International Journal of Gynecology and Obstetrics 127 (2014) 73–76

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Evaluation of confounding factors interfering with sexual function in women with minimal pelvic organ prolapse Aysun Karabulut a,⁎, Sevgi Ozkan b, Nilüfer Koçak c, Tülay Alan d a

Department of Obstetrics and Gynecology, Pamukkale University Medical School, Denizli, Turkey Denizli Health Services Vocational College, Pamukkale University, Denizli, Turkey Department of Family Medicine, Pamukkale University Medical School, Denizli, Turkey d Cancer Screening and Early Diagnosis Center, Denizli, Turkey b c

a r t i c l e

i n f o

Article history: Received 18 January 2014 Received in revised form 24 April 2014 Accepted 9 June 2014 Keywords: Overactive bladder Pelvic organ prolapse Quality of life Sexual dysfunction

a b s t r a c t Objective: To evaluate the effects of confounding factors on sexual function in women with minimal pelvic organ prolapse (POP). Methods: A cross-sectional study was conducted at a cervical cancer screening center in Turkey between December 1, 2012, and March 31, 2013. Symptom-free women with stage I or II POP were enrolled to evaluate the association between sexual function and sociodemographic variables, POP, POP-related quality of life, stress incontinence, and overactive bladder. Results: Of 243 volunteers (mean age 46.0 ± 9.1 years), 188 (77.4%) had a low Female Sexual Function Index score. Women with better sexual function tended to be younger, have a higher salary, not be in the menopause, and have no chronic illness (P b 0.05 for all). There was no difference between the groups in terms of POP Quantification measurements (P N 0.05), apart from transvaginal length (P = 0.011). Overactive bladder was more common (P = 0.005) and more severe (P = 0.002) in women with sexual dysfunction, and their POP-related quality of life was worse (P b 0.05). In a linear regression analysis, high salary had a positive effect and overactive bladder had a negative effect on sexual function. Conclusion: Sexual dysfunction is highly prevalent in women with minimal POP. Overactive bladder and low income are the major factors adversely affecting sexual function. © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction Pelvic floor disorders include pelvic organ prolapse (POP), urinary incontinence, fecal incontinence, and defecation dysfunction. Women do not usually mention problems related to the pelvic floor, and such problems tend to emerge only on detailed questioning. Although pelvic floor disorders do not cause important morbidity and mortality, they may have a major effect on quality of life and sexual function. Sexual dysfunction is defined as a disorder of sexual desire, arousal, orgasm, or sexual pain that leads to personal distress [1]. The frequency of sexual dysfunction increases with age, and up to 50% of women may be affected [2]. A previous study [3] investigated the effect of pelvic floor disorders on sexual function in symptomatic women. The effect of pelvic floor changes on sexual function in asymptomatic women is not known. We hypothesized that women with less deformed pelvic anatomy will have better pelvic function, better quality of life, and better sexual

⁎ Corresponding author at: Onelya Evleri, A-4 Yenişehir, 20125 Denizli, Turkey. Tel.: +90 258 373 3186; fax: +90 258 2131034. E-mail address: [email protected] (A. Karabulut).

function. The present study aimed to compare the clinical and anatomic characteristics of women with and without sexual dysfunction, and to evaluate the effects of overactive bladder, pelvic floor changes, and related quality of life on sexual function in women with minimal POP.

2. Materials and methods The present cross-sectional study was conducted among women who attended the Cancer Early Diagnosis, Screening, and Education Center (KETEM) in Denizli, Turkey, for a routine cervical screening test between December 1, 2012, and March 31, 2013. Symptom-free women with stage I–II POP and who had been sexually active in the previous 4 weeks were included in the study. Women who had undergone a hysterectomy were excluded. Informed consent was obtained from all participants and all women were informed about the objectives of the study and the confidentiality of the data. The project was approved by the Research Ethics Committee of Pamukkale University Medical School, Denizli, Turkey. Aslan et al. [4] found that the prevalence of low sexual function in women was 50.2%. On the basis of this information, we calculated that the minimum sample size was 233, with a significance level of 0.05, a margin of error of d = 0.063, and a population size of 9000.

http://dx.doi.org/10.1016/j.ijgo.2014.04.015 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

74

A. Karabulut et al. / International Journal of Gynecology and Obstetrics 127 (2014) 73–76

In the first part of the study, the women were interviewed to obtain information on sociodemographic factors, sexual function, and quality of life. The recorded sociodemographic variables included age, body mass index (calculated as weight in kilograms divided by the square of height in meters), educational status, presence of health insurance, income level, number of pregnancies, number and route of delivery (cesarean/vaginal), history of a macrosomic infant (N 4000 g), menopausal status, history of gynecologic surgery, and presence of systemic illness. In the second part of the study, POP assessments and residual urine measurements were performed, and a stress test was conducted after filling the bladder with 250 mL of sterile saline. The validated Turkish version of the Female Sexual Function Index (FSFI) [5] was used to evaluate sexual function. The FSFI is a 19-item multidimensional tool assessing sexual problems or function in the preceding 4 weeks. The tool has six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. Each question is scored from 0 or 1 to 5, and then the totals for each domain are multiplied by a domain factor, with the resulting values added together to give a full scale score. The highest possible score is 36, the lowest 2. Higher scores indicate better sexual function. Scores below 26.5 were considered to indicate sexual dysfunction [5]. POP was assessed and staged according to the POP Quantification (POP-Q) system [6]. All measurements were performed by the same investigator (A.K.). Residual urine was measured just after micturition. After filling the bladder with 250 mL of sterile saline, the presence of stress incontinence was tested with coughing. In agreement with the POP-Q system, stage I prolapse was defined as prolapse occurring 1 cm or more above the hymen; stage II was defined as prolapse extending up to 1 cm above or below the hymen; stage III was defined as prolapse extending more than 1 cm below the hymenal ring but remaining within 2 cm of the total vaginal length; and stage IV was defined as complete vaginal eversion extending from the hymenal ring. The validated Turkish short-form versions of the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) [7,8] were used for the evaluation of pelvic floor symptom burden and quality of life. The PFDI-20 is both a symptom inventory and a measure of the degree of bother and distress (quality of life) caused by pelvic floor symptoms. The PFDI-20 is composed of three subscales: the Urinary Distress Inventory (range 0–100); the Pelvic Organ Prolapse Distress Inventory (range, 0–100); and the Colorectal Anal Distress Inventory (range, 0–100). With the PFDI-20, patients are asked to indicate whether they have a particular symptom, and if present, how much it bothers them on a four-point scale (1 = “not at all”; 4 = “quite a bit”). The effect of pelvic symptoms on quality of life was assessed with the PFIQ-7, which is a short-form version of the PFIQ [8] and also comprises three subscales: the Urinary Impact Questionnaire (range 0–100); the Pelvic Organ Prolapse Impact Questionnaire (range 0–100); and the Colorectal Anal Impact Questionnaire (range 0–100). The degree to which pelvic symptoms affect the quality of life, in particular physical activity, travel, and social relationships, is rated on a fourpoint scale (1 = “not at all”; 4 = “quite a bit”). The presence of overactive bladder was evaluated with the validated Turkish form of the Overactive Bladder Validated Eight-Question Awareness Tool. This is a screening and awareness tool that is composed of eight questions derived from the Overactive Bladder Questionnaire [9,10]. Patients rate the degree to which each symptom affects quality of life on a six-point Likert scale (1 = “not at all”; 6 = “a very great deal”). The total score ranges from 0 to 40, and scores of 8 or greater indicate the presence of overactive bladder. The statistical analysis was performed using SPSS version 10.0 (SPSS Inc, Chicago, IL, USA). The participants were classified into two groups according to their sexual function, based on an FSFI cutoff score of 26.5. Continuous variables were expressed as mean ± SD and categorical variables as numbers and percentages. Continuous variables were compared with an independent sample t test; categorical variables were compared with the χ2 test. Multiple linear regression analysis

was performed to assess the effect of independent risk factors (age; menopausal status; scores on PFDI-20, PFIQ-7, and the Overactive Bladder Validated Eight-Question Awareness Tool; presence of systemic illness; and income level) on the FSFI score. P b 0.05 was considered statistically significant. 3. Results Of 276 patients considered for inclusion, 243 volunteers were included in the study. Their mean age was 46.0 ± 9.1 years (range, 22–68 years). Of the 243 women, 188 (77.4%) had an FSFI score below 26.5, and 55 (22.6%) had a score equal to or above this value. In the group with better sexual function, the mean age was younger, the income was higher, and the numbers of women in menopause and with chronic illness were lower (P b 0.05) (Table 1). The study population included 198 (87.5%) women with stage I POP and 45 (18.5%) women with stage II POP. The stages were distributed evenly between the two groups. No difference was detected between the groups in terms of POP-Q measurements (P N 0.05), except for total vaginal length (Table 2). Overactive bladder was more frequent and severe in women with sexual dysfunction, and their quality of life was lower (Table 3). However, the frequency of stress incontinence and the postvoid residual urine volume did not differ between the groups (Table 3). According to the regression analysis, the presence of overactive bladder and monthly income significantly affected the total FSFI score, whereas age, menopausal status, PFIQ-7 and PFDI-20 scores, and presence of a systemic illness did not (Table 4). The linear regression equation was as follows: FSFI score = 1632 + (–0.159) overactive

Table 1 Baseline characteristics of the study population.a Variable

FSFI score b26.5 (n = 188)

FSFI score ≥26.5 (n = 55)

Age, y Parity Body mass indexb Duration of menopause, y Number of vaginal deliveries 0 ≥1 Number of cesarean deliveries 0 ≥1 Infant with birth weight ≥4000 g Negative Positive Employment status Employed Unemployed Education Primary school Secondary school or higher Social security Absent Present Socioeconomic status Low income Middle or high income History of gynecologic surgery Present Absent Chronic diseases Present Absent Menopause Present Absent

46.80 ± 9.35 2.5 ± 1.1 29.1 ± 5.1 6.6 ± 5.0

43.25 ± 7.49 2.2 ± 0.8 28.9 ± 4.1 7.2 ± 7.2

0.004 0.124 0.856 0.805

32 (17.0) 156 (83.0)

7 (12.7) 48 (87.3)

0.445

153 (81.4) 35 (18.6)

44 (80.0) 11 (20.0)

0.818

171 (91.0) 17 (9.0)

47 (85.5) 8 (14.5)

0.237

137 (72.8) 51 (27.1)

33 (60.0) 22 (40.0)

0.081

138 (73.4) 50 (26.6)

38 (69.1) 17 (30.9)

0.272

24 (12.8) 164 (87.2)

3 (5.5) 52 (94.5)

0.127

155 (82.4) 33 (17.6)

33 (60.0) 22 (40.0)

0.001

161 (85.6) 27 (14.4)

51 (92.7) 4 (7.3)

0.166

120 (63.8) 68 (36.2)

48 (87.3) 7 (12.7)

0.001

82 (43.6) 106 (56.4)

9 (16.4) 46 (83.6)

b0.001

P value

Abbreviation: FSFI, Female Sexual Function Index. a Values are given as mean ± SD or number (percentage), unless otherwise indicated. b Calculated as weight in kilograms divided by the square of height in meters.

A. Karabulut et al. / International Journal of Gynecology and Obstetrics 127 (2014) 73–76 Table 2 Comparison of POP-Q measurements in women with normal and low FSFI scores.a POP-Q reference point

FSFI score b26.5 (n = 188)

FSFI score ≥26.5 (n = 55)

P value

Aa Ba C GH PB TVL Ap Bp D

–1.43 –2.88 –4.36 3.00 2.54 9.02 –1.78 –3.43 –0.5.48

–1.45 –3.12 –4.78 3.19 2.58 9.53 –1.76 –3.58 –5.88

0.881 0.158 0.273 0.272 0.759 0.011 0.882 0.173 0.261

± ± ± ± ± ± ± ± ±

0.75 1.11 2.46 0.85 0.71 2.41 0.64 0.84 2.25

± 0.66 ± 1.08 ± 2.43 ± 1.16 ± 0.88 ± 0.69 ± 0.83 ± 0.65 ± 2.28

Abbreviations: POP-Q, Pelvic Organ Prolapse Quantification; FSFI, Female Sexual Function Index; Aa, an anterior point 3 cm above the hymenal ring; Ba, lowest point of the prolapse between Aa and the vaginal apex; C, cervix; GH, genital hiatus; PB, perineal body; TVL, transvaginal length; Ap, a posterior point 3 cm above the vagina; Bp, lowest point of the prolapse between Ap and the vaginal apex; D, pouch of Douglas. a Values are given as mean ± SD unless otherwise indicated.

bladder syndrome + (0.209) income level; the F value was 5.819 (P b 0.001). A high monthly income had a positive effect on sexual function, whereas the presence of overactive bladder had a negative effect. 4. Discussion A high prevalence of sexual dysfunction was detected among the women in the present cross-sectional study. Overactive bladder adversely influenced sexual function, whereas minimal POP had no negative effect. An analysis of confounding factors revealed that a high monthly income level was the only factor correlated with better sexual function. Using a cutoff of 26.5 points on the FSFI, sexual dysfunction was detected in 77.3% of the women in the present study. Mohammadi et al. [11] detected sexual dysfunction in 55.3% of Iranian women with multiple sclerosis. One of the main differences between the Iranian study and the present study was the mean age of the study population (33.7 years in the Iranian study vs 46.0 years in the present study). Female sexual dysfunction is an age-related and progressive event [12,13]. In a hospital-based study evaluating the rates of sexual dysfunction in different age groups [4], sexual dysfunction was detected in 50.2% of Table 3 Comparison of overactive bladder, symptoms of pelvic floor dysfunction, and quality of life scores in women with high and low sexual function.a Parameter

FSFI score b26.5 (n = 188)

FSFI score ≥26.5 (n = 55)

OAB-V8 score Overactive bladder OAB-V8 score b8 OAB-V8 score ≥8 PVR urine volume, mL Stress test Positive Negative PFDI-20 total POPDI-6 CRADI-8 UDI-6 PFIQ-7 total UIQ-7 CRAIQ-7 POPIQ-7

13.45 ± 9.61

9.14 ± 8.38

0.002

60 (31.9) 128 (68.1) 6.23 ± 10.11

29 (52.7) 26 (47.3) 4.38 ± 7.28

0.005

71 (37.8) 117 (62.2) 29.62 ± 8.31 36.72 ± 13.05 35.28 ± 10.87 50.62 ± 18.58 21.63 ± 32.27 17.07 ± 24.73 3.29 ± 10.59 1.26 ± 7.45

20 (36.4) 35 (63.6) 26.17 ± 5.83 31.51 ± 7.63 33.06 ± 9.31 41.81 ± 15.06 12.12 ± 26.31 7.70 ± 16.55 3.63 ± 11.59 0.77 ± 3.39

0.850

P value

0.206

0.004 0.005 0.138 b0.001 0.047 0.009 0.844 0.494

Abbreviations: FSFI, Female Sexual Function Index; OAB-V8, Overactive Bladder Validated Eight-Question Awareness Tool; PVR, postvoid residual; PFDI-20, Pelvic Floor Distress Inventory, short form; POPDI-6, Pelvic Organ Prolapse Distress Inventory; CRADI-8, Colorectal Anal Distress Inventory; UDI-6, Urinary Stress Inventory; PFIQ-7, Pelvic Floor Impact Questionnaire, short form; UIQ-7, Urinary Impact Questionnaire; CRAIQ-7, Colorectal Anal Impact Questionnaire; POPIQ-7, Pelvic Organ Prolapse Impact Questionnaire. a Values are given as mean ± SD or number (percentage), unless otherwise indicated.

75

women aged 40–49 years, 71.3% of women aged 50–59 years, and 82.9% of women aged 60–64 years. Therefore, age is an important factor contributing to sexual dysfunction, and the present results accordingly showed better sexual function in the younger age group. To some extent, the high prevalence of sexual dysfunction in the present study may be explained by a higher mean age of the study population compared with previous studies. Menopausal status is another factor thought to be associated with sexual dysfunction [14,15]. Menopause is a time of anatomic, physiological, and psychological changes that may lead to problems related to sexual function in women. Estrogen levels decline sharply during the menopausal transition, whereas androgen levels decrease gradually with the natural aging process [15]. Physiologic impairments that interfere with the normal female sexual response may result in diminished libido, sexual arousal, lubrication, genital sensation, and orgasm. In a multivariate analysis, Aslan et al. [4] demonstrated that the state of menopause was independently associated with sexual dysfunction. In the present study, although the number of menopausal women was significantly higher in the group with sexual dysfunction, the multivariate regression model did not confirm menopause as an independent risk factor. The present study also investigated the effect of POP symptom burden and quality of life on sexual function in women with stage I–II POP. In a previous hospital-based study [16], sexual dysfunction was more common among symptomatic women (mainly POP stage II–IV) than among asymptomatic women (mainly POP stage 0–II). In this study [16], cervical descent was the main anatomic feature correlated with sexual dysfunction. By comparison, the present study population included only women with minimal POP, most of whom were asymptomatic. Therefore, the POP-Q measurements were likely to be similar between groups, and a longer transvaginal length was indeed the only measurement associated with better sexual function (P b 0.05). However, the total PFDI-20 score and the domain scores on the Pelvic Organ Prolapse Distress Inventory and Urinary Distress Inventory were higher among women with sexual dysfunction, as were the total PFIQ-7 score and the domain score on the Urinary Impact Questionnaire (P b 0.05). Therefore, although there was no anatomic difference between the two groups with minimal POP, the burden of POP and the effect on quality of life may have been different. Of note, although the total PFIQ-7 and PFDI-20 scores were significantly different between the two groups, this difference did not achieve statistical significance in the multiple regression model. This finding can also be explained by the fact that the present study population included only women with minimal POP. Women with advanced POP (stage III–IV) would be likely to show different results. The presence of chronic illness was another factor that was significantly more common among women with sexual dysfunction. Diabetes mellitus is the systemic illness that is most commonly implicated as a cause of sexual dysfunction [17], both for women and for men. However, the degree of sexual dysfunction varies depending on the duration, severity, and type of diabetes mellitus [17]. Aras at al. [18] reported sexual dysfunction in 93.7% of patients with rheumatoid arthritis compared with 64.6% in the control group, and Pasquali et al. [19] detected an increased rate of sexual dysfunction in patients with thyroid disorders (46.1% vs 20.7%). The present study population is reflective of the general population and no subgroup analysis by type of systemic illness was performed. However, the present findings are in concordance with the literature on the association of sexual dysfunction with chronic illness in general. There is a growing body of evidence that sexual and urinary problems in women are often comorbid and possibly synergistic [20–22]. In the present study, overactive bladder had a significant effect on sexual function, but stress incontinence did not. The women with stress incontinence did not present with this complaint; it was detected during the study. This may be the reason why stress incontinence had no effect on sexual function; had it been severe, the situation might have been

76

A. Karabulut et al. / International Journal of Gynecology and Obstetrics 127 (2014) 73–76

Table 4 Multiple linear regression analysis with sexual function (FSFI score) as the dependent variable.a Independent variable

Unstandardized coefficient B (95% CI)

Standard error

Standardized coefficient beta

t value

P value

Age Menopause PFIQ-7 total PFDI-20 total OAB Systemic disease Monthly income

0.000 (–0.009 to 2.027) –0.137 (–0.291 to 0.016) –8.051 (–0.002 to 0.002) –0.007 (–0.015 to 0.001) –0.138 (–0.257 to –0.018) –0.030 (–0.080 to 0.020) 0.206 (0.085–0.328)

0.216 0.078 0.001 0.004 0.061 0.026 0.062

–0.010 –0.160 –0.005 –0.134 –0.159 –0.083 0.209

–0.108 –1.760 –0.073 –1.832 –2.265 –1.184 3.340

0.914 0.080 0.942 0.068 0.025 0.238 0.001

Abbreviations: FSFI, Female Sexual Function Index; CI, confidence interval; PFIQ-7, Pelvic Floor Impact Questionnaire, short form; PFDI-20, Pelvic Floor Distress Inventory, short form; OAB, overactive bladder. a R2 = 0.157; adjusted R2 = 0.130; F = 5.819; P b 0.001. Regression equation: FSFI score = 1632 + (–0.159) OAB syndrome + (0.209) monthly income.

different. Based on a study investigating the association between sexual dysfunction and type of incontinence, Coksuer et al. [20] concluded that mixed incontinence, and to a lesser degree stress and urge incontinence, had a negative effect on sexual life. This study [20] included patients who presented with urinary incontinence. By contrast, Sacco et al. [21] detected sexual dysfunction more frequently in 188 patients with overactive bladder than in those with stress urinary incontinence. Furthermore, Del Rosso et al. [22] showed a decrease in sexual dysfunction when overactive bladder was treated with antimuscarinics. In the present study, the monthly income level was significantly associated with sexual function. In previous studies [23,24], this factor did not achieve statistical significance in regression models, even though the income level was significantly lower among women with sexual dysfunction. The discrepancy with the present finding could be explained by sociocultural factors or by an extension of the gap between income levels. The present study is important in that it shows how extensive sexual dysfunction is even among women with minimal POP and identifies possible confounding factors. However, data collection was limited by the women’s timidity to express their feelings. Although each participant had approximately half an hour to complete the forms, this might not have been enough for problems to come to light. In conclusion, sexual problems indicative of dysfunction are highly prevalent among women with minimal POP in the clinical setting. In the present study, an overactive bladder and monthly income were associated with sexual health problems, but pelvic floor changes and quality of life had no effect on sexual function in patients with minimal POP. Conflict of interest The authors have no conflicts of interest. References [1] Zielinski R, Miller J, Low LK, Sampselle C, DeLancey JO. The relationship between pelvic organ prolapse, genital body image, and sexual health. Neurourol Urodyn 2001;31(7):1145–8. [2] Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281(6):537. [3] Lewis RW, Fugl-Meyer K, Bosch R, Fugl-Meyer AL, Lauman EO, Lizz E, et al. Epidemiology: Risk factors for sexual dysfunction. J Sex Med 2004;1(1):35–9. [4] Aslan E, Beji NK, Gungor I, Kadioglu A, Dikencik BK. Prevalence and risk factors for low sexual function in women: a study of 1,009 women in an outpatient clinic of a university hospital in Istanbul. J Sex Med 2008;5(9):2044–52.

[5] Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26(2):191–208. [6] Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175(1):10–7. [7] Kaplan PB, Sut N, Sut HK. Validation, cultural adaptation and responsiveness of two pelvic-floor-specific quality-of-life questionnaires, PFDI-20 and PFIQ-7, in a Turkish population. Eur J Obstet Gynecol Reprod Biol 2012;162(2):229–33. [8] Barber MD, Walters MD, Bump RC. Short forms of two condition-specific quality-oflife questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol 2005;193(1):103–13. [9] Acquadro C, Kopp Z, Coyne KS, Corcos J, Tubaro A, Choo MS, et al. Translating overactive bladder questionnaires in 14 languages. Urology 2006;67(3):536–40. [10] Tarcan T, Mangir N, Özgür MÖ, Akbal C. OAB-V8, Overactive bladder inquiry form validation study. Ürol Bül 2012;21:113–6. [11] Mohammadi K, Rahnama P, Moayed Mohseni S, Sahraian MA, Montazeri A. Determinants of sexual dysfunction in women with multiple sclerosis. BMC Neurol 2013;13(1):83. [12] Laumann EO, Nicolosi A, Glasser DB, Paik A, Gingell C, Moreira E, et al. GSSAB Investigators' Group. Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. Int J Impot Res 2005;17(5):39–57. [13] Verit FF, Yeni E, Kafali H. Progress in female sexual dysfunction. Urol Int 2006;76(1): 1–10. [14] Goldstein I. Current management strategies of the postmenopausal patient with sexual health problems. J Sex Med 2007;4(Suppl. 3):235–53. [15] Schwenkhagen A. Hormonal changes in menopause and implications on sexual health. J Sex Med 2007;4(Suppl. 3):220–6. [16] Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 2005;112(7):971–6. [17] Pontiroli AE, Cortelazzi D, Morabito A. Female sexual dysfunction and diabetes: a systematic review and meta-analysis. J Sex Med 2013;10(4):1044–51. [18] Aras H, Aras B, Icagasioglu A, Yumusakhuylu Y, Kemahli E, Haliloglu S, et al. Sexual dysfunction in women with rheumatoid arthritis. Med Glas (Zenica) 2013;10(2): 327–31. [19] Pasquali D, Maiorino MI, Renzullo A, Bellastella G, Accardo G, Esposito D, et al. Female sexual dysfunction in women with thyroid disorders. J Endocrinol Invest 2013;36(9):729–33. [20] Coksuer H, Ercan CM, Haliloğlu B, Yucel M, Cam C, Kabaca C, et al. Does urinary incontinence subtype affect sexual function? Eur J Obstet Gynecol Reprod Biol 2011;159(1):213–7. [21] Sacco E, D'Addessi A, Racioppi M, Pinto F, Totaro A, Bassi P. Bladder pain syndrome associated with highest impact on sexual function among women with lower urinary tract symptoms. Int J Gynecol Obstet 2012;117(3):168–72. [22] Del Rosso A, Pace G, Di Pierro ED, Masciovecchio S, Galatioto GP, Vicentini C. Impact of overactive bladder on sexual function in women. Urologia 2011;78(3):200–2. [23] Singh JC, Tharyan P, Kekre NS, Singh G, Gopalakrishnan G. Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med 2009;55(2):113–20. [24] Ishak IH, Low WY, Othman S. Prevalence, risk factors, and predictors of female sexual dysfunction in a primary care setting: a survey finding. J Sex Med 2010;7(9):3080–7.

Evaluation of confounding factors interfering with sexual function in women with minimal pelvic organ prolapse.

To evaluate the effects of confounding factors on sexual function in women with minimal pelvic organ prolapse (POP)...
183KB Sizes 0 Downloads 5 Views