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An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

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Abstract

Introduction and hypothesis

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

Methods

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

Results

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5–10 years) is anticipated to keep the document updated and as widely acceptable as possible.

Conclusions

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

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Notes

  1. Coital incontinence is defined as a complaint of involuntary leakage of urine during or after coitus. Coital incontinence seems to be an aggravating factor that women generally describe as humiliating [1]. The prevalence of urinary incontinence during intercourse has been evaluated to range from 2% to 56%, depending on the study population (for eg, the general population or a cohort of women with incontinence), the definition used (any leakage, weekly, on penetration, during orgasm, only severe leakage) and the evaluation method used (questionnaire, interviews). In a literature review reported in 2002 that covered English-language papers from 1980 to 2001, Shaw [21] reported a 2–10% prevalence of coital incontinence in randomly selected community samples. The physio pathological mechanisms involved have been widely debated [22], with bladder overactivity conventionally being implicated in orgasmic incontinence and SUI in penetration incontinence. In the past 5 years, studies however, have underlined the role of the urethral sphincter in coital incontinence, which is thought to be crucial even in women with detrusor overactivity and orgasmic incontinence [23]. The penetration form of coital incontinence is largely associated with urodynamics findings of SUI, whereas orgasmic incontinence might be associated with both detrusor overactivity and SUI [23, 24]. Nevertheless, among women with OAB, orgasmic incontinence is more common than penetration incontinence. Coital incontinence on penetration can be cured by surgery in 80% of women with urodynamically proven SUI. Similarly, orgasmic incontinence can respond to treatment with anticholinergics in 59% of women with detrusor overactivity [25, 26].

  2. Rare condition mostly described in women who have genital abnormalities such as micro perforate hymen [27].

  3. A third of sexually active women with POP complain that their prolapse interferes with sexual function [29, 30]. However, it has been shown that women with POP have comparable rate of sexual activity to similarly aged individuals without POP [31, 32].

  4. A recent survey of IUGA members noted that 57% of responders considered vaginal laxity a bothersome condition that impacts relationship happiness and patient’s sexual functioning. The most frequently cited (52.6%) location responsible from laxity was the introitus and the majority of respondents (87%) thought both muscle and tissue changes were responsible [33].

  5. Dyspareunia rates reported in the literature range from 14% to 18% [34].

  6. There is often (phobic) avoidance and anticipation/fear/experience of pain, along with variable involuntary pelvic muscle contraction. Patients with vaginismus could present with severe fear avoidance without vulvar pain or fear avoidance with vulvar pain. Structural or other physical abnormalities must be ruled out/addressed [35]. There is controversy of whether or not this term should be retained; the Diagnostic and statistical manual of mental disorders 2013 proposed to replace dyspareunia and vaginismus with the term “Genito-Pelvic Pain/Penetration Disorder (GPPPD).” [36]

  7. Decreased vaginal lubrication is often involved in pain with sexual activity among postmenopausal women, women with hypo-estrogenic states for other reasons or after pelvic surgery and may result in persistent or recurrent vaginal burning sensation with intercourse (penile or any device) [4].

  8. A non-relaxing pelvic floor that is mainly associated with dyspareunia. “Examination of pelvic floor muscles” section [8].

  9. In certain disorders such as genital herpes, vestibulitis, endometriosis, or bladder pain syndrome, pain may also occur after non coital stimulation [4].

  10. The term “Hispareunia” has been first suggested by Brubaker in one editorial to describe partner dyspareunia after sling insertion [38].

  11. It has been suggested that a distinction could be made between women with sexual arousal concerns that are psychological or subjective in nature (ie, absence of or markedly diminished feelings of sexual arousal while vaginal lubrication or other signs of physical response still occur), those that are genital (impaired genital sexual arousal—reduction of the physical response), and those that include complaints of both decreased subjective and genital arousal [1, 4].

  12. A normal examination is highly informative to the women and can be of reassurance value [4].

  13. Other conditions that may influence sexual function are fissures, vulval excoriation, skin rashes, cysts, and other tumors, atrophic changes or lichen sclerosis, scars, sinuses, deformities, condylomata, papillomata, hematoma.

  14. Increased blood flow in the vaginal walls associated with arousal increases the force in the vaginal walls, which drives transudation of NaCl+ − rich plasma through the vaginal epithelium, coalescing into the slippery film of vaginal lubrication and neutralizing the vagina’s usually acidic state [33]. Reduced vulvo-vaginal sensitivity has been associated with sexual dysfunction and neurologic impairment [34].

  15. Sitting often exacerbates the pain, which may be relieved in the supine position. Presentation may be unilateral or bilateral in presentation.

  16. Intra-vaginal or intra-rectal assessment palpation is useful to provide a subjective appreciation of the PFM. PFM tone can be evaluated and defined as hypotonic, normal, and hypertonic [41], or assessed using Reissing’s 7 point scale from −3 to +3 [42]. Squeeze pressure or strength during voluntary and reflex contraction can also be graded as strong, normal, weak, absent, or alternatively by using a validated grading system such as Brink’s scale or the PERFECT scheme [42,43,44]. These scales also include quotations of muscular endurance (ability to sustain maximal or near maximal force), repeatability (the number of times a contraction to maximal or near maximal force can be performed), duration, co-ordination, and displacement. Each side of the pelvic floor can also be assessed separately to allow for any unilateral defects and asymmetry [42]. Voluntary muscle relaxation can be graded as absent, partial, complete, delayed [42]. The presence of major morphological abnormalities of the puborectalis muscle may be assessed for by palpating its insertion on the inferior aspect of the os pubis. If the muscle is absent 2–3 cm lateral to the urethra, that is, if the bony surface of the os pubis can be palpated as devoid of muscle, an “avulsion injury” of the puborectalis muscle is likely [45]. Tenderness can be scored during a digital rectal (or vaginal) examination of levator ani, piriformis and internal obturator muscles bilaterally, according to each subject’s reactions: 0, no pain; 1, painful discomfort; 2, intense pain; with a maximum total score of 12 [46].

  17. GSM is a syndrome associated with aging that results in alkalization of vaginal pH, changes in the vaginal flora, increased parabasal cell on maturation index and decreased superficial cells on wet mount or maturation index. In addition, there is a loss of collagen, adipose, and water-retention of the vulva which results in loss of elasticity, generalized reduction in blood perfusion of the genitalia. The vaginal epithelium may become friable with petechiae, ulcerations, and bleeding after minimal trauma [48].

  18. Two classification systems for complications following prolapse surgery, includes the more generic Modified Clavien Dindo [55] and the more specific IUGA ICS classification of complications related to insertion of grafts/prosthesis [40] or use of native tissue [56]. These classification systems did include pain related to prolapse surgery complications which was sub-classified depending on whether pain was at rest, provoked during examination, during sexual activities, physical activities, or spontaneous

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Acknowledgements

This document has involved 14 rounds of full review, by co-authors, of an initial draft, with the collation of comments. The co-authors acknowledge the input to an earlier version of this document by Dr. E Lukacz, Dr. V Handa, Dr. S Jha, and Professor Bernard Haylen. The authors further acknowledge the contributions of members of ICS SSC (2017). The authors would also like to acknowledge the helpful comments provided by Elisabetta Constantini, Beth Shelley, Helena Frawley, together with the substantial review by ISSWSH.

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Authors and Affiliations

  1. Department of Women’s Health, Dell Medical School, University of Texas, 1301 W 38th Street, Suit705, Austin, TX, 78705, USA

    Rebecca G. Rogers

  2. TriHealth Good Samaritan Hospital, Cincinnati, OH, USA

    Rachel N. Pauls

  3. Croydon University Hospital Croydon, London, UK

    Ranee Thakar

  4. Universite de Sherbrooke, Montreal, QC, Canada

    Melanie Morin

  5. University Teaching Hospital Berne (Inselspital), Bern, Switzerland

    Annette Kuhn

  6. University of Greifswald, Schwerin, Germany

    Eckhard Petri

  7. University Hospital Nîmes, Nimes, Languedoc-Roussillon, France

    Brigitte Fatton

  8. Drexel University College of Medicine, Philadelphia, PA, USA

    Kristene Whitmore

  9. Case Western Reserve University, Cleveland, OH, USA

    Sheryl A. Kingsberg

  10. St Vincents Hospital, University of New South Wales, Sydney, NSW, Australia

    Joseph Lee

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Contributions

RR, JL, RNP, RT, MM, AK, EP, BF, KW, SK contributed in conception and writing of manuscript.

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Correspondence to Rebecca G. Rogers.

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Conflicts of interest

RG Rogers, Royalties from UPTODATE; R Pauls, no disclosures; R Thakar, Vice President of the International Urogynecological Association, Honorariums from Astellas and Pfizer for lectures; M Morin, no disclosures; A Kuhn, no disclosures; E Petri, no disclosures; B Fatton, consultant for Astellas, Allergan, Boston Scientific; K Whitmore: Clinical Research, Coloplast, Allergan; S Kingsberg, Paid consultant to: Apricus, Emotional Brain, Sprout, Teva, SST, Pfizer, Shionogi, Novo Nordisk, Viveve, Palatin, Metagenenics; Stock options, Viveve; J Lee, Research Grant from AMS/BSCI for investigator led clinical trials.

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- This material is reproduced with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., and the International Urogynecological Association.

- Published online in Wiley Online Library (wileyonlinelibrary.com). https://doi.org/10.1002/nau.23508

- This document is being published simultaneously in Neurourology and Urodynamics (NAU) and the International Urogynecology Journal (IUJ), the respective journals of the sponsoring organizations, the International Continence Society (ICS) and the International Urogynecological Association (IUGA).

- Standardization and Terminology Committees IUGA - Eckhard Petri and Joseph Lee

- Standardization and Terminology Committees ICS - Kristene Whitmore

- Joint IUGA/ICS Working Group on Female Anorectal Terminology - Rebecca G. Rogers, Rachel N. Pauls, RaneeThakar, Melanie Morin, Annette Kuhn, Eckhard Petri, Brigitte Fatton, Kristene Whitmore, Sheryl A. Kingsberg, and Joseph Lee

- Dr. Roger Dmochowski led the peer-review process as the Associate Editor responsible for the paper.

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Rogers, R.G., Pauls, R.N., Thakar, R. et al. An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction. Int Urogynecol J 29, 647–666 (2018). https://doi.org/10.1007/s00192-018-3603-9

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