The Impact of Urinary Incontinence on Sexual Health in Older Adults

‘‘Therefore my age is as a lusty winter, frosty but kindly. ’’ In William Shakespeare’s comedy about romantic love, As You Like It (Act II, Scene 3), Adam, the elderly manservant, speaks these lines as he contemplates his aging and tries to underscore that his spirit and abilities remain robust. These words ring true today as many people hope for a similar fate with their own journey through the aging process. For many older adults, maintaining a satisfying level of sexual activity is an important part of sustaining a high quality of life. Clinical research and practice have clearly demonstrated that, although a person may be elderly, it does not mean that they are necessarily asexual. In fact, studies of residents in long-term care facilities have revealed that many of these individuals remain interested in sex and that some remain sexually active in this environment. The availability of a regular partner certainly influences the degree to which elderly individuals remain sexually active. Many older adults want to continue to experience the full range of sexual activities they enjoyed in younger years for as long as possible, but forms of sexual expression may also change with advancing age. For some older adults, masturbation may become a primary sexual outlet. In many cases, the simple acts of touch and physical intimacy may supplant penetrative sexual intercourse as highly meaningful and satisfying forms of sexual expression. Many factors can negatively influence sexual function in older adults. Significant comorbid conditions such as diabetes mellitus, hypertension, and peripheral vascular disease may limit genital blood flow. Impaired circulation may in turn lead to erectile dysfunction in men and diminished sensation or orgasmic dysfunction in women. Osteoarthritis and neurological disorders may impair physical mobility during intercourse and make certain sexual positions difficult or uncomfortable for older adults. Atrophic vaginitis is a common condition in postmenopausal women that may be associated with dyspareunia and decreased sexual activity. Hormonal changes may lead to alterations in libido for both men and women. Clinicians must ask specifically about sexual function, because many older adults will not volunteer this information or raise questions themselves. The study by Tannenbaum et al. in this issue examined the association between urinary incontinence and self-reported levels of sexual activity in a community-based postal survey of 5,000 Canadian women aged 55 and older. Particular strengths of this study were that it surveyed a broad range of women across the country and represented approximately 15% to 18% of the total female Canadian population. Data were available for 2,361 of the 5,000 women surveyed. The overall prevalence of urinary incontinence was 38%, and 27% of the women reported being sexually active. The authors found that continence status did not appear to influence participation in sexual activity for many older women. Age and marital status, a proxy measure for the availability of a sexual partner, were the strongest predictors of continued sexual activity. Although the frequency of incontinent episodes was not related to changes in sexual activity, overall physical and mental health did appear to influence this outcome. In addition, stress incontinence, nocturnal incontinence, and larger volumes of urine loss did appear to negatively affect sexual participation. The authors concluded that marital status and physical and mental health parameters must be considered in evaluating the results of intervention studies to improve sexual health in older incontinent women. In addition to the community-based design, other strengths included the exploration of multiple predictor variables such as overall physical and mental health and body image. There were also several potential limitations that the authors recognized and discussed. The results were based on a self-reported postal survey that may have some inherent response biases. The question on sexual activity was dichotomous and thus may not have accounted for varying levels or forms of sexual expression. Sexual satisfaction was also not measured in this study. The use of marital status as a proxy measure for a regular sexual partner was also potentially biased. This variable will not capture single women who may have a regular sexual partner, married women whose partner suffers from significant sexual dysfunction, or women who engage in sexual activity with other women. The generalizability of the research findings are also limited to relatively healthy, communitydwelling adults. Several other studies have examined the relationship between urinary incontinence, pelvic organ prolapse, and decreased sexual function in women. One demonstrated that urinary incontinence was significantly associated with decreased libido, vaginal dryness, and dyspareunia. These findings were independent of subject age. Another found that women with incontinence and prolapse were less sexually active than women without these problems. It also DOI: 10.1111/j.1532-5415.2006. 00864.x