SEXUAL DYSFUNCTION AND ANDROLOGY Sexual Dysfunction in Married Women With Urinary Incontinence Handan Zincir1, Gokce Demir2, Yurdagül Günaydın3, Betül Ozen4* Purpose: This study was conducted in descriptive and cross-sectional design in order to determine prevalence of urinary incontinence severity in women with urinary incontinence (UI), correlation between UI and sexual dys- function Materials and Methods: The study had descriptive and cross-sectional design. In sample selection, four Family Health Centers areas were determined by lot and totally 384 women with UI were reached by making home visits in these regions. As data collection tool, severity index in female urinary incontinence determining UI condition and Female Sexual Function index determining sexual functioning were used. Results: Average age of the women participating in the study was 37.3 ± 1.02. Mean body mass index of the wom- en was 26.3 ± 5.41. It was determined that 22.1% of the women participating in the study had UI for 3-5 years and 15.1% had UI for six years and a longer time. It was determined that 53.9% of the women participating in study had mild incontinence, 40.6% had moderate incontinence, 3.6% had severe incontinence, and 1.8% had very severe in- continence. A significant correlation was found between severity index in female urinary incontinence (ISI) score and Female Sexual Function Index (FSFI) score (p < 0.05). There was a positive and weak correlation between ISI scores and age, duration of marriage, and number of pregnancy of the women who participating in the study; and a positive and very weak correlation between ISI scores and body mass index and spontaneous abortion (p < 0.05). Conclusion: Almost half of women with UI were determined to have moderate and more severe urinary inconti- nence. A significant correlation was found between ISI and FSFI score. Keywords: Sexual dysfunction; Urinary incontinence; Woman. INTRODUCTION Urinary incontinence (UI) is a multidisciplinary problem that affects woman from all ages and may negatively influence life quality with social aspects. Its prevalence in female population is estimated to be at the rate of 17% and 58.4%. Prevalence of UI, an im- portant problem, varies between 10 and 30% in women aged between 15-64 years, and between 17 and 55% in elderly people(1,2). As studies conducted on women with urinary inconti- nence were examined; they were found to experience problems such as having low body images, high sense of shame, not feeling themselves feminine in terms of physical and sexual aspects, being concerned because of smell, always using pad/diaper, and phobia of uri- nary incontinence(3). Urinary incontinence experienced during coitus, negative reactions of spouse, and think- ing reduction of attraction cause different types of sexu- al dysfunctions influencing sexual life of women nega- tively. It was determined in previous studies that social and occupational lives of individuals with UI were af- fected and their sexual lives and marriage relationships were damaged(4). Because women with UI are not capa- ble of controlling their urinary functions, they may ex- perience problems such as urinary incontinence during 1Department of Community Health Nursing, Erciyes University Faculty of Health Sciences, 38039, Kayseri-Turkey. 2Department of Community Health Nursing, Ahi Evran University College of Health Department of Nursing, 40100, Kırsehir-Turkey. 3Department of Community Health Nursing, Erciyes University Faculty of Health Sciences, 38039, Kayseri-Turkey. 4Department of Community Health Nursing, Erciyes University Faculty of Health Sciences, 38039, Kayseri-Turkey. *Correspondenc: Department of Community Health Nursing, Erciyes University Faculty of Health Sciences, Kayseri 38039, Turkey. Tel: +90-352-207 66 66-28561. Fax: +90-352-437 92 81. E-mail: betulozen@erciyes.edu.tr. Received June 2017 & Accepted October 2017 coitus, negative reactions of husband/partner, thinking about reduction in attraction, and decreased self-confi- dence. Depression experienced based on these prob- lems may cause sexual dysfunctions (SD) negatively in- fluencing sexual lives of women(5). In a study conducted on 216 women aged between 19-66 years with UI com- plaint, 34% of women were determined to have reduced sexual drive, 23% had dysfunction of sexual arousal, and 11% had insufficiency of orgasm(6). Because of this important problem influencing women, preventing UI to develop, encouraging women suffering from UI to answer questions specific to sexuality, and enabling them to express their concerns about sexual issues are found among fundamental responsibilities of nurses. According to these information, the study was conduct- ed in descriptive and cross-sectional design in order to determine prevalence of urinary incontinence severity in women with UI, correlation between UI and sexual dysfunction, and the effective factors. MATERIALS AND METHODS Study Population The study was planned as a cross-sectional type be- tween March-July 2016. The population of the study consisted of nine Family Health Centers (FHC) with Vol 15 No 04 July-August 2018 193 different socio-economic characteristics in the city center of Kırşehir. The sample group was formed by simple random sampling technique. The frequency of urinary incontinence was unknown in the population of the study. For this reason, sample size of study was calculated as 384 by examining means of other studies conducted on urinary incontinence(1,2) and using formula of unknown number of individuals in the population (d = 0.05, p = 0.50, t = 1.96 were taken at confidence in- terval of 95%)(7). Inclusion And Exclusion Criteria The women who were diagnosed with urinary incon- tinence at least for 6 months, were older than 15, had no psychological disability, and were married, were included in the study. The women who did not agree to participate in the study and were in pregnancy and lactation periods were not included in the study. Procedures The study was conducted in accordance with the prin- ciples of Helsinki declaration in 2008 [World Medical Associations Declaration of Helsinki.2008]. Approval was received from Ethics Committee (2016-03/14). Verbal and written consents were received from the women who agreed to participate in the study. In sam- ple selection, four FHC areas were determined totally 384 women with UI were reached by making home vis- its in these regions. The data were collected by using face-to-face interview method. Evaluations This questionnaire was prepared by the researchers upon the literature review(3,4,7-9).As data collection tool, the questionnaire including socio-demographic charac- teristics and some obstetric characteristics of the wom- en, severity index in female urinary incontinence deter- mining UI condition and Female Sexual Function index determining sexual functioning were used. Severity index in female urinary incontinence (ISI): ISI is a scale consisting of two items and measuring sever- ity of female urinary incontinence. ISI was developed by Sandvik et al., in 1993(10). Turkish validity and relia- bility analysis of the scale was conducted by Uyar-Haz- ar and Sirin in 2008 and cronbach’s alpha coefficient was found as 0.67(11). The index consists of two mul- tiple-choice questions. One of the questions measures frequency of incontinence and the other one measures its amount. The first question has four choices and the second question has three choices and these choices are scored between 1-4 and 1-3, respectively. In calcula- tion of index score; scores received from both questions are multiplied. Accordingly, scores are as follows, 1-2 points are mild incontinence, 3-6 points are moderate, 8-9 points are severe, and 12 points are very severe(10,11). Cronbach’s alpha coefficient of this scale was found as 0.61 in the present study. Female Sexual Function Index (FSFI): FSFI is a lik- ert-type scale consisting 19 items and evaluating female sexual dysfunction. FSFI was developed by Rosen et al., in 2000 and cronbach’s alpha coefficient was found as 0.82(12). Turkish validity and reliability analysis of the scale was conducted by Öksüz and Malhan in 2005 and cronbach’s alpha coefficient was found as 0.95(13). The index consists of six individual titles as desire, arousal, lubrication, orgasm, satisfaction, and pain. Each title is scored between 0/1-6 points. The lowest score is two and the highest score is thirty six. High score refers to a better function(12,13). In the study conducted by Rosen et al., (2000) and Taş et al., (2006), functional condition was classified as good if FSFI score is > 30, as moder- ate if between 23-29, as poor if < 23(12,14). Existence of sexual dysfunction is accepted in women who received 23 points and less in this study in which cronbach’s al- pha coefficient was 0.93. Data Assessment The data were analyzed by using SPSS Statistics ver- sion 22.0 (IBM Corp., Armonk, New York,USA). The data were evaluated by using number, percentage, mean, median, and Spearman’s correlation analysis. Multiple linear regression analyses backward method were used to test the relation between the determined dependent and independent variables. The extraction value was taken as 0.10. The results for other statistical analyzes were evaluated at 95% reliability level, and the significance was set to p < 0.05. In the study, independ- ent variables, which were thought to be effective on dependent variables, were evaluated by using multiple regression analysis. RESULTS Average age of the women participating in the study was 37.3 ± 1.02. Mean body mass index of the women was 26.3 ± 5.41. Average marriage age of the women was 20.3 ± 3.43 and average duration of marriage was 16.9 ± 1.14 years. Mean pregnancy number of the wom- en was 2.5 ± 1.75 and 18.5% of the women stated to have intentionally an abortion at least once, and 36.2% had spontaneous abortion at least once. It was determined that 22.1% of the women participat- ing in the study had UI for 3-5 years and 15.1% had UI for six years and a longer time. 45.6% of women suffer- ing from UI were affected by sexual life, and 68.2% did not consult a physician because of UI (Table 1). It was determined that 53.9% of the women participat- ing in study had mild incontinence, 40.6% had moderate Table 1. Distribution of women’s FSFI scores in terms of severity of urinary incontinence Duration of UI diagnosis n (N=384) % Less than 1 year 126 32.8 1-2 years 115 29.9 3 -5 years 85 22.1 6 years and more 58 15.1 Affected Sexual Life after UI Yes 176 45,6 No 208 54.2 Consulting a Physician Due to Affected Sexual Life (n=176) Yes 56 31.8 No 120 68.2 Severity of Incontinence n (N=384) % FSFI score distribution Test Mild (1-2 points) 207 53.9 16.6 ± 6.02 Moderate (3-6 points) 156 40.6 16.9 ± 6.64 χ² = 7.942 Severe (8-9 points) 14 3.6 16.4 ± 8.51 P = .039 Very severe (12 points and higher) 7 1.8 12.6 ± 1.14 Table 2. Distribution of women’s FSFI scores in terms of severity of incontinence Sexual Dysfunctıon In Urınary Incontınence -Zincir et al. Sexual Dysfunction and Andrology 194 incontinence, 3.6% had severe incontinence, and 1.8% had very severe incontinence. A significant correlation was found between ISI score and FSFI score (P < .05) Accordingly, FSFI mean score of the women with very severe UI was lower and sexual 1function was worse (Table 2). Categorical variables were defined as dummy variable. In Table 3, it was found that there was a significant cor- relation between variables Model 1- FSFI (r2 = 0.082 f value= 7.860, p < 0.001), Model 2-Desire (r2 = 0.200 f value=24.987, P < 0.001), Model 3- Arousal (r2 = 0.029 f value=6.762, P < 0.001), Model 4 –Lubrication (r2 = 0.126 f value = 12.016, P = 0.001), Model 5 -Orgasm (r2 = 0.082 f value = 9.606, P < 0.001), Model 6 -Sat- isfaction (r2 = 0.038 f value = 5.984 , P < 0.001), and Model 7-Pain (r2 = 0.122 f value = 14.309, P < 0.001) (Table 3). There was a positive and weak correlation between ISI scores and age, duration of marriage, and number of pregnancy of the women who participating in the study; and a positive and very weak correlation between ISI scores and body mass index and spontaneous abortion (P < .05). According to this, severity of incontinence increased as age increased, body mass index, number of pregnancy, and number of spontaneous abortion increased, and duration of marriage increased. In ad- dition, there was no correlation between intentionally having an abortion and ISI score (P > .05). A positive and weak correlation was found between FSFI score and age of the women participating in the study; and a positive and very weak correlation between FSFI score and body mass index, duration of marriage, and num- ber of pregnancy (P < .05). Accordingly, sexual func- tion decreased as age increased, duration of marriage increased, body mass index and number of pregnancy increased (Table 4). DISCUSSION UI is a medical problem which affects women from all ages and is seen widely, and a condition that af- fects women in terms of physical, hygienic, psychoso- cial, economic, and sexual aspects. UI is also one of health problems that may influence all subscales within the scope of life quality and is experienced for a long time. Koçak et al., determined that 79.8% of women who were 18 and older had mild urinary incontinence, 15.7% had moderate urinary incontinence, and 4.5% had severe urinary incontinence(15). In this study, 53.9% of the women were found to have mild urinary incon- tinence, 40.6% moderate urinary incontinence, 3.6% severe urinary incontinence, and 1.8% very severe uri- nary incontinence (Table 2). 22.1% of the women who participated in the study were also determined to have UI for 3-5 years and 15.1% had for six years and more (Table 1). The reason behind why results of moderate level in this study were found to be higher compared to the other study was thought to be age factor and that they experienced UI for a long time. As severity of UI increases, SD increases. According to statement of Önem et al., UI and pelvic organ prolapse are found to be primary among risk factors causing SD in women(16). It was reported that UI had negative impacts on female sexual functions and prevalence of sexual dysfunction in this patient group ranged between 26% and 43% (6,17). Prevalence of SD in the study con- ducted by Özerdoğan et al., was determined to be 4.290 times more frequent in those with UI compared to those without UI(18). In the study conducted by Coyne et al., on UI and sexual dysfunction, they reported that the wom- en without incontinence problem had sexual intercourse more frequent than those with incontinence problem (91% - 50%), their sexual desires decreased depending on incontinence, and they felt embarrassment because of incontinence and this caused a decrease in their body images(19). While Van Balken et al., reported that even Independent variables Dependent variables Model 1-Total FSFI Model 2-Desire Model 3-Arousal β* se t p β* se t p β* se t p Age 0.658 0.106 3.947 .001 -0.532 0.034 -3.426 .001 0.172 0.025 3.226 .001 BMI 0.109 0.063 2.060 .040 _ _ _ _ _ _ _ _ Number of live birth 0.123 0.353 1.777 .076 _ _ _ _ _ _ _ _ Spontaneous abortion -0.186 0.425 -3.529 .001 0.210 0.137 4.289 .001 0.145 0.323 -2.723 .007 Type of marriage -0.592 0.102 -3.303 .001 0.688 0.031 4.351 .001 _ _ _ _ Model, adjusted r2 = 0.082 Model, adjusted r2 = 0.200 Model, adjusted r2 = 0.029 f value = 7.860, p < 0.001 f value = 24.987, p < 0.001 f value = 6.762, p < 0.001 Model 4- Lubrication Model 5 –Orgasm Model 6-Satisfaction β* se t p β* se t p β* se t p Age 0.968 0.083 5.948 .001 0.699 0.066 4.203 .001 _ _ _ BMI 0.094 0.050 1.836 .067 0.106 0.039 2.022 .044 0.113 0.040 2.134 033 Number of live birth 0.137 0.277 2.032 .043 _ _ _ _ 0.122 0.176 2.249 .025 Spontaneous abortion -0.209 0.333 -4.080 .001 -0.207 0.265 -3.940 .001 -0.161 0.269 -3.084 .002 Type of marriage -0.993 0.080 -5.676 .001 -0.616 0.060 -3.627 .001 _ _ _ _ Model, adjusted r2 = 0.126 Model, adjusted r2 = 0.082 Model, adjusted r2 = 0.038 f value = 12.016, p < 0.001 f value=9.606, p < 0.001 f value = 5.984 , p < 0.001 Model 7- Pain β* se t p Age 0.776 0.076 4.768 .001 BMI _ _ _ _ Number of live birth _ _ _ _ Spontaneous abortion -0.227 0.306 -4.419 .001 -0.661 0.069 3.988 .001 Model, adjusted r2 = 0.122 f value = 14.309, p < 0.001 Table 3. The effect of variables of age, BMI, number of live birth, spontaneous abortion and type of marriage on FSFI total and subgroup score Sexual Dysfunctıon In Urınary Incontınence -Zincir et al. Vol 15 No 04 July-August 2018 195 women experiencing less problems concerning urinary system had high levels of sexual dysfunction(20), Han- da et al., reported that sexual anorexia, vaginal dry- ness, and sexual pain disorders were more prevalent in women with severe UI(21). Pathiraja et al., reported that the prevalence of women with incontinence was 10%, with stress and urge incontinence was 29.9%.(22). It was found in this study that 45.6% of women with UI were affected by sexual life (Table 1) and there was a signif- icant correlation between ISI score and FSFI score (P < .05) (Table 2). Accordingly, it can be asserted that FSFI mean score of the women with very severe urinary incontinence was lower and their sexual functions were poor. A significant correlation was found between model 1-7 FSFI and independent variables in women with UI (Ta- ble 3) (P < .05). There was a significant correlation between ISI and subscale desire of FSFI (P < .001). Al- most half of the women stated their sexual lives were affected and therefore they did not consult a physician (Table 1). This might be associated with decrease of sexual desire and the fact that the women did not con- sider it as a problem. As a result of their study, Beji et al., determined that sexual lives of 43.7% of the women were affected by UI, the women tried different ways for having their husbands not to recognize this prob- lem, and endeavored to postpone sexual intercourse(23). As development level of countries increases, status of woman rises and as status of woman increases, prev- alence of SD may vary because woman makes healthy decision about her own body. In above-mentioned nu- merous studies, in studies conducted in both Turkey and in several countries of the world, prevalence SD con- fronts us as an important health problem having a prev- alence seen in more than half of women and waiting for solution. However, the reason behind why women did not consult a physician and seek for solution might be that sexual issues in Turkish society are considered as a taboo due to both religious and cultural reasons. SD are affected by several independent factors such as age, chronic diseases, BMI, parity, type or time of mar- riage. Age among these independent factors is defined as the most important factor having an effect on female sexual dysfunction(6). As well as decrease in functional capacity of tissues and organs with increased age, in- creasing number of birth and hormonal changes may cause sexual dysfunction in advanced ages compared to young age(6,24). Prevalence of female SD increases with age and chronic diseases(25,26). In compliance with the literature, it was determined that there was a positive correlation between FSFI and ISI score and age (Table 4) and sexual lives of almost half of women were affect- ed (Table 1). Frequent urinary incontinence in elderly population is associated with age-dependent changes such as decreased estrogen, decreased capacity of blad- der, and impairment in ability to urinate. A significant correlation was found between BMI, num- ber of live birth, spontaneous abortion, and type of mar- riage, which were thought to be effective on dependent variables in the study, and independent variables (mod- el 1- FSFI, r2 = 0.082 f value = 7.860, P < 0.001). In the study conducted by Gunhilde et al., on 140 women, they determined that mean BMI was 27.2 (kg/m2), was 29 (kg/m2) in women with incontinence, and 25.4 (kg/ m2 ) in continent women(27). In the study conducted by Koçak et al., on 1012 women aged between 18-92 years, BMI of 31.3% of women with incontinence was reported to be over 25 (kg/m2) and BMI was lower than 25 (kg/m2) in 14.5%(28). Fertility process causes some permanent and temporary changes in reproduc- tive organs. These experienced changes; some special cases such as frequent, many, early and advanced age pregnancies, difficult delivery, interventional birth may influence sexual life because of risk for damaging on reproductive organs(29). Different results are remarkable in studies conducted in order to determine correlation between fertility and SD. While superfecundity was determined as a risk factor in terms of SD in most of studies supporting our results(30), there was no correla- tion between fertility and SD in certain studies(31). The reason behind why these results are different might be the effect of socio-cultural characteristics of sample in the study. In addition, higher prevalence of SD in wom- en married via prearranged marriage can be explained by these women’s possibility to have low educational level and low social status in general. Almost half of women with UI were determined to have moderate and more severe urinary incontinence. A significant correlation was found between ISI score and FSFI score. Age, BMI, parity, and type of marriage were determined to influence total FSFI score of the women with UI. In accordance with these results; -Women with UI having the risk factors of sexual dys- function should be early diagnosed and multidiscipli- nary approach should be considered for those women to prevent severe sexual problems. -It will be beneficial to conduct studies to be planned about sexual consultancy and sexual education on groups showing different ethnic and socioeconomic structure, and different settlement (rural, urban) char- acteristics. -Training programs and psychological counseling ser- vices increasing sexual self-confidence, sexual self-ef- ficacy, and marital satisfaction levels of married indi- viduals can be developed. -It is recommended for healthcare personnel to know the effect of culture on treatment of diseases and ac- cordingly to give care individuals. Table 4. Correlation analysis of women’s some characteristics, ISI and FSFI scores Characteristics Correlation level of ISI score* p Value Correlation level of FSFI score* p Value Age .280 .201 .001 .001 Body mass index .160 .168 .002 .001 Duration of marriage .304 .001 .168 .001 Number of pregnancy .290 .001 .115 .025 Number of spontaneous abortion .148 - .029 .004 .571 *Spearman’s correlation analysis. Sexual Dysfunctıon In Urınary Incontınence -Zincir et al. Sexual Dysfunction and Andrology 196 Limitations of the Study Domestic life and sexual life are regarded as a taboo in culture of Turkish society and what are experienced in this aspect are kept in family. For this reason, results of the study cannot be generalized to all women with UI. However, it is important because the number of similar studies conducted in Turkey is limited and also under- standing problems in domestic life and sexual lives of these families will facilitate helping these families. ACKNOWLEDGEMENT This research was presented orally at International Con- ference on Nursing (ICON 2017). CONFLICTS OF INTEREST The authors have no conflict of interest to declare. REFERENCES 1. Biri A, Durukan E, Maral I et al. Incidence of stress urinary incontinence among women in Turkey. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17: 604–10. 2. Van der Vaart CH, Lamers BHC, Heintz APM. Feasibility and patient satisfaction with pelvic organ prolapse and urinary incontinence day surgery. Int Urogynecol J. 2007;18:531–6. 3. Bilgiç D, Beji NK, Yalçın Ö. Ürojinekoloji hastalarında cinsel fonksiyon değerlendirmesi. Journal of Turkish Society of Obstetrics and Gynecology. 2011; 9:248-58. 4. Oh SJ, Ku JH, SooChoo M, Yun JM, Kim DY, Park WH. Health-related quality of life and sexual function in women with stress urinary incontinence and over active bladder. Int J Urol. 2008;15:62–7. 5. Tennstedt SL, Fitzgerald MP, Nager CW et al. Quality of life in women with stress urinary incontinence. Int Urogynecol J. 2007;18:543– 9. 6. Salonia A, Zanni G, Nappi RE et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence:Results of a cross-sectional study. Eur Urol. 2004;45:642–8. 7. Sümbüloğlu K, Sümbüloğlu V. Biyoistatistik. 13. Baskı. Hatiboğlu yayınları. Ankara 2009:265. 8. Turhan A, Akhan SE, Bastu E et al. The effect of urinary incontinence on sexual functioning in turkish women of reproductive and menopausalages. Int J Sex Health. 2015;0:1– 10. 9. Atrash GE, Ali MH, Abdelwahab HA, Abdelreheem LA, Shamaa M. Theassessment of sexual dysfunction in Egyptian women with lower urinary tract symptoms. Arab J Urol. 2014;12:234–8. 10. Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik A, Bratt H. Validation of a severity index in female urinary incontinence and its implementation in an epidemiological survey. J Epidemiol Community Health. 1993;47:497- Sexual Dysfunctıon In Urınary Incontınence -Zincir et al. 9. 11. Uyar-Hazar H, Şirin A. İnkontinans şiddet indeksinin geçerlik ve güvenirliği çalışması. ADÜ Tıp Fakültesi Dergisi. 2008; 9: 5-8. 12. Rosen R, Brown C, Heiman J et al. The female sexual function index (FSFI): A multidimensional self- report instrument fort he assessment of female sexual function. J Sex Marital Ther. 2000;26:191-208. 13. Öksüz E, Malhan S. Prevalence and risk factors for female sexual dysfunction in turkish women. J Urol. 2006;175:654-8. 14. Taş I, Yağız A, Altay B, Özdedeli K. Spinal kord yaralanmalı hastalarda cinsel fonksiyon bozuklukları ve nörolojik düzey ile ilişkileri. Türkiye Fiziksel Tıp ve Rehabilitasyon Dergisi. 2006;52:143-9. 15. Koçak I, Okyay P, Dündar M, Erol H, Beser E. Female urinary ıncontinence in thewest ofturkey: prevalence, risk factors and ımpact on quality of life. Eur Urol. 2005;48:634–41. 16. Önem K, Ahmedov I, Kadioğlu A. Kadın cinsel fonksiyonun patofizyolojisi, “Kadioğlu A, Başar M, Semerci B (ed): Erkek ve Kadın Cinsel Sağlığı. Türk Androloji Derneği Yayını.2004. İstanbul. 17. Sen I, Onaran M, Aksakal N, et al. The impact of urinary incontinence on female sexual function. Adv Ther. 2006;23: 999-1008. 18. Özerdoğan N, Sayıner FD, Köşgeroğlu N, Ünsal A. 40–65 Yaş Grubu Kadınlarda Cinsel Fonksiyon Bozukluğu Prevalansı, Depresyon ve Diğer İlişkili Faktörler. Maltepe Üniversitesi Hemşirelik Bilim ve Sanatı Dergisi. 2009;2: 46-59. 19. Coyne KS, Margolis MK, Jumadilova Z, Bavendam T, Mueller E, Rogers R. Overactive bladder and women's sexual health: what is the impact?. J Sex Med. 2007;4:656–6. 20. Van B, Verguns H, Bemelmans B. Sexual fonctioning in patients with lower urinary tract dysfunction improves after percutaneous tibial nerve stimulation. Int J Impot Res. 2006;18:470-5. 21. Handa VL, Harvey L, Cundiff GW, Siddique SA, Kjerulff KH. Sexual function among women with urinary incontinance and pelvic organ prolapse. Am J Obstet Gynecol. 2004;191:751-6. 22. Pathiraja R, Prathapan S, Goonawardena S. Urinary incontinence of women in a nationwide study in sri lanka: prevalence and risk factors. Urol J. 2017;14:3075-80. 23. Beji NK, Yalçın O, Ayyıldız EH, Kayir A. Effect of urinaryleakage on sexual function during sexual intercourse. Urol Int. 2005;74:250-5. 24. Demir Ö, Parlakay N, Gök G, Esen AA. Hastane Çalışanı Bayanlarda Cinsel İşlev Bozukluğu. Androloji. 2007;33: 156-60. Vol 15 No 04 July-August 2018 197 Sexual Dysfunctıon In Urınary Incontınence -Zincir et al. 25. Aslan E, Beji NK, Gungor I, Kadioglu A, Dikencik BK. Prevalence and risk factors for low sexual function in women: a study of 1,009 women in an outpatient clinic of a university hospital in Istanbul. J Sex Med. 2008;5:2044- 52. 26. Singh JC, Tharyan P, Kekre NS, Singh G, Gopalakrishnan G. Prevalence and risk factors for female sexual dysfunction in women attending a medical clinic in south India. J Postgrad Med. 2009;55:113-20. 27. Gunhilde GM, Chin M, Glantz C, Guzick D. Prevalence of urinary incontinence and associated risk factors in a cohort of nuns. Obstet Gynecol. 2002;100:226. 28. Koçak I, Okyay P, Dündar M, Erol H, Beser E. Female Urinary Incontinence in theWest of Turkey: Prevalence, Risk Factors and Impact on Quality of Life. Eur Urol. 2005;48: 634– 41. 29. Demirci N. Kadının Yaşam Dönemlerinde Cinsellik ve Cinsel Sağlık. Coşkun A, editör. Kadın Sağlığı ve Hastalıkları El Kitabı. 2. Baskı. İstanbul: Koç Üniversitesi Yayınları; 2012: 540-78. 30. Erbil N. Prevalence and risk factors for female sexual dysfunction among Turkish women attending a maternity and gynecology outpatient clinic. Sex Disabil. 2011; 29:377- 86. 31. Güvel S, Yaycıoğlu Ö, Bağış T, Savaş N, Bulgan E, Özkardeş H. Evli kadınlarda cinsel fonksiyonlara etkin faktörler. Türk Üroloji Dergisi. 2003; 29: 43-8. Sexual Dysfunction and Andrology 198