of the treatment of female SUI on the sexual function of male partners.
| Studies | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Hsiao (2018)22 | 3 mo after TOT or TVT-O | Questionnaire | 13 | Sexual intercourse: 54% (7/13) improved and 46% (6/13) no change. Pain: no change in pain due to vaginal narrowing or dryness. Only 1 partner noticed the tape during intercourse |
| Lim (2018)14 | 6 mo after treatment with pulsed magnetic stimulation | GRISS | 48 | Mean scores decreased immediately and 6 mo after treatment with regard to erectile dysfunction, premature ejaculation, nonsensuality, dissatisfaction, infrequency, and overall GRISS score but no statistical analysis. |
| Tien (2017)15 | 3 and 6 mo after laser treatment | Questionnaire | 30 | Sexual activity: 53.3% (16/30) improved 3 mo after treatment and 40% (12/30) improved 6 mo after treatment |
| Ko (2016)19 | 3, 6, and 12 mo after TOT | MSHQ | 56 | Significant improvements were observed regarding sexual relationship, quality of sex life, partner’s affection, and communication about sex (P = .007, <.001, <.001, and <.001). |
| Studies | Invention | Scale | Sample | Outcome |
|---|---|---|---|---|
| Hsiao (2018)22 | 3 mo after TOT or TVT-O | Questionnaire | 13 | Sexual intercourse: 54% (7/13) improved and 46% (6/13) no change. Pain: no change in pain due to vaginal narrowing or dryness. Only 1 partner noticed the tape during intercourse |
| Lim (2018)14 | 6 mo after treatment with pulsed magnetic stimulation | GRISS | 48 | Mean scores decreased immediately and 6 mo after treatment with regard to erectile dysfunction, premature ejaculation, nonsensuality, dissatisfaction, infrequency, and overall GRISS score but no statistical analysis. |
| Tien (2017)15 | 3 and 6 mo after laser treatment | Questionnaire | 30 | Sexual activity: 53.3% (16/30) improved 3 mo after treatment and 40% (12/30) improved 6 mo after treatment |
| Ko (2016)19 | 3, 6, and 12 mo after TOT | MSHQ | 56 | Significant improvements were observed regarding sexual relationship, quality of sex life, partner’s affection, and communication about sex (P = .007, <.001, <.001, and <.001). |
Abbreviations: GRISS, Golombok-Rust Inventory of Sexual Satisfaction; MSHQ, Male Sexual Health Questionnaire; TOT, transobturator suburethral tape; TVT-O, tension-free vaginal tape obturator.
Secondary results: indirect assessment of female SUI treatment on male partners’ sexual function
Overall analysis
Nine studies indirectly investigated male partners’ sexual function after anti-incontinence surgery by surveying female patients with SUI via the PISQ (7 used the PISQ-1223-29 and 2 used the PISQ-IR32,33).
Five studies23-27 presented results for all items of the PISQ-12; among these, items 10 and 11 are related to erectile function and premature ejaculation, respectively. Our meta-analysis results of these 5 studies demonstrated that erectile function (MD = 0.08; 95% CI, −0.11 to 0.27; P = .4, I2 = 20%) and premature ejaculation (MD = 0.07; 95% CI, −0.17 to 0.32; P = .54, I2 = 55%) were not significantly different after anti-incontinence surgery (Figure 3).
Meta-analysis of studies on the effect of anti-incontinence surgery on male partners’ sexual function based on items 10 and 11 of the PISQ-12. For indirect assessment, female partners provided their perceptions of male partners’ sexual function. PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire–12.
Subgroup analyses
To further identify the possible factors that influence male partners’ sexual function after anti-incontinence surgery for female patients with SUI, we conducted subgroup analyses based on the follow-up time, surgery type, and region. The erectile function and premature ejaculation items of the PISQ-12 continued to exhibit no significant differences in any subgroup (Table 4).
Subgroup analysis detecting the effect of anti-incontinence surgery among female patients with SUI on the sexual function of male partners by indirect assessment with the PISQ-12.
| Problem with erection | Premature ejaculation | |||||||
|---|---|---|---|---|---|---|---|---|
| No. | Random effects SMD (95% CI) | I2, % | P value | No. | Random effects SMD (95% CI) | I2, % | P value | |
| Overall analysis | 5 | 0.08 (−0.11, 0.27) | 20 | .40 | 5 | 0.07 (−0.17, 0.32) | 55 | .54 |
| Follow-up time | ||||||||
| 6 mo | 3 | −0.04 (−0.28, 0.21) | 0 | .76 | 3 | −0.09 (−0.32, 0.13) | 0 | .42 |
| 12 mo | 2 | 0.19 (−0.18, 0.56) | 65 | .32 | 2 | 0.20 (−0.20, 0.60) | 74 | .32 |
| Types of surgery | ||||||||
| TVT | 2 | −0.02 (−0.27, 0.23) | 0 | .89 | 2 | −0.01 (−0.28, 0.26) | 0 | .96 |
| TOT or TVT-O | 3 | 0.16 (−0.16, 0.48) | 49 | .32 | 3 | 0.12 (−0.29, 0.53) | 76 | .56 |
| Burch | 0 | 0 | ||||||
| Region | ||||||||
| Asia | 4 | 0.11 (−0.11, 0.33) | 33 | .33 | 4 | 0.09 (−0.20, 0.37) | 66 | .56 |
| Europe | 1 | 1 | ||||||
| Problem with erection | Premature ejaculation | |||||||
|---|---|---|---|---|---|---|---|---|
| No. | Random effects SMD (95% CI) | I2, % | P value | No. | Random effects SMD (95% CI) | I2, % | P value | |
| Overall analysis | 5 | 0.08 (−0.11, 0.27) | 20 | .40 | 5 | 0.07 (−0.17, 0.32) | 55 | .54 |
| Follow-up time | ||||||||
| 6 mo | 3 | −0.04 (−0.28, 0.21) | 0 | .76 | 3 | −0.09 (−0.32, 0.13) | 0 | .42 |
| 12 mo | 2 | 0.19 (−0.18, 0.56) | 65 | .32 | 2 | 0.20 (−0.20, 0.60) | 74 | .32 |
| Types of surgery | ||||||||
| TVT | 2 | −0.02 (−0.27, 0.23) | 0 | .89 | 2 | −0.01 (−0.28, 0.26) | 0 | .96 |
| TOT or TVT-O | 3 | 0.16 (−0.16, 0.48) | 49 | .32 | 3 | 0.12 (−0.29, 0.53) | 76 | .56 |
| Burch | 0 | 0 | ||||||
| Region | ||||||||
| Asia | 4 | 0.11 (−0.11, 0.33) | 33 | .33 | 4 | 0.09 (−0.20, 0.37) | 66 | .56 |
| Europe | 1 | 1 | ||||||
Abbreviations: PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, short form; SMD, standardized mean difference; SUI, stress urinary incontinence; TOT, transobturator suburethral tape; TVT, tension-free vaginal tape; TVT-O, tension-free vaginal tape obturator.
Subgroup analysis detecting the effect of anti-incontinence surgery among female patients with SUI on the sexual function of male partners by indirect assessment with the PISQ-12.
| Problem with erection | Premature ejaculation | |||||||
|---|---|---|---|---|---|---|---|---|
| No. | Random effects SMD (95% CI) | I2, % | P value | No. | Random effects SMD (95% CI) | I2, % | P value | |
| Overall analysis | 5 | 0.08 (−0.11, 0.27) | 20 | .40 | 5 | 0.07 (−0.17, 0.32) | 55 | .54 |
| Follow-up time | ||||||||
| 6 mo | 3 | −0.04 (−0.28, 0.21) | 0 | .76 | 3 | −0.09 (−0.32, 0.13) | 0 | .42 |
| 12 mo | 2 | 0.19 (−0.18, 0.56) | 65 | .32 | 2 | 0.20 (−0.20, 0.60) | 74 | .32 |
| Types of surgery | ||||||||
| TVT | 2 | −0.02 (−0.27, 0.23) | 0 | .89 | 2 | −0.01 (−0.28, 0.26) | 0 | .96 |
| TOT or TVT-O | 3 | 0.16 (−0.16, 0.48) | 49 | .32 | 3 | 0.12 (−0.29, 0.53) | 76 | .56 |
| Burch | 0 | 0 | ||||||
| Region | ||||||||
| Asia | 4 | 0.11 (−0.11, 0.33) | 33 | .33 | 4 | 0.09 (−0.20, 0.37) | 66 | .56 |
| Europe | 1 | 1 | ||||||
| Problem with erection | Premature ejaculation | |||||||
|---|---|---|---|---|---|---|---|---|
| No. | Random effects SMD (95% CI) | I2, % | P value | No. | Random effects SMD (95% CI) | I2, % | P value | |
| Overall analysis | 5 | 0.08 (−0.11, 0.27) | 20 | .40 | 5 | 0.07 (−0.17, 0.32) | 55 | .54 |
| Follow-up time | ||||||||
| 6 mo | 3 | −0.04 (−0.28, 0.21) | 0 | .76 | 3 | −0.09 (−0.32, 0.13) | 0 | .42 |
| 12 mo | 2 | 0.19 (−0.18, 0.56) | 65 | .32 | 2 | 0.20 (−0.20, 0.60) | 74 | .32 |
| Types of surgery | ||||||||
| TVT | 2 | −0.02 (−0.27, 0.23) | 0 | .89 | 2 | −0.01 (−0.28, 0.26) | 0 | .96 |
| TOT or TVT-O | 3 | 0.16 (−0.16, 0.48) | 49 | .32 | 3 | 0.12 (−0.29, 0.53) | 76 | .56 |
| Burch | 0 | 0 | ||||||
| Region | ||||||||
| Asia | 4 | 0.11 (−0.11, 0.33) | 33 | .33 | 4 | 0.09 (−0.20, 0.37) | 66 | .56 |
| Europe | 1 | 1 | ||||||
Abbreviations: PISQ-12, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, short form; SMD, standardized mean difference; SUI, stress urinary incontinence; TOT, transobturator suburethral tape; TVT, tension-free vaginal tape; TVT-O, tension-free vaginal tape obturator.
Publication bias
Based on the Begg funnel plots, no publication bias was discovered for any outcome (Figure S3).
Discussion
In this study, we assessed the effects of female SUI and related treatments on male partners’ sexual function for the first time. A male whose female partner has SUI may have issues with sexual function. Male partners’ sexual function (as assessed by the IIEF) significantly improved statistically after female patients with SUI underwent TOT surgery, but the improvements were of unclear clinical significance. Furthermore, after anti-incontinence treatment, female patients with SUI did not perceive a significant improvement in the erectile function or premature ejaculation of their male partners.
Urine leakage during sexual intercourse can lead to abnormal sexual psychology, anxiety, low self-esteem, and even depression.40 Although a reduction in the quality of female sexual function may adversely affect males, only 2 studies investigated the effect of SUI without treatment on male partners’ sexual function.9,10 Given the results shown in Table 2, we can reasonably speculate that males whose female partners had urinary incontinence had more problems with sexual function (especially erectile dysfunction and sexual dissatisfaction) and a lower frequency of sexual intercourse, as compared with males with female partners without SUI. This serves as an important reminder for clinicians in the field of urogynecology. Patients often do not initiate conversations about their sexual dysfunction and so often need guidance from clinicians. Although the literature on SUI in women has focused on the impact on the patients, we should pay more attention to the possible effects on the partners’ sexual function.
In theory, treatment of SUI may improve patients’ sexual function, with improvement in urine leakage during sexual intercourse benefiting couples’ sex lives. Three studies11-13 used the IIEF to investigate the effect of TOT surgery on male partners’ sexual function and found significant improvements in sexual desire, intercourse satisfaction, and overall satisfaction, though not in erectile function or orgasmic function. In contrast, our meta-analysis of these 3 studies11-13 revealed statistically significant improvements in all IIEF items, including erectile function (MD = 1.49; 95% CI, 1.08-1.89; P < .00001, I2 = 0%) and orgasmic function (MD = 0.35; 95% CI, 0.13-0.56; P = .001, I2 = 0%) (Figure 2), though these improvements did not reach the minimal clinically important difference. We look forward to more relevant studies being conducted such that a more comprehensive review can be performed of the impacts of female SUI and related treatments on male partners’ sexual function.
Two meta-analyses7,8 assessed the effect of anti-incontinence surgery on the sexual function of female patients with SUI by using the PISQ; however, they did not focus on the partner-related domain. We demonstrated that the partner-related domain of the PISQ-12 (items 10-12) improved in female patients with SUI after treatment (Figure S1). Yet, items 10 and 11 did not significantly improve; these represent the female patient’s views about her male partner’s erectile dysfunction or premature ejaculation, respectively (Figure 3). The reason for the difference in these results may be that item 12 represents the female’s views about her orgasms, which is influenced by the sexual function of the female herself as well as her partner. Our meta-analysis of 2 studies that assessed the partner-related domain of the PISQ-IR revealed no significant improvement (MD = –0.09; 95% CI, −0.23 to 0.06; P = .24, I2 = 29%), which requires verification in future studies. The difference in the outcomes in Figures 2 and 3 may be related to the different concerns of males and females and the appropriateness of the different scales. In Figure 2, males were surveyed with the IIEF-5, which showed that surgery resulted in a statistically significant improvement, though not a clear clinically significant improvement, in male partners’ total score and all items, including erectile function and orgasmic function. In Figure 3, females were surveyed with the partner-related domain of the PISQ-12, which showed that surgery failed to significantly improve male partners’ erectile function (item 10) or premature ejaculation (item 11). The limited number of studies available is also an issue that should be rectified in future studies.
It is worth noting that some researchers have raised concerns about the safety of SUI treatment, especially surgical treatment. First, surgical incisions may affect the “G” spot, which is a sensitive area that can be involved in orgasm. Second, the use of biomaterials carries the risks of neurovascular damage and dyspareunia. Third, a study reported reduced clitoral blood flow and sensation after midurethral sling surgery.41 Only 1 study22 in this review focused on the possible negative effects of TOT surgery on male partners’ sexual function and found no postsurgery change in pain due to vaginal narrowing or dryness, though 1 partner (1/13) complained of pain due to the tape.
This study had several limitations. First, the number of studies was limited; some results could not be fully analyzed quantitatively due to missing data; and there was a lack of studies that directly assessed the effects of common surgery types on male partners’ sexual function. Second, several outcomes had high heterogeneity, and we could not perform further subgroup analyses due to the limited number of studies. Third, few studies involving standardized research have been conducted in this study area: many studies differed in terms of the formal outcome measures used, and some studies even used informal outcome measures. Fourth, there was a lack of discussion on treatment complications, and the studies lacked long-term follow-up periods. Finally, given the complex nature of sexual function and the variety of anti-incontinence treatments, it is difficult to make clear clinical recommendations.
Despite these limitations, we believe that this systematic review still has clinical significance. Sexual function is an important part of evaluating the quality of life of patients with pelvic floor disorders and their quality of life after treatment. However, few studies have focused on this aspect, particularly for male partners. In this review, we present a summary of studies showing the impact of female SUI and related treatments on male partners’ sexual function for the first time, which may provide a reference for future scientific research and clinical practice.
Conclusion
In this study, we demonstrated that males whose female partners had SUI may have issues with sexual function. Additionally, based on their direct survey, male partners’ sexual function demonstrated statistically significant improvement after female patients with SUI underwent TOT surgery, but the improvements were of unclear clinical significance. Furthermore, female patients with SUI who underwent anti-incontinence surgery did not perceive significant improvement in their male partners’ erectile function or premature ejaculation. Owing to the limitations of this study, additional studies are needed for validation: ones with high-quality design, large sample sizes, and longitudinal follow-up.
Funding
This study was supported by grants from the Beijing Natural Science Foundation (No. Z190021), National Natural Science Foundation of China (No. 81971366), CAMS Innovation Fund for Medical Sciences (CIFMS 2020-I2M-C&T-B-043), Special Fund for Prevention and Treatment of Pelvic Floor Dysfunction in Chinese Women (No. 201801004), and National High Level Hospital Clinical Research Funding (2022-PUMCH-B-087).
Conflicts of interest: None declared.
References
Author notes
Z.T. and X.W. contributed equally.
