Sexual Health and Urogynecology- What Trainees and Fellows Should Know

Dr. Leon Plowright Urogynecology and Reconstructive Pelvic Surgeon Sexual health holds a level of mystery for providers at all stages of their career. During their thought-provoking session, Drs Anna Padoa, Maurizio Serati, and Magdalena Grzybowska unpacked the complexities of sexual health, underscoring that it is not merely a physical issue but a deeply interconnected aspect of psychological and relational well-being. In this lecture it was emphasized that sexual health is a multifaceted, multidimensional aspect of well-being, influenced by physical, psychological, and relational factors. In women with pelvic floor dysfunction (PFD) this balance can be disrupted. Symptoms such as dyspareunia, reduced desire, anorgasmia, and embarrassment related to incontinence or prolapse can significantly diminish one’s quality of life. Despite its prevalence, it remains underreported, as only a small percentage of women disclose sexual concerns unless directly asked. Research shows that among patients attending urogynecology clinics, 37–64% experience some form of sexual dysfunction. This includes not only physical discomfort but also emotional repercussions, such as altered body image and diminished partner intimacy. Partner-related factors—such as fear of causing discomfort or erectile difficulties—can further compound the problem, underscoring the need for a couple-centered approach to care. Urogynecologists are uniquely positioned to normalize discussions around the topic, integrating medical, psychological, and relational perspectives. Urogynecologists therefore play a vital role in demystifying sexual health and affirming its central place in overall well-being. Dr. Padoa further underscored the intricate interplay between sexual health and comorbid conditions, emphasizing the importance of validated tools to aid comprehensive screening and assessment. Psychosexual disorders, such as genito-pelvic pain/penetration disorder (GPPPD), illustrate this complexity. These conditions often stem from a cycle of pelvic floor hypertonicity, anxiety, and maladaptive coping, sometimes intensified by trauma or perfectionist traits. Treating these disorders requires a holistic approach, combining pelvic floor physical therapy with sex therapy, mindfulness, and in some cases, pharmacologic intervention. Importantly, the goal of treatment must shift away from a focus on penetrative intercourse alone and toward the reestablishment of enjoyable, pain-free intimacy. Tools such as the Female Sexual Function Index (FSFI) are useful for assessment, but must be interpreted alongside the patient’s own goals, cultural context, and emotional landscape. Stress urinary incontinence (SUI) is a highly prevalent form of pelvic floor dysfunction that exerts a particularly detrimental effect on sexual function. Dr. Serati emphasized that women with SUI frequently experience reduced sexual desire and may avoid intimacy altogether due to the fear of urine leakage during penetration. Coital incontinence, a symptom strongly associated with SUI, is especially distressing and independently correlates with lower sexual satisfaction scores. Even in women with “dry” SUI—without observable leakage—fear and embarrassment can lead to decreased arousal and anorgasmia. Treatment strategies such as pelvic floor muscle training and midurethral sling (MUS) procedures often improve continence and, by extension, sexual function. However, up to 20% of patients may experience new-onset dyspareunia post-surgery, typically due to mesh tension or scarring. Thorough preoperative counseling is essential to balance continence goals with sexual health outcomes. Lastly, the discussion turned to the impact of pelvic organ prolapse (POP) on sexual well-being. Dr. Grzybowska highlighted that women with POP frequently experience vaginal pressure, altered body image, and positional discomfort during intercourse—factors that often contribute to decreased libido and avoidance of sexual activity. Surgical correction, particularly with uterine-sparing procedures or sacrocolpopexy, has been shown to improve body image and overall sexual satisfaction. Conservative measures, such as pessary use, can also improve symptoms and are particularly beneficial for sexually active women, especially when used intermittently. In conclusion, the intersection of pelvic floor disorders and sexual health is complex and frequently under-addressed. Across all stages of a provider’s career, sexual health remains an evolving area of knowledge. Addressing sexual health requires proactive screening, individualized care, and multidisciplinary collaboration. A couple-centered approach that prioritizes restoring enjoyable, pain-free intimacy is essential. Whether managing SUI, POP, or more intricate psychosexual dysfunctions, clinicians must approach treatment with empathy, open communication, and a focus on restoring quality of life beyond symptom control. Urogynecologist play a central role in this effort.