Sexual Functions in Women with Stress Urinary Incontinence After Mid-Urethral Sling Surgery: A Systematic Review and Meta-Analysis of Prospective Randomized and Non-Randomized Studies
Authors: Lai Shicong , Diao Tongxiang , Zhang Wei , Seery Samuel , Zhang Zhipeng , Hu Maolin , Meng Lingfeng , Ma Tianming , Liu Xiaodong , Wang Jianye , Zhang Yaoguang 
Published: July 2020

Abstract

Background
Stress urinary incontinence (SUI) is a common, distressing health issue which affects many women. Mid-urethral sling (MUS) surgeries are recommended as gold standard interventions, although evidence regarding their impact on female sexual function remains controversial.

Aim
To provide high-quality evidence of the impact of MUS surgeries on sexual functions in women with SUI.

Methods
A systematic search of PubMed, Embase, and the Cochrane Library was conducted to identify studies assessing the effect of MUS treatments on sexual functions in women with SUI. The included studies were prospective randomized or non-randomized trials which assessed patients using 2 validated questionnaires, the Female Sexual Function Index (FSFI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Pre- and postoperative data regarding sexual function were extracted. Meta-analysis of comparable data was performed using Review Manager (version 5.3) software.

Main outcome measures
The relationship between MUS interventions and sexual functions was analyzed by pooling weighted mean differences (WMD) with 95% CI from studies which used either the FSFI or PISQ-12 questionnaires, before and after receiving surgical interventions.

Results
Of the 22 eligible studies, 13 utilized FSFI and 9 adopted the PISQ-12. Pooled analysis indicates that 6-month postoperative PISQ-12 scores were significantly higher than preoperative scores (WMD −3.31 points; 95% CI −5.32 to −1.30; P = .001). Similar results were found at the 12-month juncture (WMD −3.30 points; 95% CI −6.01 to −0.58; P = .02) and at 24 months (WMD −4.44 points; 95% CI −5.45 to −3.44; P &lt; .00001). Likewise, pooled postoperative FSFI total scores were significantly higher than preoperative scores at 6 months (WMD −2.22 points; 95% CI −3.36 to −1.08; P = .00001) and 12 months (WMD −3.49 points; 95% CI −5.96 to −1.02; P = .006). Postoperative FSFI sub-scores also suggest that desire, arousal, orgasm, lubrication, satisfaction, and pain during sexual intercourse significantly improved postoperatively (all P &lt; .05). Moreover, combined evidence highlighted a significant reduction in coital incontinence postoperatively (risk ratio 5.78; 95% CI 3.16–10.58; P &lt; .00001).

Clinical Implications
These assessment tools might be more appropriately used to create opportunities for counseling.

Strengths & Limitations
We encountered substantial heterogeneity and insufficient long term follow-up data. There is also a distinct lack of standards, in terms of data recording and reporting across this evidence base which adds to the problems with the PISQ-12 and FSFI which, even though validated, appear unsophisticated and not necessarily fit-for-purpose.

Conclusion
This meta-analysis confirms that sexual functions do improve after MUS surgeries for women with SUI.