Ureterorenoscopy with Stenting and Its Effect on Female Sexual Function
Ekrem Akdeniz*, Mustafa Suat Bolat
Purpose: Various etiological factors have been studied which negatively affect female sexual function, but the
effects of ureteroscopic stone surgery on women's sexual dysfunction remain unknown. The aim of this study was
to investigate the effect of ureteroscopic stone surgery with postoperative stenting on female sexual function.
Materials and Methods: This study included 30 sexually active female patients who underwent ureteroscop-
ic stone surgery with JJ stenting (study group) and 26 age-matched female patients with ureteral stone surgery
without JJ stenting (control group). Sexual function was assessed at preoperative and at the first and 3rd months
postoperative using the Female Sexual Function Index. Overall satisfaction in relation to the age, operation time,
presence of stents, body mass index, educational status, previous operations, income status, and psychogenic status
was evaluated.
Results: Sexual function was adversely affected by ureteroscopic stone surgery with JJ stenting; but psychogenic,
educational and income status remained stable. Mean individual female sexual function subscores were statistically
significant between the study and control groups, but the differences in the mean Beck scores minimally improved
between the two groups at preoperative (p = 0.19) visit, whereas first month (p = 0.08) and third month (p = 0.31)
of postoperative controls were deteriorated but the differences were not statistically significant, respectively.
Conclusion: Ureterorenoscopy with JJ stenting has considerably negative effects on female sexual function. JJ
stenting causes temporary sexual deterioration in women and it generally ceases at the end of the 3rd month after
ureteroscopic surgery. Therefore, JJ stenting should be avoided or used for as short a time as possible. If JJ stenting
is inevitable, patients should be warned about a temporary decline in their sexual function during the first month of
the operation that resolves at most in three months.
Keywords: Female sexual function, ureterorenoscopy, JJ catheterization.
INTRODUCTION
Sexuality plays an important role in an individual's quality of life. Female sexuality is a complex func-
tion encompassing interactions between the nervous,
endocrine, and vascular systems, as well as a variety
of structures involved in sexual excitement, intercourse,
and satisfaction(1). Psychological, biological and social
factors mostly affect women's sexuality,(2,3). This may,
in turn, cause emotional stress and affect a woman's
well-being and social interactions.
Urinary stone disease is a common problem. Among
the general population, there is a 10.2% lifetime risk
of developing the urinary stone disease, with peak inci-
dence occurring when individuals are 20–40 years old
(4). The treatment strategy for the urinary stone disease
should be based on stone size, localization and num-
ber of stones, anatomic properties of the patient and the
surgeon's experience. Ureteroscopy (URS) and percu-
taneous nephrolithotomy (PNL) are key components of
surgical removal of stones in all parts of the kidneys and
ureter(5). In addition to classical methods such as shock
wave lithotripsy (SWL) or open surgeries, in recent
years, new surgical techniques have been developed to
address this condition. These techniques include flexi-
ble ureteroscopy (FURS), rigid ureteroscopy or laparo-
scopic procedures. and are used when other treatment
methods fail. Rigid ureteroscopy is the most preferred
technique for ureteral stones among urologists.
Generally, it is difficult to conduct an assessment of a
woman's sexual function, and there is a limited number
of studies in the literature addressing the issue of sexual
function among women(6). Many studies have focused
on various etiological factors which negatively affect
female sexual function(7-10). However, there is currently
no evidence-based data in the literature concerning how
women's sexual function may be affected by uretero-
scopic stone surgery. The present study uses the con-
text of evidence-based medicine to assess whether URS
with stenting was associated with postoperative female
sexual dysfunction (FSD).
MATERIALS AND METHODS
This clinical study was prospectively designed for con-
secutive patients referred for ureteroscopic stone sur-
gery over a period of three months. The primary aim
was to evaluate the effects of ureteroscopic stone sur-
gery on female sexual function for three months postop-
erative. Secondary aims were the assessment of effects
Urology Department, Samsun Training and Research Hospital, Health Sciences University, Samsun, Turkey.
*Correspondence: Urology Department, Samsun Training and Research Hospital, Health Sciences University, Samsun, Turkey.
phone:+090 362 311 1500. mobile phone:+90 5422358980. E-mail: msbolat@gmail.com.
Received December 2016 & Accepted April 2017
ENDOUROLOGY AND STONE DISEASE
Endourology and Stone Diseases 3059
of body mass index (BMI), JJ catheter time, psycho-
genic aspect, stone size, income status, and educational
status of female sexual function.
Patient Selection and Evaluation
Inclusion criteria were being female older than 18
years, a presence of regular sexual activity, an absence
of prior URS history, impaired renal function, radical
pelvic surgery, prior pelvic radiotherapy before, and
a presence of ureteral stones resistant to medical pro-
pulsive treatment despite 4–6 weeks waiting period or
shock wave lithotripsy. From June to December 2015,
30 female patients with ureteral stones were enrolled
in the study. These women comprised the study group
and 26 age-matched female patients who underwent
ureteral stone surgery without JJ stenting were served
as the control group. This sample size was determined
based on a power analysis. After obtaining approval of
the Ethics Committee from Ondokuz Mayis Univer-
sity (B.30.2.ODM.0.20.08/1780), all of the patients
were informed about the study and informed consent
was obtained from all study participants. Due to ethical
concerns, patients were informed about the study and
surgical procedure preoperatively. The female sexual
function was evaluated using the Turkish-version of the
Female Sexual Function Index (FSFI), which consists
of 19 questions validated by the Turkish Society of An-
drology(11). Higher FSFI scores indicate better sexual
functioning. Within the individual domains, a domain
score of zero indicates that the respondent reported hav-
ing no sexual activity during the past month. "Factors"
have been created for all domains. The factors for de-
sire, arousal, and lubrication and orgasm and satisfac-
tion are 0.6, 0.3, and 0.4, respectively. Individual scores
of the domains were multiplied by the corresponding
domain factor. The total scale score varied from 2 to 36
(Table 1). The normal cut-off value was assumed to be
equal to or greater than 25. If a respondent's total scale
score was below this value, sexual dysfunction was as-
sumed.
Satisfaction in relation to age, operation time, psycho-
genic status, stent durations, BMI, educational status,
previous operations, income status, localization of the
stone and stone-free rates was recorded. The Beck de-
pression scale, which consists of 21 items validated
from 0 to 3, was used to assess psychological status.(12)
The psychological state of each patient was classified
as minimal depression (0–9 points), mild depression
(10–16 points), moderate depression (17–29 points) and
severe depression (30–63 points).
Surgical Technique
Once sterile urine was proved, a plain kidney-ure-
ter-bladder (KUB) was obtained on the morning of the
Table 1. Female Sexual Function Index Domain Scores and Full Scale Score.
Domain Questions Score Range Factor Minimum score Maximum score
Desire 1,2 1-5 0.6 1.2 6
Arousal 3-6 0-5 0.3 0 6
Lubrication 7-10 0-5 0.3 0 6
Orgasm 11-13 0-5 0.4 0 6
Satisfaction 14-16 0 (or 1)-5 0.4 0.8 6
Pain 17-19 0-5 0.4 0 6
Full Scale Score Range 2 36
Variable P-value
No. of the patients 30 26
Age (year), mean± SD (min-max) 41.9 ± 7.5 (22-51) 39.7 ± 9.3 (25-58) 0.25
Body mass index (kg/m2) 29.1 ± 5.8 (21.3-44.9) 27.8 ± 4.0 (18.4-33.3) 0.19
Stone burden (mm2) 66.7 ± 39.4 71.2 ± 21.6 0.09
The mean hospital stay (hours) 38.4 ± 10.8 (24-58) 31.2 ± 5.4 (24-48) 0.07
JJ stay time (days) 15.7 ± 2.4 (14–21) - -
Monthly Income (TL) 1083.3 ± 951.3 (0-3000) 1142.2 ± 526.1 (0-3000) 0.12
Education (n/%)
Primary 23 (76.6) 21 (70.0)
High school 2 (6.7) 4 (13.3)
Table 2. Demographic Characteristics of the Patients.
Ureterorenoscopy and female sexual function-Akdeniz et al.
Vol 14 No 03 May-June 2017 3060
surgery, and all the patients underwent cystoscopy.
Following the guide-wire catheter placement into the
ureter under scopic vision, a 7.5 F rigid ureteroscope
was introduced for stone fragmentation using laser lith-
otripter. The ureteral catheter was placed into the ure-
ter at the end of the procedure. Retrograde pyelogram
was routinely performed to rule out any extravasation
after the procedure. JJ stenting was done for high vol-
ume stones, solitary kidney or proximally located stone
diseases. All the patients were closely followed with
KUB and ultrasound for assessment of residual stones
and obstruction. A urine culture was repeated in the first
and third postoperative controls. At first and 3rd month
controls, FSFI, and Beck depression scales were repeat-
ed and recorded prospectively.
Statistical analysis was performed using SPSS soft-
ware, version 15. Data were presented as mean±-
standard deviation (SD) and frequency (%). The Shap-
iro-Wilk test was used to analyze normal distribution
assumptions of the quantitative outcomes. To compare
two independent groups, we used the Mann-Whitney U
test for nonnormal data. Results were evaluated using
the nonparametric Kruskal-Wallis test for comparisons
between groups. To compare two groups, we used the
paired sample t test. Pearson's chi-square and Fisher's
exact tests were used for comparisons of percentages.
A p value of less than 0.05 was considered statistically
significant.
RESULTS
The mean ages of the patients in the study and control
groups were 41.9 ± 7.5 (22–51) and 39.7 ± 9.3 (25–
58) years (P = .25); the mean BMIs were 29.1 ± 5.8
(21.3–44.9) and 27.8 ± 4.0 (18.4–33.3) kg/m2 (P = .19).
The mean hospital stays were 38.4±10.8 and 31.2 ± 5.4
hours in the study and control groups, respectively (P =
.07). The mean JJ stay time was 15.7 ± 2.4 (14–21) days
in the study group. The other demographic data and pe-
rioperative variables have been presented in Table 2.
The mean preoperative total FSFI scores were 14.5±9.6
and 13.2 ± 7.4, the mean 1st postoperative total FSFI
scores were 12.8 ± 6.8 and 16.1 ± 5.1, and 3rd post-
operative total FSFI scores were 17.7 ± 5.4 and 18.2 ±
5.8 in the study group and control group, respectively.
The mean total FSFI scores were statistically signifi-
cant between groups at 1st postoperative month (P <
Ureterorenoscopy and female sexual function-Akdeniz et al.
Table 3. The mean FSFI subdomains and relationship between Study and Control groups
FSFI Subdomains Preoperative Postoperative 1st month Postoprative 3rd month
(mean±SD)
Desire Study gr 3.4 ± 1.4 3.2 ± 1.6 3.8 ± 1.3
Control gr 3.4 ± 1.6 3.3 ± 1.5 3.7 ± 1.4
Arousal Study gr 1.8 ± 1.1 2.1 ± 1.8* 2.8 ± 1.6
Control gr 2.0 ± 0.9 2.6 ± 1.7 3.2 ± 1.4
Lubrication Study gr 1.9 ± 1.8 1.8 ± 2.2 2.8 ± 1.8
Control gr 1.8 ± 2.2 2.7 ± 1.2 2.8 ± 1.4
Orgasm Study gr 1.6 ± 1.9 2.1 ± 1.6* 2.8 ± 1.2
Control gr 1.8 ± 1.4 2.6 ± 1.4 2.8 ± 1.8
Satisfaction Study gr 1.8 ± 1.4 2.6 ± 1.3* 3.4 ± 1.8
Control gr 2.0 ± 1.6 3.1 ± 1.2 3.4 ± 1.6
Pain Study gr 2.9 ± 1.8 2.8 ± 1.6* 2.1 ± 1.8
Control gr 2.7 ± 1.6 2.1 ± 1.2 2.2 ± 0.8
Total Study gr 14.5 ± 9.6 12.8 ± 6.8* 17.7 ± 5.4
Control gr 13.2 ± 7.4 16.1± 5.1 18.2 ± 5.8
Sexual Study gr 18.2 ± 5.8 53.3 56.8
Dysfunction (%)
Control gr 70.9* 62.4 57.6
*p < 0.05
Beck's depression score Preoperative Postoperative 1st month Postoperative 3rd month
Study group 6.1±1.3 4.1±1.3 4.1±1.3
Control group 4.9±1.8 5.6±1.7 5.2±0.8
p value 0.19 0.08 0.31
Table 4. Beck depression scale and sexual dysfunction rate variations in both groups.
Endourology and Stone Diseases 3061
.05), whereas preoperative and 3rd postoperative total
FSFI scores were not (P > .05). The mean individual
first postoperative arousal, orgasm, and satisfaction
subdomains statistically decreased, and pain subdomain
increased in the study group compared to control group
(P < .05). All the subdomains were similar at preopera-
tive and 3rd postoperative controls between two groups
(P > .05) (Table 3).
Sexual dysfunction rates were 53.3%, 70.9% and 56.2%
in the study group and 56.8%, 62.4 and 57.6% in the
control group at preoperative and at 1st and 3rd postop-
erative months (Table 3). Sexual dysfunction rate was
significantly increased in the study group at postoper-
ative 1st month (P = .02), whereas preoperative (P =
.06) and postoperative 3rd month controls were not (P =
.08). The mean Beck depression scores at preoperative,
1st and 3rd month postoperative in controls were 6.1 ±
1.3, 4.1 ± 1.3, and 4.1 ± 1.3, and 4.9 ± 1.8, 5.6 ± 1.7, and
5.2 ± 0.8 in the study and control groups, respectively.
There were no statistically significant differences be-
tween groups (P > .05). In the control group, the mean
Beck score was 4.2 ± 1.1. When the Beck scores were
compared, there was no statistically significant differ-
ence between the study and control group (P = .31)
(Table 4).
DISCUSSION
Descriptive epidemiological data were shown in the lit-
erature indicate that 40–67.9% of adult women have at
least one manifesting sexual dysfunction, and medical
interventions may provoke this condition(13–15). Surgical
interventions may cause FSD, and sexual disturbance
may have a negative effect on physical and mental
health(16). In the current study, sexual dysfunction rates
increased at postoperative 1st month and then normal-
ized to the preoperative level at the 3rd month, com-
pared to control group (53.3%) (Table 3). Deterioration
of sexual health in women after ureteroscopy and an
improvement at the 3rd month evaluation has been at-
tributed to lower urinary access and ureteral stent use
(17–19). Our findings on FSD supported that the study
group was much more affected due to JJ catheteriza-
tion. Although we do not routinely prefer JJ catheter-
ization, it is mandatory to insert a catheter in certain
circumstances, such as high volume stones, solitary kid-
ney, urine leakage due to ureteral trauma or proximally
located stone diseases. With this study, we are encour-
aged to use JJ stenting for limited periods or not to in-
sert JJ catheter, if possible. Patients often suffer from
symptoms related to JJ stents, such as intolerance to the
stent, depression, severe stent-related pain, hematuria,
or urgency due to the shape of the JJ catheter, rather
than the presence of urinary infection (20). Although sig-
nificant improvements have been achieved in regard to
stent materials, a proportional comfort has not been ob-
served to date.
None of the patients were stentized due to urine extava-
sation. Hematuria was observed in half of the patients,
and urgency in one-third in the postoperative period.
Minimality or absence of these symptoms in the preop-
erative and third postoperative periods suggests that the
catheter can cause itself urgency in patients by chronic
irritation. Urgency can be managed using anticholin-
ergic agents, but sometimes it can be difficult to cope
with this symptom during the early postoperative period
(21). In such cases, early withdrawal of the JJ catheter
may aid in the early relief of urgency. Moreover, using
a one-day ureteral catheter instead of a JJ catheter for
uncomplicated and thoroughly disintegrated stones may
help prevent urgency.
The mean time of stent removal was 15.7 ± 2.4 (14–21)
days, and it was kept as short as possible in order to
avoid early complications.
Anxiety and depression typically become prominent
with diseases provoked by painful crises and have a
negative impact on an individual's psychological status
(22). The relationship between urological stone manage-
ment and anxiety or depression was shown to cause in-
creased anxiety (23). Rather than short-term treatment of
the benign diseases, anxiety and depression are shown
to be higher in chronic conditions such as malignant
diseases(24). In this study, we found no significant dif-
ference using Beck's depression score to evaluate the
mental status of the patients (P = .31). This finding
suggested that FSD is not affected by the psychological
status of the patients (Table 4). Contrary to our results,
Joshi et al. stated that significant morbidity due to JJ
stents might provoke emotional and physical alterations
in patients(19). It is reasonable that patients may expe-
rience a temporary decline in their sexual function in
the postoperative period. This study showed once again
that while urologists were focusing on protecting renal
function from adverse effects of ureteral stones in daily
practice, and exert utmost efforts should be taken for
patients' social and sexual life in the postoperative peri-
od. For this reason, we think that sufficient preoperative
information should be given and JJ stenting should be
minimalized as much as possible.
The relationship between BMI and FSD remains con-
troversial in the literature(16, 25). Our results showed no
relationship between FSD and BMI (P = .19). Monthly
income and educational status have been shown to be
predictive factors for FSD in women, with a reported
2.54 fold increased the chance of FSD in low-income
women(26–28). Contrary to the literature, we found no
correlation between sexual dysfunction and monthly
income or educational status. This can be explained by
the close proximity of monthly income levels between
patients (P > .05).
CONCLUSIONS
Ureterorenoscopy with JJ stenting has a considerable
negative effect on FSD. Although the deterioration of
sexual function is temporary and generally ceases at
the end of the 3rd month after ureteroscopic surgery, JJ
stents should be avoided whenever possible. If JJ stent-
ing is necessary, patients with stent should be informed
that they may have some degrees of sexual dysfunction
during the first month of the operation that resolves at
most in three months. In addition, if JJ catheterization
proves necessary the indwelling should be kept as short
as possible.
CONFLICTS OF INTEREST
The authors report no conflict on interest.
REFERENCES
1. Rao TS, Nagaraj AK. Female sexuality. Indian
J Psychiatry. 2015; 57(Suppl 2):S296-302.
2. Hosseini L, Iran-Pour E, Safarinejad MR.
Sexual function of primiparous women after
Ureterorenoscopy and female sexual function-Akdeniz et al.
Vol 14 No 03 May-June 2017 3062
elective cesarean section and normal vaginal
delivery. Urol J.2012; 9:498-504.
3. Mezzich JE, Hernandez-Serrano R. In:
Psychiatry and Sexual Health – An Integrative
Approach. Lanham: Jason Aronson;
2006. Epidemiology and public health
considerations; pp. 33–43.
4. Tseng TY, Preminger GM. Kidney stones.
BMJ Clin Evid. 2011; 2011. pii: 2003.
5. Türk C, Petřík A, Sarica K, et al. EAU
Guidelines on Interventional Treatment for
Urolithiasis. Eur Urol. 2016; 69:475-82.
6. Eryildirim B, Tuncer M, Kuyumcuoglu U,
Faydaci G, Tarhan F, Ozgul A. Do ureteral
catheterisation procedures affect sexual
functions? A controlled prospective study.
Andrologia. 2012; 44:419–23.
7. Carrilho PJF, Vivacqua CA , de Godoy EP,
et al. Sexual dysfunction in obese women is
more affected by psychological domains than
that of non-obese. Rev Bras Ginecol Obstet.
2015; 37:552-8.
8. Scheepe JR, Alamyar M, Pastoor H, Hintzen
RQ, Blok BF. Female sexual dysfunction in
multiple sclerosis: Results of a survey among
Dutch urologists and patients. Neurourol
Urodyn. 2017; 36:116-20.
9. Frost DM, Meyer IH, Schwartz S. Social
support networks among diverse sexual
minority populations. Am J Orthopsychiatry.
2016; 86:91-102.
10. Oren A, Megiddo E, Banai S, Justo D. Sexual
dysfunction, cardiovascular risk factors,
and inflammatory biomarkers in women
undergoing coronary angiography. J Women
Aging. 2015; 22:1-8.
11. Rosen R, Brown C, Heiman J, et al. The
Female Sexual Function Index (FSFI) J Sex
Marital Ther. 2000; 26:191–208.
12. Beck AT, Ward CH, Mendelson M, Mock
J, Erbaugh J. An inventory for measuring
depression. Arch Gen Psychiatry. 1961;
4:561-71.
13. Lewis RW, Fugl-Meyer KS, Corona G, et
al. Definitions/Epidemiology/Risk Factors
for Sexual Dysfunction. J Sex Med. 2010;
7:1598–607.
14. Oksuz E, Malhan S. Prevalence and Risk
Factors for Female Sexual Dysfunction in
Turkish Women. J Urol. 2006; 175:654-8.
15. Laumann EO, Paik A, Rosen RC. Sexual
dysfunction in the United States: prevalence
and predictors. JAMA. 1999; 281:537-44.
16. Smith AM, Patrick K, Heywood W, et al.
Body mass index, sexual difficulties and
sexual satisfaction among people in regular
heterosexual relationships: a population-based
study. Intern Med J. 2012; 42:641-51.
17. Joshi HB, Stainthorpe A, MacDonagh RP,
Keeley FX, Jr, Timoney AG. Indwelling
ureteral stents: evaluation of symptoms,
quality of life and utility. Journal of Urology.
2003; 169:1065–9.
18. Haleblian G, Kijvikai K, de la Rosette J,
Preminger G. Ureteral stenting, and urinary
stone management: a systematic review. J
Urol. 2008; 179:424-30.
19. Joshi HB, Newns N, Stainthorpe A, MacDonagh
RP, Keeley FX Jr, Timoney AG. Ureteral stent
symptom questionnaire: development and
validation of a multidimensional quality of life
measure. J Urol. 2003; 169:1060.
20. Kogan MI, Mojsjuk JG, Shkodkin SV,
Sajdulaev DA, Idashkin JB. Effectiveness of
ureteral stents with nanostructured coating
in renal transplantation (preliminary results).
Urologia. 2015; 1:58-61.
21. Lee YJ, Huang KH, Yang HJ, Chang HC, Chen
J, Yang TK. Solifenacin improves double-J
stent-related symptoms in both genders
following uncomplicated ureteroscopic
lithotripsy. Urolithiasis. 2013; 41:247-52.
22. Diniz DH, Blay SL, Schor N. Anxiety and
depression symptoms in recurrent painful
renal lithiasis Braz J Med Biol Res. 2007;
40:949-55.
23. Brown SM. Quantitative measurement of
anxiety in patients undergoing surgery for
renal calculus disease. J Adv Nurs. 1990; 15:
962-70.
24. Alacacıoğlu , Öztop I, Yılmaz U. The Effect
of Anxiety and Depression on Quality of Life
in Turkish Non Small Lung Cancer Patients.
Tur Toraks Der. 2012; 13: 50-5.
25. Mozafari M, Khajavikhan J, Jaafarpour M, et
al. Association of Body Weight and Female
Sexual Dysfunction: A Case-Control Study.
Iran Red Crescent Med J. 2015; 17: e24685.
26. Diehl A, Silva RL, Laranjeira R. Female
sexual dysfunction in patients with substance-
related disorders. Clinics (Sao Paulo). 2013;
68:205-12.
27. Worly B, Gopal M, Arya L Sexual dysfunction
among women of low-income status in an
urban setting. Int J Gynaecol Obstet. 2010;
111:241-4.
28. Laumann EO, Paik A, Rosen RC Sexual
dysfunction in the United States: prevalence
and predictors. JAMA. 1999; 81:537-44.
Ureterorenoscopy and female sexual function-Akdeniz et al.
Endourology and Stone Diseases 3063