Excerpts from The Incontinence Solution: Answers for Women of All Ages, by William H. Parker, MD, Amy E. Rosenman, MD and Rachel Parker (Simon and Schuster, 2002)


Our sex lives are sometimes hard for us to talk about. We struggle to tell our children “the facts of life,” and we struggle to tell our partners what pleases us. Sex is personal, and, at its best, is an intimate treasure savored privately. We each want to please and be pleased, to feel warm, safe, and desired. For many women, perceived problems with their weight, overall appearance and desirability can cause enormous anxiety. When a woman chooses to have sex, oftentimes her worries and insecurities get right into bed with her. Does he like my body? Am I pretty? Are my thighs too big? As you age, those issues may make you more ill at ease. Add prolapse or incontinence to the mix, and things can get pretty complicated. Incontinence may turn that little voice of insecurity into a roar.


▷ Does Incontinence Affect Your Sexuality?
The good news is that a recent study tells us women with incontinence or prolapse report the same amount of sexual activity, comfort, and enjoyment with sex as women without incontinence. There’s more: 80% of the women with either prolapse or incontinence felt their partners were also satisfied with their sexual relationship. Naturally the woman’s feeling about her partner and the relationship has a lot to do with whether she is satisfied sexually or otherwise. But the incontinence and the prolapse turned out to be less important than expected. Incontinent or not, many women stay sexually active well into their seventies and eighties.


However, the same study stated that women with the most severe prolapse or most frequent incontinence did report that their physical condition interfered with their sex lives. As a result, these women were more distressed about their medical situations and were less content. While the women with less severe incontinence did not have a significant problem with sexual satisfaction, those with severe problems found it was a detriment to their sex lives.


▷ Can Young Women Have Incontinence During Sex?
Surprisingly, young women actually have incontinence during intercourse more than older women. A study performed in Israel found that while only 3% of women over age 65 reported incontinence with sexual activity, 29% of women under age 60 had this problem. And, as might be expected, this incontinence caused these women some anxiety. While almost all the women in this study were in stable marriages, 43% of them felt anxiety because of the incontinence during intercourse. Although there is no comparable study for single women, more than likely the absence of a stable relationship only makes things worse.


▷ Can Incontinence Cause a Problem with Sex?
Incontinence makes some women feel unclean and, consequently, undesirable. They may consequently avoid sex or feel less pleasure and freedom when they do have sex. The type of incontinence a woman has can greatly affect how much it troubles her. Women with stress incontinence usually have fewer problems with sex than women with urgency incontinence. Stress incontinence often happens at predictable times, most often right at the beginning of intercourse when penetration alters the angle of the bladder and urethra. Urinating just before having sex will usually prevent this problem.


Urge incontinence, the result of an overactive bladder, causes more distress because it is unpredictable and unavoidable. Women with urge incontinence often lose urine during an orgasm, which may be particularly upsetting. Also, the amount of urine leaked because of an overactive bladder is usually greater than with stress incontinence. One study found that almost 70% of women with urgency or urge incontinence had unsatisfying sexual relations while only 20% of women with stress incontinence had this complaint.


▷ Can Prolapse Cause Problems with Sex?
Prolapse does not usually cause problems with sex. If prolapse results in bulging of the bladder or rectum into the vagina, the bulge can be easily pushed back into place before intercourse, and most women with prolapse say they don’t notice it during intercourse. Also, if you have a prolapse, you should know that intercourse will not cause any harm to whatever is bulging: your bladder, vagina, uterus or rectum.

It is common for women to notice that the prolapse is much less apparent when they are lying down, a likely position during sex, allows the prolapse to move out of the way. However, if the prolapse is severe, the vagina may be exposed to the drying effect of the air and intercourse may be irritating and uncomfortable. In that situation, a lubricant can be very helpful.


▷ Does Incontinence Make You Less Attractive?
Incontinence can undeniably complicate life in an unpleasant way. Many women modify what they wear and how they live as a result. Some tell us they feel less feminine and less independent. Their wardrobe is suddenly limited to only dark clothing in order to hide any possible leaks. They avoid situations where they won’t have easy access to a bathroom. Some women so dread of embarrassing themselves that they only feel comfortable at home. They may also be concerned about odor and may fear that nobody will want to sit next to them at social events. However, as we hope readers will learn from this book, there are now many ways to prevent incontinence. The social and physical isolation that incontinence sometimes brings is unnecessary.


▷ How Can You Talk with Your Partner about Incontinence?
Both women and men with incontinence may suffer from feelings of isolation. Embarrassment and fear of humiliation often keep them from talking to their partners about the subject. Usually the fear is worse than the reality. Unnecessary tension and emotional distancing hurts both people in the relationship. We know that good communication between lovers helps to make sex more joyful, under any circumstance. If you have incontinence, talking to your partner about it may be the most important thing you can do. Good communication will lead to greater affection and trust. Talking about any kind of problem is usually easier in a long-term, intimate relationship, but even in a new relationship, getting things out in the open often brings relief. 


If you have incontinence with intercourse, discussing this with your partner before having sex might help you both. Many women, although embarrassed at first, are surprised at how easily the conversation goes. Oftentimes mentioning that there might be a bit of dribbling is all that is needed. Some men worry about getting a bladder infection from an incontinent partner. Although loss of urine may feel unclean, urine is entirely sterile. Your partner can be reassured that no risk of transmitting infection exists. Others worry needlessly about hurting a woman with a prolapse when all that is needed is to push the prolapse back and use a lubricant. The bottom line is very clear. Incontinence does not need to get in the way of sexuality.


▷ Should You Discuss Sexual Problems with Your Doctor?
If many women have problems talking to their partners about sex, isn’t it even more difficult for them to broach the subject with their doctors? To complicate things even further, doctors are often uncomfortable about discussing sex and are rarely well trained to do so. Adding incontinence to a conversation may make both a woman and her doctor even more reluctant to pursue further discussion.


To illustrate what a significant problem this is, interviews with 324 sexually active women found that only 2 women had volunteered information about having incontinence during sex. However, when specifically asked about this symptom, 77 additional women acknowledged that they had incontinence during intercourse.


Patients and doctors need to do a better job communicating about incontinence and sexuality. If your doctor doesn’t ask about incontinence, it is important for you to bring it up if there is a problem. If your doctor seems uncomfortable with the subject, ask for a referral to someone who regularly deals with incontinence. If you are having a problem with incontinence and sexuality, more than likely you will need to bring this up as well. If your doctor is not equipped to discuss this with you, ask for the name of a knowledgeable therapist who can help.


If your doctor doesn’t know such specialists, make an effort to find someone on your own (see chapter 13). The important thing is to get what you need. You’re not alone with this problem.


▷ Can Kegel Excercises Prevent Leaking During Sex?
Kegel exercises can certainly help. Women who learn to do Kegels correctly and do them regularly (see page xx) have less leaking during intercourse. A recent study from Norway found that women who were taught by a physical therapist the correct way of performing Kegels were more likely to have more satisfying sex than a group of women who were not properly taught these exercises. These women had fewer problems with their sex life and less discomfort with intercourse. We encourage you to do Kegel exercises on a regular basis. 


▷ What Else Can Help Prevent Leaking During Sex?
Another way to prevent leaking during sex is to keep your bladder reasonably empty during intercourse. Try to avoid drinking fluids for an hour or so before you expect to have intercourse. This will keep the bladder from filling up too quickly once you get into bed. If you empty your bladder just before you begin lovemaking, leaking is much less likely. 


▷ What are the Best Positions to Prevent Leaking?
Some positions make leaking much less likely. A woman on top has control over penetration and better control of her pelvic muscles. Some women find more control in positions they find less tiring. Intercourse on your side is usually less strenuous. Rear entry will keep pressure directed away from the bladder and urethra. However, everyone is different so you should experiment with different positions until you find the ones that work for you. 


▷ Will Sex Be Better If You Have Surgery?
To answer this, a recent American study questioned a group of women before and after surgery to repair a prolapse or incontinence. About half of these women were sexually active. Before surgery, 82% of the sexually active women reported being happy with their sex lives, and after surgery, 89% of the women felt happy with their sexual relationship. 


However, study brought out a number of interesting findings. For one, the frequency of intercourse did not change following surgery. And two, while only 8% of the women had pain with intercourse before surgery, 19% noted pain with intercourse after surgery. About one quarter of the women who had a repair of a bulging rectum (rectocele) developed pain with intercourse. About one third of the women who had repair of a rectocele and a bladder suspension had painful intercourse. Unfortunately, the researchers did not ask these women why they were more satisfied with their sex lives even though more of them had painful intercourse.


Another study performed in Sweden may shed some light. This study found that one third of women noted an increased interest in sex after incontinence surgery, and one half of their male partners were more interested in sex. It could be that knowing the repair for the prolapse or incontinence had been addressed was enough to make the couples feel better about sex.


▷ What Can You Do If Intercourse is Painful?
One way to reduce discomfort during intercourse is to use a lubricant. Ask the pharmacist to recommend a good lubricant or try a few to see which one works well for you. Try to avoid using Vaseline or hand lotion, as these tend to dry out quickly. If vaginal dryness is a longstanding problem, consider asking your doctor about vaginal estrogen. Estrogen makes the vagina more elastic and increases natural lubrication. Local forms of estrogen, available as creams, estrogen-containing silastic rings or small pills inserted into the vagina can improve vaginal health without any significant absorption of the estrogen into the bloodstream and the body.


▷ If You Have Interstitial Cystitis, Can Anything Help Make Sex More Comfortable?
For a woman with IC, finding out what works for her and her partner can involve some trial and error. In general, women tell us that sexual positions where the pressure is off the bladder are the most comfortable. Many report the most comfortable positions are lying on their side or rear entry. Again, the best idea is to experiment until you find what works for you. Some couples substitute oral sex if intercourse is too painful. Using a vibrator to stimulate only the clitoris without involving the vagina may also give pleasure. Keeping a heating pad on the pelvic area before sex brings blood to the area and may help facilitate orgasm. A cold pack applied on the pelvic area after sex keeps inflammation and discomfort down.


▷ Helpful Hints to a Better Sex Life
Here are bits of information our patients with incontinence have told us helped them improve their sex lives:
1. This is the most important and obvious – be sure you have an understanding partner. Talk to your partner about your situation. Whether you are incontinent or not, a supportive and caring lover is what you need. Make sure you have the partner you deserve or help your partner become one. Seek professional counseling if neccessary. 
2. Always empty your bladder before intercourse. This should help avoid leaking and help you maximize your enjoyment. 
3. Try to avoid fluids just before intercourse. This doesn’t mean you need to be dehydrated or dry-mouthed, but avoiding that cup of coffee or cola may make a big difference. 
4. If you think you might need them, use towels, disposable pads, or rubberized sheets to keep the bed dry and fresh. Planning ahead may minimize any anxiety you have. 
5. Be calm if you leak. Urine is a sterile fluid, and a little leakage is just not that important. A sense of humor might help defuse the situation, while anger or frustration may only increase your anxiety or that of your partner. Sometimes our bodies seem to be loaded with booby traps for potential embarrassment. That’s the way we humans are. 
6. Do Kegel exercises regularly. Toned muscles often decrease or eliminate leaking, and they can increase pleasure for both partners. 
7. Experiment with your partner to find the most comfortable positions for you both. 


▷ References
Berglund A, Eisemann M, Lalos A, et al. Social adjustment and spouse relationships among women with stress incontinence before and after surgical treatment. 1996 Social Science and Medicine 42:1537.


Berglund A, Fugl-Meyer K. Some sexological characteristics of stress incontinent women. 1996 Scandanavian Journal of Urology and Nephrology. 30:207.


Gordon D, Groutz A, Sinai T, et al. Sexual function in women attending a urogynecology clinic. 1999 International Urogynecology Journal. 10:325.


Roe B, May C. Incontinence and sexuality: findings from a quality prospective. 1999 Journal of Advanced Nursing. 30:573.


Weber A, Walters M, Piedmonte M. Sexual function and vagianl anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. 2000 American Journal of Obstetrics and Gynecology. 182:1610.


Weber A, Walters M, Schover L, et al. Sexual function in women with uterovaginal prolapse and urinary incontinence. 1995 Obstetrics and Gynecology 85:483.