There are many factors that influence sexual function in the state of urinary incontinence / lower urinary tract symptoms (LUTS), does urinary incontinence have an impact on sexual function? Does incontinence have an impact on sexual function? Does treatment improve sexual function or may it exacerbate it? These questions are still open. In Nature Reviews Urology, Brigitte Fatton et al. discuss the impact of urinary incontinence and LUTS on women’s sexual functioning and address the evaluation of questionnaires, treatments, and outcomes. The original article was published on September 9 and is compiled below. The causes of sexual dysfunction in women with urinary incontinence are multifactorial, encompassing physical, psychological, emotional, social, and cultural factors, and affect not only the patient but also her partner. Epidemiologic surveys estimate that 45% of postmenopausal women have pelvic floor dysfunctions (PFDs), which adds a considerable burden to patients and the public health system. Voiding control requires good anatomical and urethral integrity support in addition to increased intra-abdominal pressure. These effective supports come from the intact ligaments lateral to the urethra as well as the distal anterior wall of the vagina attached to the surrounding structures (i.e., fascial fusion), the pelvic fascial tendon arches, and the anal raphe muscles (Figure -1). Loss or disruption of these supportive structures can lead to urethral hypermobility and Stress Urinary Incontinence (SUI). In addition, the integrity and mechanical closure of the urethra play an important role in preventing SUI. The integrity and mechanical closure of the urethra requires normal uroepithelium, vascular plexus, and effective musculature, and damage to these structures will lead to dilator muscle insufficiency, and thus SUI. Studies exploring the effects of PFDs on sexual function have shown wide variations in conclusions from study to study. Differences in study populations, methods used, and types of questionnaires can explain the variability in conclusions, but this also makes it difficult to draw the right conclusions through literature analysis. Nevertheless, it is possible to estimate that between 19% and 50% of women with PFD or urinary incontinence complain of sexual dysfunction, difficulty with sexual intercourse, or reduced libido. Similarly, approximately 46% of women with Lower Urinary Tract Symptoms (LUTS) have sexual dysfunction.Another problem for women with PFD is incontinence during sexual intercourse, which also has a negative impact on sexual function. These conditions are rarely reported voluntarily by patients, so its prevalence is often underestimated. Human sexual function is affected by many factors, and its complexity is a major reason for the inconsistency of research findings. Regardless of the specificity of the questionnaire, a woman’s past history, age and hormone levels, partner intimacy, and sociocultural influences are difficult to evaluate simply by questionnaire. The heterogeneity of the study population (general population, elective surgery population, or post-treatment population), and the instruments used to assess sexual function (e.g., whether the questionnaire used was validated and self-administered; whether the data were obtained through face-to-face or telephone interviews) all add to the difficulty of the assessment. Furthermore, the term “sexual dysfunction” itself can be confusing. Some researchers believe that Pelvic Organ Prolapse (POP) and urinary incontinence can cause sexual problems. But there are also researchers who disagree with this, or at least insist that theories of female sexual functioning support the idea that psycho-emotional factors are a central cause of sexual dysfunction. But the fact is that any published study should be compared with findings on sexual health in the general population. For example, the prevalence of dyspareunia ranges from 7.9% to 16.8% in Australia and from 5.7% to 22.9% in Japan, depending on the age of the cohort. In a study of 329 obstetrics and gynecology outpatients in the United States, 11.3% complained of painful intercourse. More generally, large epidemiologic studies suggest that 35% to 45% of adult women have at least one sexual disorder. In a British study of 1194 female patients attending obstetrics, gynecology, or genitourinary departments, 437 (37%) had sexual dysfunction, of which only 17% voluntarily reported it, and 83% admitted it only at the time of consultation. Sexual function problems are common in self-reports, and large epidemiologic studies have shown that these disorders affect >40% of U.S. women; in contrast, personal distress related to sexual function problems is underreported (12% overall, 22% age-adjusted). These findings are supported by another study, which found that 45% of patients felt bothered by these disorders. These findings exemplify the importance of critically assessing the prevalence of sexual disorders that affect individuals and require clinical attention. In this review, the authors focus on the impact of LUTS, specifically SUI, on female sexual function and discuss clinical tools for assessing sexual dysfunction and prognosis of sexual function after SUI. II.SEXUAL FUNCTION QUESTIONSNAIRES Sexual function in female patients is assessed by several questionnaires, which can be divided into two categories. Generalized questionnaires are used to screen large populations but are not able to detect nuances within specific populations (e.g., women with PFD). Disease-specific questionnaires, on the other hand, are used to assess patients with specific diseases and are therefore more sensitive to disease-specific aspects. Some validated non-specific questionnaires include the Sexual History Form36 and 12, the Dyadic Adjustment Scale, the Derogatis Sexual Functioning Inventory, the Derogatis Sexual Functioning Inventory, the Assessment of Sexual Functioning Impairment, and the Dyadic Adjustment Scale. The Dyadic Adjustment Scale, the Derogatis Sexual Functioning Inventory, which assesses marital satisfaction and sexual functioning, the Female Sexual Function Index, which assesses satisfaction during female sexual response, and the Brief Index of Sexual Functioning for Women. Women.) These generalized questionnaires have been validated and proven to be effective, but are not suitable for use in research. There are many unvalidated questionnaires in the literature, and since validated questionnaires are now available, it is not reasonable to use them. However, in some cases they can be used as a supplement in specific areas, in particular postoperative assessment (vaginal narrowing, shortening or stenosis) – issues not covered by validated questionnaires. 3. Specific validated questionnaires The International Continence Society (ICS) has evaluated a number of tools for quantitatively evaluating urinary incontinence and sexual functioning in women with POP and recommends three tools (Level A, highly recommended). The International Consultation on Incontinence QuestionnaireI-Female Urinary Tract Symptoms (ICIQ-LUTS), which assesses sexual functioning problems and distress associated with female urinary tract symptoms. Sexual Functioning Section (International Consultation on Incontinence QuestionnaireI-Female Urinary Tract Symptoms, ICIQ-LUTS, which assesses female urinary tract symptom-associated sexual functioning problems and disturbances), and two versions of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ), which consists of 31 questions and 12 questions, respectively.) The long version of the PISQ was reported by Rogers in 2001 and contains a validated methodology, i.e. it contains specific correlations with previously validated questionnaires (SHF-12 and the Incontinence Impact Questionnaire-7 (IIQ-7)). The long version of the PISQ has 31 questions, all of which are answered by the patient, and can be divided into 3 modules: behavioral/emotional (15 questions), partner-related (6 questions), and somatic (10 questions). The short version of the PISQ, which has 12 questions, covers the three modules of the long version, and has a highly correlated total score and subgroups scores with the long version, and is commonly used in clinical studies. The advantage of the short version is that it takes less time. This advantage is quite evident in clinical work where patients need to complete multiple questionnaires to fully assess their symptoms and impact on their lives. Over the past 10 years, the short version of the PISQ has gained universal acceptance as a reference tool for analyzing sexual function in patients with PFD. In 2013, the International Urogynecological Associ ation (IUGA) published a revised version of the PISQ, the PISQ-IR, with the aim of modifying some of its shortcomings. The PISQ-IR takes into account women without sexual partners and sexually inactive women, and validates the applicability of the PISQ-IR in the female population with fecal incontinence. The questions of the PISQ-IR can be divided into 3 modules: sexual inactivity; sexual response; and sexual quality, satisfaction and desire. The PISQ-IR consists of 20 questions, the first of which is whether or not the patient is sexually active. The questions for sexually inactive women include a module on sexual inactivity and a module on quality and satisfaction, which includes an assessment of the impact on general health and partner relationships (in terms of sexual functioning). The questions for sexually active women include a sexual response module and a sexual quality of life module (dealing with sexual arousal, orgasm, partner-related problems, and the impact of PFD on sexual function). Third, the impact of LUTS on sexual functioning There is a wide variation in the impact of urinary incontinence on sexual functioning as reported in the literature. Human sexual function is affected by many factors, and its complexity can largely explain the differences between studies. For example, one study showed that 68% of sexually active women believed that urinary incontinence had a negative impact on their sexual life, but Temml et al. reported that 74, 9% of incontinent women reported that urinary incontinence had no effect on their sexual functioning. Common reasons for patients to abstain or have less sex include nocturnal leakage, leakage during intercourse, discomfort and depression. 1. Stress urinary incontinence In studies that have explored the effects of urinary incontinence on sexual function, almost all have failed to differentiate between the pathophysiologic mechanisms of the different types of incontinence, making it very difficult to assess the specific effects of each type of incontinence on sexual function. Studies of SUI often include patients with genital prolapse, thus introducing additional bias. In a cross-sectional study, Coksuer et al. used the PISQ-12 to analyze the effect of urinary incontinence on sexual function in 170 patients with urinary incontinence. Patients with organ prolapse staging ≥2 (Pelvic Organ Prolapse Quantification, POP-Q) were not included in the study. The lowest score (worst sexual function) was for patients with mixed incontinence. Unlike other studies, SUI had a worse effect on sexual function than Overactive Bladder (OAB). 2.Coital Incontinence Sexual intercourse incontinence (Coital Incontinence) is the involuntary leakage of urine during sexual intercourse. Coital incontinence is an aggravating factor that women commonly describe as “embarrassing”. The prevalence of coital incontinence has been estimated to be between 2% and 56%, depending on the study population (e.g., general population or cohort study population with urinary incontinence), the definitions used in the study (any leakage, weekly, during penile penetration, at orgasm, or severe leakage only), and the method of assessment (questionnaires, interviews). The prevalence of sexual intercourse incontinence in randomly selected community samples ranged from 2 to 10%, as reported in a 2002 English-language literature literature review covering the period 1980 to 2001. Higher prevalence rates have been reported in other heterogeneous clinical cohort studies (varying initial disease status, age, and severity of incontinence), with a mean of 22% (10-56%). The pathophysiologic mechanism of sexual intercourse incontinence is inconclusive, and it is generally believed that incontinence during orgasm is due to bladder overactivity, whereas incontinence during penile penetration is due to SUI. In the last 5 years, studies have identified a role for the urethral dilator muscle in sexual intercourse incontinence, and it is even thought to play an important role in forced urethral muscle overactivity and incontinence during orgasm in women. Urinary incontinence during penile penetration is largely related to SUI, whereas incontinence during orgasm may be related to overactivity of the urethral muscles and SUI. However, orgasmic incontinence is more common in women with OAB than penile penetration incontinence. Eighty percent of urodynamically diagnosed SUI with penile thrust incontinence can be cured surgically. Similarly, 59% of climacteric incontinence with overactivity of the urethral muscles responds to anticholinergic medications. Interestingly, however, urinary incontinence at orgasm proved to be a negative predictor for antimuscarinic medication in the treatment of detrusor overactivity. Some authors have hypothesized that urinary incontinence during intercourse is due to insufficient dilator muscle function rather than recalcitrant detrusor overactivity, and thus would not respond favorably to anticholinergic medications. Some women experience ejaculation at orgasm, a phenomenon that is difficult to diagnose and poorly understood at present. Vaginal lubrication is a common phenomenon of female sexual arousal, but the expulsion of these fluids may also occur by means of “female ejaculation”. The term “female ejaculation” is not precisely defined, and the fluid can be any fluid that is released during sex. Ejaculatory orgasm is a physiological response to sexual arousal, and can be manifested as “true” female ejaculation (a small amount of thick, white fluid from the para-urethral glands), or as the ejaculation or eruption of a large amount of diluted, altered urine. Female ejaculation is a rare physiologic reaction that occurs in only a small number of women, but is sometimes similar to urinary incontinence during orgasm. Female patients complaining of this type of ejaculation, but without other LUTS, do not require further investigation. In a 2013 review, Pastor emphasized the importance of distinguishing between physiologic (ejaculation at orgasm) and pathologic (incontinence during intercourse) phenomena. 3. In other LUTS epidemiologic surveys, all types of incontinence are usually treated as one condition. A number of studies have begun to attempt to assess specific types of urinary incontinence. There have been several studies assessing the impact of OAB on quality of life, but for many years its impact on sexual functioning was ignored. A 2006 study examined the ability of three questionnaires to detect sexual function in women with incontinence secondary to OAB: the Sexual Quality of Life Questionnaire, the Sexual FuncHN` Questionnaire, and the PISQ. PISQ. Although patients perceived most of the questions in all the questionnaires to be relevant to their symptoms, the SQoL-F and sexuality were most relevant. The choice of the questionnaire to assess the patient’s prognosis is an important step in the patient assessment: the SQoLF has the best validity and a high correlation with OAB; however, if the assessment is not about quality of sexual life, but about sexual functioning, then the SFQ or the PISQ should be chosen. In addition, this study was not designed to address the impact of OAB on sexual functioning, but patients included in the study reported a greater effect of urinary incontinence on sexual functioning. Interestingly, incontinence during intercourse was found to have a significant impact on sexual function. Interestingly, sexual incontinence did not affect sexual function, whereas postcoital urge incontinence and urinary frequency did. In a multicenter web-based survey, OAB symptoms and incontinence were significant predictors of sexual disorders, with OAB symptoms having a stronger negative impact than incontinence. In the Multicenter Assessment of Transdermal Therapy in Overactive Bladder with Oxybutinin (MATRIX) study, investigators found that OAB had a significant impact on sexual function and couple’s relationship. 52% of subjects reported decreased libido after the disease. After transdermal treatment with oxybutynin, more than 23% of patients reported an increase in libido while 12% reported a decrease in libido. In addition, the study found significant improvements in patients’ feelings of “embarrassment” (35.5%) and partner relationships (19.6%). Tolterodine has also been shown to significantly improve sexual function in women with OAB in a prospective cohort study of 30 patients. 46% of 216 patients with urinary incontinence, recurrent or persistent LUTS in the cohort in the study by Salonia et al. reported sexual dysfunction including low libido (34%), impaired sexual arousal (23%), lack of orgasms (11%), and pain with sexual intercourse (11%). Difficulty with intercourse and noncoital genital pain, 44%). Of these patients with painful intercourse, 61% complained of recurrent bacterial cystitis. Painful intercourse may have several biological causes, such as vaginal atrophy, bacterial vaginitis, vaginal candidiasis, and chronic urethritis. Therefore estrogen supplementation therapy and elimination of urethral or vaginal inflammation can significantly improve intercourse discomfort or pain. To evaluate the relationship between LUTS and urinary incontinence on female sexual dysfunction, Cohen et al. conducted a retrospective study containing 236 patients, and those included completed the FSFI questionnaire and underwent urodynamic examination. Based on history and physical examination, these women were categorized into 4 groups: SUI, dry overactive bladder (OAB symptoms without comorbid urge incontinence), wet hyperactive bladder (OAB symptoms with urge incontinence), and mixed incontinence (SUI + wet OAB). Urodynamic findings such as urinary leakage, bladder capacity, and forcing muscle overactivity were used to further evaluate these patients. The investigators found that a maximum bladder capacity of <200 ml did not significantly impair female sexual function. Patients with a clinical diagnosis of dry OAB had the best sexual function (FSFI scores 23, 9) and patients with mixed incontinence had the worst sexual function (FSFI scores 17, 8). Urinary incontinence and forced urethral hyperactivity sexual dysfunction were the most severe and significantly worse than in urodynamically normal patients. Interestingly, there was a tendency for sexual function to become worse in patients with overactive forced urinary muscles with or without urinary leakage. The aspects of sexuality most affected by urinary incontinence and detrusor overactivity were libido, vaginal lubrication, orgasm, and sexual satisfaction. In an Italian cross-sectional study, researchers assessed 188 female patients with sexually active LUTS by having them complete the PISQ-12 questionnaire and urodynamic examination. Patients with painful bladder syndrome had the worst sexual function (PISQ-12 overall score 46, 1), followed by detrusor overactivity, with clinical urgency, mixed incontinence, SUI, dry OAB, and voiding-phase LUTS accounting for the rest of the results. Surgery and pelvic floor muscle training (PFMT) are the mainstay of treatment for SUI in women. Surgery and Pelvic Floor Muscle Training (PFMT) are the main treatments for SUI in women. Both methods have shown varying improvements in urinary symptoms, but surgery has also been shown to improve sexual function. Over the past 15 years, midurethral suspension has become the standard procedure for SUI. Fillers, adjustable urinary control devices, or artificial urethral dilators are beyond the scope of this review. Pelvic floor rehabilitation Conservative treatment based on pelvic floor muscle exercises is an important therapeutic approach in the management of SUI because it restores the mechanism of urethral closure as well as pelvic floor organ support PFMT is minimally invasive, reproducible, and recommended as the first line of treatment for SUI, and surgery is considered only after no improvement in PFMT. Complete pelvic floor rehabilitation consists of biofeedback therapy, functional electrical stimulation, and pelvic floor muscle exercises, which may (or may not) be combined with vaginal cone device therapy. The integrity of the pelvic floor muscles appears to play an important role in urinary control mechanisms; there is also theoretical support for the prevention of urinary incontinence with PFMT, which is designed to strengthen the pelvic floor muscles and improve urethral closure pressure in patients with SUI. Pelvic floor rehabilitation can help improve sexual function in incontinent women who complain of sexual dysfunction. A cohort study of 37 patients, 23 of whom presented with sexual dysfunction, showed a significant improvement in FSFI scores after transvaginal electrical stimulation (15-30 min, twice a week for three months). Another cohort study (with 16 patients) suggested significant improvement in all 6 modules of FSFI scores after 5 months of pelvic floor rehabilitation (including biofeedback, functional electrical stimulation, PFMT, and vaginal cones).Similar findings were seen in a study by Zahariou et al, who had 58 patients with urodynamically diagnosed SUI who were treated with PFMT for 1 year. It was found that all FSFI modules improved significantly, with the median post-training score increasing from 20,3 to 26,8. In a 2011 randomized controlled clinical trial, 445 patients with SUI were treated with uterotonics (n=149), behavioral therapies (PFMT and urine-control strategies, n=146), or a combination of therapies (n=151). Sexual function was assessed with the short form of the Personal Experiences Questionnaire (short-PEQ ) and the PISQ-12 before the study and after 3 months of treatment, respectively. After treatment, there were no differences in sexual functioning items tested between groups (no differences in scores on the PISQ-12, short-PEQ, or within the questionnaire). However, compared with patients who failed SUI, those who were successful in treatment showed greater improvement in the PISQ-12, a significant reduction in the incidence of urinary incontinence during sexual intercourse, and a reduction in the proportion of patients who restricted intercourse due to fear of urinary incontinence. In addition, the improvement in sexual intercourse incontinence was significantly more pronounced in the combination therapy and behavioral therapy groups than in the uterine rests in patients with successful treatment of SUI, and therefore the authors recommend behavioral therapy for feminized individuals with SUI affecting sexual function. Little is known about the effect of PFMT on sexual intercourse incontinence. Two well-designed studies demonstrated that PFMT significantly reduces episodes of incontinence during intercourse. In a randomized controlled clinical trial (30 patients), the rate of sexual incontinence decreased from 20% to 10% in the PFMT (after 6 months of treatment) group, while the rate in the control group decreased from 45,8% to 41,7%. A single-center prospective study (58 patients) showed a significant reduction in the number of episodes of urinary leakage during sexual intercourse after biofeedback treatment. According to current theories, women with SUI should undergo surgery. For example, midurethral suspension can restore urethral support, while padding, adjustable urinary control devices, and artificial urethral dilators can prevent urethral dilator insufficiency. The Tension-free Vaginal Tape (TVT, see Figure -2) was the first widely used synthetic midurethral sling and is currently the gold standard for the treatment of SUI. The TVT procedure is relatively simple, can be performed as an outpatient procedure, and has a higher cure rate than the traditional retro-pubic urethrovaginal suspension (Burch's Colposuspension). Despite the proven effectiveness of TVT and its widespread use worldwide, some surgeons have become concerned about the less common but serious complications of TVT. For example, blind retropubic perforation with a curved needle can lead to bladder perforation in 5% of cases and increases the risk of rare but life-threatening bowel and great vessel injuries. To minimize (but not completely avoid) these risks, in 2001 Delorme et al. proposed the Transobturator Tape (TOT, Fig. 3).Both TOT and TVT are minimally invasive procedures, but the TOT needle is directed outwardly, whereas the TVT-O needle is directed inwardly. These procedures have also given rise to single-incision "micro-slinging" (shorter sling) procedures. Surgical treatment has been more comprehensively evaluated in terms of prognosis for sexual function. Many studies have focused on the effects of retropubic midurethral suspension, transforaminal suspension, and single-incision suspension on sexual function, but many of these studies have used questionnaires, and older studies, in particular, have used invalid questionnaires. However, these studies do demonstrate that surgeons are becoming increasingly concerned about the long-term impairment of sexual function in some women who simply have functional disorders. In 2012, Jha et al. published a more comprehensive review of changes in sexual function after SUI. The review included 1578 patients and used "improvement," "no change," and "worsening" as criteria for evaluating changes in sexual function after surgery. After SUI and POP, 55.5% of patients showed no change in sexual function, 31.9% showed improvement and 13.1% showed deterioration. If only midurethral suspension was considered, then 56.7% had no change in sexual function, 33.9% improved and 9.4% deteriorated. In addition, cure of coital incontinence was strongly correlated with patient sexual satisfaction, which largely explains the overall improvement in postoperative sexual function. 53% of patients with coital incontinence cured had better postoperative sexual quality of life. However, patients without preoperative coital incontinence reported no change in postoperative sexual quality of life. Therefore, sexual incontinence can be a prognostic factor for postoperative improvement in sexual function. The results of the most commonly used sling procedure - TVT - vary from result to result. In some studies, overall sexual function improved after TVT, but others reported significant deterioration. Several head-to-head studies have compared the effects of retropubic and transforaminal sling procedures on sexual function. Overall, both procedures improve sexual function to some extent, but there is no significant difference between the two procedures. However, despite no change or improvement in sexual function after midurethral suspension, it can lead to decreased libido, difficulty with intercourse, and sexual inactivity. Postoperative sexual function scores were higher in patients with successful SUI surgery than in those with unsuccessful surgery, regardless of the procedure. Mid-urethral suspension (especially the retropubic and prepubic styles) may improve orgasm by directly affecting the clitoral nerves (especially the dorsal clitoral nerve), but questions remain about the effect of mid-urethral suspension on sexual function.Achtari and Dwyer's autopsy study found that the distance between the dorsal clitoral nerve and the TVT sling was 10,7±4,8 mm; injury to the dorsal clitoral nerve is thought to to be responsible for impairment of orgasmic function. The vascularity of the erectile tissue of the clitoris may be altered after TVT, as confirmed by ultrasound. In contrast, the TOT procedure is not associated with orgasmic dysfunction (confirmed by Bekker et al). Their results showed that TVT-O should not precede the dorsal clitoral nerve, but TVT affects the autonomic nerves of the vaginal wall and the clitoris. Elzevier et al. reported that 11, 5% of TOT and 10% of TVT-O resulted in poor clitoral sensitivity and swelling. These results suggest that good studies are needed in the future to evaluate the bulbocavernous reflex and dorsal clitoral nerve conduction after retropubic and transforaminal surgery. Data on changes in sexual function after single-incision suspension are currently very scarce. a 2014 systematic review and meta-analysis of randomized controlled clinical trials comparing different surgical modalities found that difficulty with intercourse was rare overall but surprisingly more common after microsuspension than after retropubic or transforaminal suspension. The causes of new onset of intercourse difficulties after midurethral suspension may be sling exposure, poor healing, or improper placement of the sling. These are also causes of painful intercourse in the sexual partner. However, these complications can be prevented by using a Type 1 large-hole soft sling, avoiding folded slings and excessive tension, and carefully completing the procedure. Removal of the sling has a positive effect on preventing new postoperative dyspareunia, but there is a 30% chance of recurrence of incontinence due to the change in urethral support provided by the sling. In addition, transforaminal surgery may also cause specific types of dyspareunia due to the "spinal effect" of the vaginal vault (recto-uterine pit). Paraurethral slings can cause tenderness or pain and can be uncomfortable for the sexual partner. When inserting a sling, the vagina should be carefully examined to see if the sling is in the wrong position (through or too tangential). In this case the sling should be removed or replaced. Retropubic suspension should be recommended if the patient has a well-developed paraurethral groove and a deep vaginal vault. If the patient has an exposed polypropylene sling in the vagina, it can be treated conservatively, such as topical estrogen therapy or outpatient clipping of the exposed sling (only the exposed portion is easy to manipulate). For larger sling exposures or where the exposed portion is difficult to maneuver, surgery is indicated if conservative treatment fails (cutting off the exposed portion of the sling after incising and moving the surrounding normal vagina). Patients who do not have sling exposure postoperatively but develop postoperative pain or new-onset difficulty with intercourse should be treated conservatively such as pelvic floor muscle exercises, topical estrogen in the vagina, use of anti-inflammatory medications, or hormonal/anesthetic infiltration at trigger points. Localized or total removal of the sling mesh can be an option, but the surgeon must be aware that this also does not guarantee complete elimination of pain. Overall, there is insufficient data to recommend any specific surgical treatment for sexual function problems. Surgeons can refer to the clinical data to choose their most skillful procedure and adjust it appropriately to the local anatomy. V. CONCLUSION Female sexual function encompasses a complex interaction of anatomical, neurological, physiological, and environmental factors, and can therefore be directly affected by urinary incontinence. The effect of pelvic floor muscle dysfunction on sexual function varies depending on the study population and study methodology, but premorbid sexual satisfaction can be an accurate predictor of sexual function after genitourinary disease. Sexual function can be altered by incontinence but can also be improved by surgical repair. Sexual dysfunction occurring after surgery has been rarely mentioned in the past years, but with quality of life being the focus of the moment, sexual function has become one of the central issues in the surgical treatment of PFDs. Rigorous prospective studies using validated tools should be encouraged to produce reliable results and conclusions. Although sexual function is usually not altered or even improved after surgery (due to the surgical resolution of sexual incompetence); the risk of new postoperative difficulties in sexual intercourse should not be ignored because of the enormous impact of sexual function on quality of life. To avoid these poor prognoses for sexual function, surgeons need to screen patients with preoperative dyspareunia more carefully, strictly follow the indications and contraindications for surgery, and use reliable and reproducible intraoperative techniques and technologies. Future research needs to include a better understanding of changes in clitoral sensitivity and responsiveness as important issues. Treatment of new-onset intercourse difficulties after midurethral suspension is not easy and success is not guaranteed. No surgery is without risk, but surgery to treat incontinence should avoid compromising sexual function as much as possible.