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Sexual and psychological dimensions in women with urinary incontinence: a pilot study in an Italian sample.

Abstract
Background: urinary incontinence is a disease that inevitably affects the quality of women's lives in many ways. In accordance with the analysis of the literature and the specific nature of the disorder, it is believed that two of the relevant factors for assessing the quality of life of these women are sexuality and psychological well-being. Methods: according to this framework, it proposes a pilot study on a sample of 97 Italian women attending an outpatient urology department to investigate sexuality in women with urinary incontinence. To better understand the way in which these women live their sexuality, this dimension was placed into relation with couple satisfaction, with depression and, for the first time, with alexithymia, trying to determine if there is any correlation between these different variables. Results: the results show that, despite the presence of a good couple relationship, there is a difficulty in the sexual sphere. In addition depressive aspects effect a limited part of the sample and, if compared to the reference population, these women present a significant difference with regard to one dimension of alexithymia called �externally oriented thinking�.
The results show that there is no connection between the variables considered: sexual problems, couple satisfaction, depression, alexithymia and even for the type of incontinence. The only exception is the correlation between depression and some type of sexual problem, despite the substantial drop-out in response to questions about sexual difficulties. Conclusions: in order to better understand the complex nature of the interplay between this different variables it would be appropriate both to carry out a careful inquiry on the couple's sexuality before the onset of incontinence symptoms and to consider the subjectivity of the experiences of each individual patient during clinical assessment.
Keywords: sexuality, urinary incontinence, women, depression, alexithymia, couple satisfaction 

List of Abbreviations
CBA � 2.0 = Cognitive Behavioural Assessment 2.0
DAS-7 = Dyadic Adjustment Scale � Short Form 
DO = Detrusor Overactivity 
MUI = Mixed urinary incontinence
SCL-90-R = Symptom Checklist-90-R 
SUI = Stress urinary incontinence
TAS-20 = Toronto Alexithymia Scale  
TOT = Trans-obturator tape
TVT = Tension-Free Vaginal Tape 
TVT-O = Tension free vaginal tape-obturator 
UI = Urinary incontinence
UUI =  Urge urinary incontinence
WHO = World Health Organization
Sexual and psychological dimensions in women with urinary incontinence: a pilot study in an Italian sample.

Introduction
Urinary incontinence (UI), is defined as involuntary leakage of urine [1] and it has been recognized by the World Health Organization (WHO) to be one of the current and important health problems. It is divided into different types (stress, urge, mixed, functional and overflow incontinence) according to the causes that originated it.
Numerous studies have evaluated the prevalence of UI and, despite the wide variability of estimates, ranging from 3% to 65%, depending of urinary incontinence type and considered the different age of population taken in consideration, it appears a rather widespread problem among population, mainly women [2]. It can be stated that approximately 250 million people are regularly incontinent of urine in the world population [3]. 
As regards the studies on Italian samples can be seen a prevalence of UI around 11% for 50-years-old women [4] and around 16.4% for women with an age of 65 years and over [5].
Although it isn�t a disease which could lead to a life-threatening condition, it has detrimental effects on quality of life. In fact, several studies show that urinary incontinence negatively affects lives of women who suffer from this disease [6-14]. This is particularly true for certain types of UI - stress urinary incontinence (SUI) and urge urinary incontinence (UUI) - that are most bothersome for women; this factor allows to assume that the impact on quality of life is determined in part by the type of UI [6, 8, 9, 14]. The symptoms caused by this disease can interfere with women�s normal daily activities (domestic, social and occupational) and, consequently, influence their quality of life from social and physical point of view. In fact, women who suffer from urinary incontinence feel limited in behavior, often refuse to do physical activity, limiting fluid intake, frequently go to the toilet, they do not spend much time away from home and avoiding social situations as much as possible because they might feel embarrassed [8, 9, 11, 15]. 
Urinary Incontinence and Sexuality
One of the significant factor in the evaluation of quality of life is sexuality. In the urinary incontinence situations the sexual dimension is often accompanied by difficulties. The effect of UI on sexual functioning and sexual satisfaction has been investigated in several studies and many have clearly demonstrated the impaired sexual function [14, 16-22]. Yip et al. [23] claim that sexual satisfaction and incontinence related emotion are associated with married life and negatively affected women who had SUI or Detrusor Overactivity (DO). However, regardless of the type of UI, it is true that this disease can generate in women great concern and anxiety due to odor and urine leakage during sexual intercourse [16, 24-26]. This leads women to avoid sexual activity and, as a result, they report low sexual satisfaction in couple [25, 27]. In fact, women's fears are not entirely unfounded, since it has been shown that a third of the women had urine leakage during sexual intercourse [26]. The loss of urine can occur in different phases of the sexual activity, that is to say during arousal, during the penetration of the vagina or during the achievement of orgasm [28].
Certainly the anatomical factor and the impact of symptoms on daily life produce an effect on sexuality. However, if sexuality was only compromised by these two components, we should expect an improvement of sexuality as a result of interventions that improve incontinence. Nevertheless, in this area, the research is not conclusive.
At present, regarding the incontinence surgery, it can be stated that one of the most effective and popular procedure for the surgical treatment of SUI is represented by Tension-Free Midurethral Slings: Tension-Free Vaginal Tape (TVT), tension free vaginal tape-obturator (TVT-O), trans-obturator tape (TOT) [29]. A number of prospective studies, reviews, and meta-analyses demonstrated the efficacy and safety of mid-urethral slings, showing long-lasting benefits several reports have been published also on the effects of TVT and the other slings on female function [30-33]. A positive impact of incontinence surgery has also been described but the available data are not homogeneous and often even discordant [33-35]. 
Among non-invasive treatments, Kao et al. [36] found that Pelvic Floor Muscle Exercise had a positive effect on urinary incontinence and sexuality. However, the findings demonstrated that sex is taboo topic for research sample, composed by Taiwan women. Therefore, with the sensitive management of Pelvic Floor Muscle Exercise Programs, this issue can be addressed, loosening the taboo. As a result, the cause of the improvement of sexuality remain ambiguous. 
Urinary Incontinence, Sexuality and Depression: A complex mix
A body of research have called attention to the co-occurrence of depression and sexual difficulties among women population [37-40].  Regarding the relationship between depression and sexual dissatisfaction its direction is unclear. Some studies have tried to assess if there was a possible temporal precedence or a causal relationships between these two factors. Peleg-Sagy and Shahar [40], for instance, believe that sexual dissatisfaction in turn is likely to bring about �clinical� depression. Instead, Kalmbach et al. [39], say that there is a temporal precedence of mood on sexual symptoms. In a recent research emerge correlation between depression and sexual problems [37].  An alternative (though not mutually exclusive) explanation, proposed by Kalmbach et al. [39], is that the depression and sexual dysfunction symptoms may be manifestations of the same underlying processes and occur simultaneously. 
According to this framework, it seems clear that the relationship between depression and sexuality becomes further complicated in the case of women with urinary incontinence [41-43]. In this respect, several studies have suggested that there is an association between UI and depression, although, until now, the relationship between these two diseases is not clearly understood [44-48]. However it appears that the symptoms associated with urinary incontinence together with the functional impairment may increase the risk of depression [45]. Melville et al [45]., claim that Major depression is three times more present in women with urinary incontinence than in women who do not suffer from this disease; moreover the link between depression and UI becomes stronger with increasing severity of this last one. For researcher, the comorbid depression in incontinent women leads to greater perception of symptoms, to an increased risk of social isolation, a decrease of help-seeking behaviors and a lowering of the quality of life [49-50].
Looking from a different perspective sexual and psychological problems can be expressed as incontinence or voiding problems and be a symptom of a psychosomatic disease [51]. Other authors argue that sexual satisfaction appears to be independent of urogynecological problems and sexual life is correlated with depressive mood, which is not based on this kind of diagnosis [24, 52]. 
Leaving aside the question of causal relationship between urinary incontinence, sexual difficulties and depression, there are women with urinary incontinence that present depression [42, 44-50],  repeated sexual problems, reduced sexual activity, low desire, vaginal dryness and dyspareunia [17, 23, 53-56].
The contribution of alexithymia to illness behavior, sexuality and depression
Another element to be considered is the assessment of alexithymia. It is a personality construct that includes the inability to identify, describe and communicate the emotions [57, 58]. This condition of little emotional awareness has also consequences on the interpersonal level: difficulty in differentiating the emotions of others, low degree of empathy and ineffective emotional response.
Historically alexithymia was considered a predisposing factor in the onset of psychosomatic illnesses. This belief arose from the assumption that the inability to experience feelings, to identify the emotions and express them verbally could lead the person to misinterpret the emotional excitement as illness signal [59-61] and to develop different somatic symptoms in emotionally stressful situations [58, 62]. Different contributions [60, 63-70] suggest that alexithymia is a risk factor in the experience of illness, in reporting symptoms, in unhealthy behavior and in the use of 
facets, several studies have found a high level of alexithymia in different diseases [71]: irritable bowel syndrome [72], cardiac disease [73, 74], arthritis [74], somatoform disorders [75-78], post-traumatic stress disorder [79, 80], substance dependence [81, 82], pathological gambling [83, 84], anxiety [85], obsessive-compulsive disorder [86-88], cancer [74, 89], essential hypertension [90, 91], diabetes [92], eating disorders [93-98], morbid obesity [99], fibromyalgia [100-102],  kidney failure [74], etc. 
Therefore, can be said that alexithymia is not specific for psychosomatic disorders but it intervenes in all those physical and mental health problems that are influenced by emotion regulation,  including undifferentiated negative moods such as depression [71, 103, 104]. Depression must be taken into account as a confounding factor when studying alexithymia in general populations due to the strong association between alexithymia and depression [105]. Various epidemiological studies show an overlap between alexithymia and depression and it is believed that depression contributes to explain the variance of alexithymia in a measure estimated to be between 10 and 20% [106].� 
As it regards the connection between alexithymia and sexuality in women it is only known that the alexithymia for females is associated with lower frequency of penile-vaginal intercourse [107]. Just as specifically penile� vaginal intercourse, but not other sexual behavior, has been shown to scores be associated with more favorable indices of health [108]. However, in literature, the association between alexithymia and UI is not investigated, although alexithymia is significant in emotional relationships and in the expression of sexuality. This last point, therefore, is still an open field study.
The analysis of the literature shows, therefore, a complex vision in which the female incontinence problems are interwoven with those of sexuality and depression without a unanimous agreement with respect to the co-occurrence of these factors.
On the basis of these assumptions, we have proposed a pilot study on a sample of Italian women attending an outpatient urology department in northern Italy. It was also decided to expand the focus to other variables that, according to an analysis of the literature on other populations that have similarities with our sample, may be related to each other.
The first aim of this research is to investigate sexuality in women with urinary incontinence with a focus on sexual difficulties. To better understand the way in which these women live their sexuality, it was placed into relation with couple satisfaction, with depression and, for the first time, with alexithymia, trying to determine if there is any correlation between these different variables. It is assumed that these different variables, if related, self-sustaining each other in order to create a sort of vicious circle.

Materials and Methods
Setting
This study was conducted in the outpatient urology department of the Brescia Civil Hospital, in the northern Italy.
Participants
Participants consisted of 97 female patient aged between 23 and 68 years old (M = 44.96; SD = 11.46). The inclusion criteria of patients is the presence of UI (stress, urge, mixed, functional and overflow incontinence). Women who had UI due to tumors were excluded, but patients with prolapsed were included. Concerning education, 5 had attended primary school, 23 middle school, 37 had a high school degree, 10 a diploma and 21 a university degree.�As regards marital status we registered that 69 women were married, 10 were single, 4 widow, 2 separated, 7 had a common-law husband and 4 were divorced. Finally, the data on urinary incontinence show that 60 women suffering SUI, 12 UUI and 16 mixed urinary incontinence (MUI). Through statistical analysis significant differences were not found among patients with these different types of disease. When measuring how long these women suffer from UI it can be seen that the average is 5 years. 
Instruments
The assessment form includes various instruments. In particular, Schedule 4 of Cognitive Behavioural Assessment 2.0 (CBA � 2.0) is used to collect medical and psychological history information [109]. It was also investigated the sexual life of the patients thanks to Schedule 4 of CBA 2.0, which contain a specific questions about Affective-Sexual Area. In addition the interest about psychological treatment was evaluated. The couple�s satisfaction was evaluated by Dyadic Adjustment Scale � Short Form (DAS-7) [110]. The short form is composed by 7-item Likert Scale with 6 response categories (except for the last item with 7 response categories); the items assess the consensus (three items), cohesion (three items) and dyadic satisfaction (one items). Depressive symptoms are detected by the Symptom Checklist-90-R (SCL-90-R) [111]. Finally, it is asked to fill out Toronto Alexithymia Scale (TAS-20) [112], a self-report questionnaire for  alexithymia, which is a condition characterized by difficulty identifying emotions and differentiating between emotions and bodily sensations of emotional arousal, and an externally oriented cognitive style. 
Procedure
After obtaining the consent from the referent authority, during regular visit at the outpatient department, health personnel proposed to the female patients to participate at the research and to fill out questionnaires closed in an envelope. It was not required to report personal data and the completed questionnaires, closed in an envelope, were returned by patients, placing them in a box. In this way were protected the privacy of the data. 
Statistical analysis 
Statistical analysis was performed using software called SPSS 22.0. It was preferred to use non-parametric tests, respecting the nature of the data, which are for the majority ordinal data, but, according to common practice, parametric analyses were used when conditions allow.

Results 
Sexuality and Couple Satisfaction in UI Women
Each item related to sexual difficulties had/provided 4 point Likert scale without mid-point (0 = no; 1 = for months; 2 = for years; 3 = always). This kind of items has found a strong drop-out: from 15 to 26 women do not respond to the proposed questions. This is particularly surprising when we consider the specific nature of the medical problem and the research context: questions are certainly intimate, but it should not have been disregarded. A narrow range (10-15%) of the sample reveals wider disturbances in sexuality (too brief reports, annoyance and lack of interest for the partner). Concerning, in particular, sexual desire, it is important to highlight that, although 22 subjects did not respond, and 18.7% of the sample declares an absence of sexual desire (10.7% = for months; 8% = for years), the decrease of the same interests 43.9%. (15 subjects do not respond and 36, out of a total of 82 respondents, say they suffer this discomfort). Given the limited numerosity of data, it can�t propose a detailed investigation, however, is already very significant narrative information according to which only 14.4% of the sample believed that their sexual life is completely satisfactory. 
Significant negative correlation emerge between the quality of the relationship with the partner and decreased sexual desire (rs (97) = .31, p < .01) and positive correlation between the quality of the relationship and the couple happiness (rs (97) = .46, p < .001). However, there isn�t statistically significant correlation between the decrease of the sexual desire and the couple happiness.
The items concerning the relational aspects have apparently given very positive data: 88 subjects (90.7%) claim to have a stable emotional relationship and, as regards DAS-7, its result of dyadic satisfaction (item 7) show that 67% of the samples define the degree of happiness in their relationship from �happy� to �perfect�.
The other items of DAS-7 indicate that the women in our sample present high couple agreement not only on the consensus (philosophy of life, values, time spent together),  but also on the cohesion, which is expressed as frequency of couples activities (work activities, discuss something together, exchange of ideas). 
Over time, this relationship would then have remained stable and even increased some positive characteristics, such as a feeling of closeness, dialogue, complicity; the feature that has grown more over time and is linked to " esteem and respect " (35%). 
Sexuality and Depression in UI Women
The assessment of depression, according to SCL-90-R, show that little less than one third of the subjects is depressed: 17.5% is moderately depressed and 11.3% is severely depressed.
The results about the relationship between depression and sexual problems highlight various significant correlation independently from the type of UI. Depression correlates positively with the decrease of sexual desire (rs (82) = .42, p < .001), the lack of desire (rs (75) = .42, p < .001), the absence of sexual pleasure during intercourse (rs(78) = .33, p < .01), the annoyance about the thought of having sexual intercourse (rs(79) = .41, p < .001), partner's unpleasant demands (rs(76) = .29, p < .05), too brief sexual intercourse (rs(71) = .26, p < .05) and lack of sexual satisfaction derived from partner (rs(77) = .29, p < .01). 
Sexuality and Alexithymia in UI Women 
Regarding TAS-20 the distribution is comparable to the reference population with the exclusion of the third factor. In fact, the sample reports a higher level of operating-concrete thought (M = 18.94, SD = 4) that significantly differs (t(97) = 4.55, p < .001) from the Italian healthy normative population (Bressi et al., 1996). In addition, the third factor positively correlates with age (r(97) = .24, p < .05). 
Help-Seeking Behaviors in UI Women
Given the fact that the symptoms of urinary incontinence in women, if associated with psychological distress, can reduce help-seeking behaviors, it was decided to ask some questions about this kind of behavior. As regards the more specific questions about psychological distress more than half of the sample (58.7%) said that they had psychological problems in the past, while only 32% said they currently had. Compared to the suffering in the past, most showed having professional help (18.4% said they were helped by psychotherapy, 8.4% by medical specialists and 4.1% by drugs) and not so many by emotional relationships (11.2% from family, 1% from friends). In addition, although the proposed protocols did not indicate clear data of psychological suffering, in the face of the possibility of psychological help, only 12.9% of the sample declared its disinterest. When asked if they were interested in following psychological treatment if it proved useful for a greater comfort, 12 subjects answered no (12.9%), 18 had to think about it and 13 had to ask for advice (19.4% and 14.0%), 19 would only follow if it was short (20.4%) and 21 although long (22.6%), 10 already had treatment in progress (10.8%). Overall, 76.4% of the respondents would be willing to consider a kind of care that also deepened the emotional aspects. This information is particularly significant because the question was worded so as not to connect the resolution of the somatic problem to psychological treatment.

Discussion
The data we have do not allow us to draw definitive conclusions. The results show that, in the sample of women with urinary incontinence, no connection emerges between the variables considered: sexual problems, couple satisfaction, depression, alexithymia and even for the type of UI. The only exception is the correlation between depression and some type of sexual problem (decrease of sexual desire, lack of desire, absence of sexual pleasure during intercourse, annoyance about the thought of having sexual intercourse, partner's unpleasant demands, too brief sexual intercourse and lack of sexual satisfaction derived from partner). Therefore, the hypothesis according to which these different components, if related, self-sustaining each other in order to create a sort of vicious circle, can�t be confirmed. It is, however, confirmed the correlation between depression and sexual difficulties, and the lack of direction of association between these two variables. What is known is that with the increase of depression increases the importance of certain sexual problems and vice versa. However, it is necessary to remember that the percentage of depressed women is 28.8% (17.5% is moderately depressed, 11.3% is severely depressed) and that the percentage of women who say they have a fully satisfying sexual life is limited to 14.4% of the sample. There is, therefore, a large proportion of women in the sample that is not depressed but, in any case, does not have a satisfying sexual life.
A significant element, which is not reflected in other studies, is the strong drop-out than the population in response to questions about sexual difficulties.
In fact, sexuality in the other studies, despite being a taboo, finds an answer, whereas in our study, identified the difficulty in getting an answer on this issue despite the specific nature of the medical problem, the research context and, especially, the very positive results to DAS-7. It is important, in fact, to note that couple relationships are decidedly positive. Therefore,  although in the normal population the level of sexual satisfaction is considered a key factor in relationship satisfaction  [113, 114] in our sample this bond has no clear response. Moreover the dissatisfaction related to sexual relations is much broader than dissatisfaction on the frequency of the same; this is also a fact in contrast to the normal population [115] since in spite of the number of men and women who were dissatisfied with their frequency of sex, a large majority reported feeling fully satisfied sexually. However, it should be emphasized that our assessment was related to sexual relations and not to the greater range of sexual practices. 
In addition, it would be appropriate a careful inquiry on the couple's sexuality before the onset of urinary incontinence symptoms. This deepening is certainly complicated given the late access to health facilities and the possible distortion of distant memories. One possible way would be to evaluate the underlying dynamics involved in the representation of sexuality. One might suppose that in a very idealized relationships there is greater difficulty in living sexuality which by its nature is rather concrete and carnal, and perhaps even aspects of urinary disease emphasize even more these dimensions, connoting sex in a way that is not very syntonic for the features of these couple. This interpretative hypothesis should be evaluated in future studies because it is not claimable by our data, which, moreover, are just belonging to a female sample, while nothing is known with respect to the evaluation of sexuality by the partners.
Analyzing the results of the TAS-20, through the comparison of the sample with the reference population, a significant difference is visible with regard to third factor called �externally oriented thinking�.
There is not a specific literature on the third factor of TAS-20 about UI, but in some other research on somatic or mental disorders, emerges as it has a different performance than the other two factors, namely �identifying� and �describing feelings�.
It would appear that in the case of somatic disorders the strongest association is given by the �externally oriented thinking� factor, while in the case of psychic sufferings it is not associated, but the other two factor are significant [116-119].
Moreover, it is interesting to note how the third factor appears to play a particularly pertinent role in terms of inhibiting negative material [120]. The role of the externally oriented thinking could be twofold: on the one hand may lead to an underestimation of the negative components, on the other hand the third factor of the TAS 20 may signal an increased anchoring to the operational dimension, a propensity to process more concrete data, which would translate into a representation of reality in which the physical and somatic aspects are more important than psychological components. It could, therefore, be assumed that the markedly positive assessment of emotional relationships, as well as reduced the presence of depression, affected also an underestimation of the negative aspects; this underestimation is not applied in the evaluation of specific aspects, such as the expression of sexuality, because this last dimension was investigated in concrete behavior. All these data together � the high score of the third factor, the couple satisfaction and sexual difficulties related to depression � could lead to think that the couple harmony conceals some inability to express disagreement, to live in contrast and to stay in relationship where there are also individual spaces.
It is not easy to make a correct interpretation of these data (TAS-20 3rd Factor) in relation to the availability to undertake an eventual psychological treatment. On the one end the third factor expresses a sample disinclined to the awareness of psychological discomfort; the other side it can be seen that the sample is open to a type of treatment that leads to investigate the emotional aspects. Trying to link these results one might speculate that psychological treatment with this type of women should start from their needs to the �concrete� physical problem resolution and then go to investigate, only at a later stage, their emotional experience.

Conclusions
While the UI has, from a medical point of view, its certain definition and delimitation (there are, in fact, various forms of UI), from the psychological point of view there isn�t a correspondence, but there are a multiple mental operations, a varied universe, in which takes place the severely depressed person with sexual difficulties, as well as the person not at all depressed, with satisfactory couple life and without sexual problems. This great variety even more accentuates the responsibility of clinicians, who have the task of performing a wide and proper evaluation. The results found about the third factor of the TAS-20 lead to the hypothesis that a multifactor assessment of the woman who suffers from UI may lead to a more appropriate decision making regarding treatment (e.g. surgical treatment vs Pelvic Floor Muscle Exercise). This assessment should not neglect listening to the mental suffering and the opportunity to a possible referral to a mental health professional (sex therapist, psychotherapist, etc.). At the same time, it is necessary that the clinician doesn�t make the mistake to assume a priori that the physical symptoms necessarily implies relationship difficulties, or considered resolved any sexual, relational, or personal problems with the resolution of the physical symptom.

Ethics approval and consent to participate
Authors declare to have obtained ethics approval and consent for this research from Brescia Civil Hospital.
Consent for publication
Not applicable.

Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
There is not funding. 

Authors' contributions
All authors write read and approved the final manuscript.

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