Overactive bladder and sexual function: a nightmare couple

Authors


Prokar Dasgupta, Department of Urology, Guy's Hospital, Kings College London, St. Thomas Street, London SE1 9RT, UK. e-mail: prokarurol@gmail.com

Abbreviations
ASEX

Arizona Sexual Experience Scale

BoNT/A

Botulinum toxin A

ED

erectile dysfunction

FSFI

the Female Sexual Function Index

HRQL

health-related quality life

OAB

overactive bladder

PDE5-I

phosphodiesterase type 5 inhibitor.

INTRODUCTION

In the last decade enormous interest has developed in the sexual life of patients affected by overactive bladder (OAB). The Epidemiology of Lower Urinary Tracts Symptoms (EpiLUTS) study, including 14 400 men and women, showed that OAB negatively affects sexual enjoyment and activity in both sexes. In addition, this survey showed links between OAB and both lower desire and arousal in women and higher erectile dysfunction (ED) and ejaculatory dysfunction in men. In this study, the authors reported that rates of decreased sexual enjoyment were 25% and 20% in incontinent and continent women with OAB respectively, and 2% in those with no/minimal urinary symptoms. Rates of mild or greater ED were 35% and 32% in incontinent and continent men with OAB respectively, and 18% in those with no/minimal urinary symptoms [1]. Nilsson et al. [2] found that most of the women considered sexuality very important in their life; to avoid urinary leakage during intercourse they adopt methods that decrease sexual satisfaction, consequently desire and psychological health. A nested case-control analysis of a subset of the European Prospective Investigation into Cancer and Nutrition (EPIC) study showed that men with OAB have significantly reduced sexual activity due to urinary symptoms compared with controls (14% vs 4%); moreover the chance of having ED was significantly increased in patients with OAB than controls, with prevalence similar to that for men with other risk factors for ED [3]. Several standardised self-administered questionnaires were used to assess OAB symptoms, their impact on health-related quality life (HRQL) and sexual function (Table 1) [4–9]. These instruments are needed to quantify the problem, correlate different domains, help patients to provide all the information being sought and reduce the likelihood that they become confused and frustrated. Despite the adverse effect of OAB on sex, few studies have investigated the impact of OAB treatment on sexual function.

Table 1.  Questionnaires Thumbnail image of

In 2006, Sand et al. [10] showed that female patients treated with transdermal oxybutynin reported improvements in sexual function and marital relationship at 6 months. Disappointingly, only 23% of women with coital incontinence were cured, whereas 77% did not respond to treatment. Hajebrahimi et al. [11] in their small series of 30 sexually active women with OAB reported significant improvements in the mean ASEX score after tolterodine immediate release. Improvements at all follow-up time points (1, 2, and 3 months) from baseline were statistically significant (P < 0.01). In support of this, in a multi-centre, double-blind, placebo-controlled trial including 411 sexually active women, the tolterodine extended-release group reported significant improvements in urinary and sexual outcomes at 3 months, compared with placebo [12]. These results were maintained or improved at 6 months [13]. Signorello et al. [14] in their group of 16 females who underwent two-stage sacral neuromodulation, found differences in total FSFI score were significantly associated with changes in incontinence episodes (P = 0.003), frequency (P = 0.003) and voided volume (P < 0.001). These correlations show a strong link between urinary and sexual improvement. On the other hand, Gill et al. [15] showed improved sexual function was not statistically correlated to improved urinary condition after sacral neuromodulation.

More therapeutic interventions, including new anticholinergics and other methods, in both men and women, are needed to evaluate the effect of OAB on sexual life. To date, several studies have shown that Botulinum toxin A (BoNT/A) is an effective treatment for OAB in those patients refractory or intolerant to anticholinergics [16]. Several publications on BoNT/A intravesical injections support its effectiveness in improving HRQL in patients affected by neurogenic and idiopathic OAB [17,18], but to our best knowledge none mentions the impact of this treatment on patients' sexual life.

The phosphodiesterase type 5 inhibitors (PDE5-Is) is another interesting group of drugs that are potentially useful in improving urinary symptoms and sexual life. Some double-blind placebo-control studies have shown that PDE5-Is improve urinary tract symptoms suggestive of BPH, ED and HRQL [19]. Recently, it has been shown that a single dose of vardenafil significantly decreases detrusor overactivity and increases bladder capacity in spinal cord injured patients [20]. Overall these findings are intriguing and deserve further investigation to evaluate the role of PDE5-Is in both OAB and ED therapy. It would be also interesting to assess this therapeutic option in women. Lastly augmentation cystosplasty, despite many new treatments, remains an important, meaningful, time-proven method to cure patients affected by OAB; some studies would be necessary to evaluate the role of this surgical procedure in improving sexual life in these patients. Several recent studies found a close relationship between sexual functioning and satisfaction, and OAB symptoms among both men and women. Although the exact mechanism underlying this association is not completely understood, successful treatment of OAB has been observed to produce beneficial effects also on patients' sexual life.

ACKNOWLEDGEMENTS

P.D. and A.S. acknowledge support from the National Institute for Health Research (NIHR) Biomedical Research Centre, MRC Centre for Transplantation and The Urology Foundation. Arun Sahai and Mohammed Shamim Khan are funded by Allergan Ltd.

CONFLICT OF INTEREST

Antonella Giannantoni, Arun Sahai and Mohammed Shamim Khan are Paid Consultants to Allergan Ltd and are Study Investigators funded by Allergan Ltd.

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