Formulating the research question

To ensure a comprehensive exploration of the topic, the research question was developed using the Population-Concept-Context (PCC) framework: What is the impact of interventions for urinary incontinence on sexual health outcomes, and how do interventions focused on sexual function compare to those primarily targeting urinary incontinence?”

• Population (P): Women with urinary incontinence
• Concept (C): Strategies or interventions aimed at improving sexual health (Although sexual health is a multidimensional construct encompassing physical, psychological, and relational aspects of sexuality, the outcomes synthesized in this review primarily reflect sexual function as measured by validated questionnaires, which are commonly used proxies for sexual health–related outcomes in clinical research.)
• Context (C): Healthcare settings, including clinics, hospitals, and specialized health centers

Data sources and search strategy

A comprehensive literature search was conducted in scientific databases such as PubMed, Scopus, Web of Science, ScienceDirect, the World Health Organization (WHO) repository, the National Institute for Health and Care Excellence (NICE), and the Agency for Healthcare Research and Quality (AHRQ) to identify relevant studies.

The search strategy incorporated controlled vocabulary (e.g., MeSH terms) and relevant keywords were: Sexual Health, Sexual Health Improvement, Reproductive Health, Sexual Health Provider, Urinary Incontinence, Stress Urinary Incontinence, Urge Urinary Incontinence, Overflow Incontinence, Mixed Urinary Incontinence, Sexual Health Service. Sexual health–related terms were intentionally broadened to include dyspareunia, libido, sexual desire, arousal, and vaginal pain to minimize the risk of missing relevant studies.

The search was restricted to peer-reviewed English articles (quantitative, qualitative, mixed-methods studies, and review articles) published between 2015 and 2025. (The search strategy is detailed in Table 1.) The literature search was limited to studies published between January 2015 and December 2025. This timeframe was selected to capture evidence reflecting contemporary clinical practice in the management of urinary incontinence, including modern surgical techniques (e.g., current mid-urethral sling approaches), updated pelvic floor muscle training (PFMT) protocols, and the widespread use of validated sexual function instruments such as the FSFI and PISQ-12 with standardized scoring and interpretation. Given substantial changes in intervention techniques and outcome measurement over the past decade, restricting the timeframe was intended to enhance the clinical relevance and interpretability of the findings.

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Table 1. Search Strategy.

https://doi.org/10.1371/journal.pone.0346256.t001

Additionally, gray literature was considered, including books, book chapters, government reports, clinical guidelines, and policy documents from recognized institutions such as the National Information Center on Health Services Research and Health Care Technology (NICHSR).

Eligibility criteria

Studies were included if they involved adult women (≥18 years) diagnosed with any type of urinary incontinence and assessed sexual health outcomes (e.g., sexual function, satisfaction, or partner-related factors). Studies focusing on neurological populations or men were excluded. Partner-related outcomes were considered only when reported alongside female participants.

Study selection

Two independent reviewers screened the titles and abstracts using a standardized selection tool. Studies meeting inclusion criteria underwent a full-text review, followed by independent double screening. A third reviewer resolved discrepancies. Studies were assessed for quality using the Mixed Methods Appraisal Tool (version 2018). Although quality appraisal is not routinely used to exclude studies in scoping reviews, the MMAT was applied in this review to support its role as a preparatory phase for future guideline development in sexual health among women with urinary incontinence. To ensure that mapped intervention strategies were derived from methodologically sound evidence, studies scoring below 3/5 were excluded due to substantial limitations in study design, outcome measurement, or reporting quality. Fig 1 presents the PRISMA flow diagram of the selection process [20].

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Fig 1. PRISMA 2020 flow diagram.

https://doi.org/10.1371/journal.pone.0346256.g001

Data extraction and synthesis

A standardized data extraction form was used to systematically collect study characteristics, including study design, population, type of UI, interventions, and key findings. Two researchers independently extracted data, and inconsistencies were resolved through discussion.

Sexual function outcomes were extracted as reported in the primary studies using validated questionnaires such as the Female Sexual Function Index (FSFI) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Baseline sexual dysfunction status was not consistently reported across studies; therefore, changes in sexual function scores were descriptively synthesized without assuming the presence of clinically diagnosed sexual dysfunction at study entry. No uniform thresholds for clinically significant change were applied, as these were rarely defined in the original studies.

Given the heterogeneity of study designs, interventions, and outcome measures, the researchers employed a narrative data Synthesis approach as described by Popay et al. [21].

The extracted data were compiled into summary tables, detailing study characteristics, target populations, UI subtypes, intervention strategies, and reported outcomes. Common themes were identified and compared across studies to generate a comprehensive understanding of the strategies used to improve sexual health in women with UI.

Human Ethics and Consent to Participate declarations: This study did not involve human participants or identifiable personal data and therefore did not require institutional ethics approval.

Study characteristics

The studies cover a wide range of interventions, including surgical procedures such as transobturator tape (TOT), midurethral sling (MUT), tension-free vaginal tape (TVT), native tissue repair, vaginal hysterectomy, sacrospinous hysteropexy, and mesh-based repairs, as well as non-surgical approaches like pulsed magnetic stimulation (PMS), pessary use, and cognitive-behavioral therapy (CBT). The populations predominantly consist of sexually active women, though some studies include broader groups with pelvic floor disorders, including those with POP stages II–IV, uterine prolapse, or coital incontinence. Sample sizes vary widely, from small cohorts (e.g., 20 women in Vitale et al., 2018) to large registries (e.g., 1210 women in Solhaug et al., 2024) [22], reflecting diverse methodological approaches. The majority of the studies utilized validated questionnaires, such as the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire and the Female Sexual Function Index, to assess changes in sexual health outcomes. The follow-up periods varied from a few weeks to over 10 years, providing insights into both short-term and long-term effects of different interventions. Supplementary file1summarizes the key findings of the included studies

Analysis of the studies

Results were categorized into four main groups: Impact of non-surgical Interventions on sexual function, Effectiveness of Surgical Interventions on sexual function, Comparative Outcomes of Surgical vs. Non-Surgical Approaches, and Partner Sexual Function (Reported changes in sexual function scores reflect study-specific findings and should not be interpreted as treatment effects for established sexual dysfunction).

Impact of non-surgical Interventions on sexual function

Non-surgical strategies, including pelvic floor muscle training (PFMT), electrical stimulation (ES), pulsed magnetic stimulation (PMS), cognitive-behavioral therapy (CBT), pessary use, and anticholinergics, demonstrate a significant potential to enhance sexual function in women with UI. PFMT, as a cornerstone of conservative management, consistently improves sexual function by enhancing pelvic muscle tone and sensation, as evidenced by Jha et al. [23] in their RCT. The lack of difference between standard PFMT and PFMT with ES suggests that additional technologies may not always yield superior outcomes, though ES’s cost-effectiveness [23,24] highlights its practical utility in resource-limited settings. Similarly, PMS emerges as a novel and effective option, with Studies Lim et al. and González-Isaza et al. [25,26] reporting significant improvements in sexual function and UI symptoms over short follow-up periods, underpinned by high patient satisfaction. CBT [27] uniquely addresses psychological dimensions, enhancing sexual self-esteem alongside function, suggesting a holistic approach for women with UI-related distress. Pessary use [28] maintains sexual function while improving UI symptoms, offering a non-invasive alternative for those avoiding surgery. While anticholinergics can reduce OAB urgency, they don’t improve sexual function, potentially due to psychosomatic factors or side effects like dryness [23]. Evidence for anticholinergic efficacy remains inconclusive, primarily stemming from a small study without urodynamic confirmation of detrusor overactivity. Collectively, these findings underscore the importance of non-surgical strategies as first-line management for women with UI, particularly those seeking minimally invasive options. However, the variability in treatment efficacy emphasizes the necessity for personalized therapeutic approaches tailored to individual patient needs and clinical profiles.

Effectiveness of surgical Interventions

Surgical interventions for UI, including midurethral slings (MUTs), colposuspension, fascial slings, and prolapse repairs, demonstrate significant efficacy in improving sexual function—primarily by mitigating coital incontinence, a major impediment to sexual health in affected women. A study [23] revealed that approximately one-third of women undergoing continence surgery report improved sexual function, while 55.5% experience no change and 13.1% note deterioration, highlighting the heterogeneous outcomes of these interventions.

Among surgical options, MUTs—such as tension-free vaginal tape (TVT) and transobturator tape (TOT)—are particularly effective, with studies [22,29–34] documenting sustained benefits over follow-up periods ranging from 12 months to 20 years. These procedures not only restore continence but also enhance sexual satisfaction, likely attributable to regained confidence and reduced leakage during intercourse. Modified colposuspension [35] and native tissue repairs [36,37] similarly yield high patient satisfaction and durable symptom relief, as evidenced by long-term follow-up data.However, outcomes vary across techniques. Fascial slings are associated with higher rates of dyspareunia [38], while some MUT recipients report worsened sexual function due to postoperative pain or altered sensation. Advanced surgical approaches, such as adjustable mesh systems [39] and laparoscopic sacrocolpopexy [40], show promise in further optimizing outcomes with low complication rates, suggesting that technological refinements contribute to improved efficacy. Some studies comparing different hysterectomy types found that hysterectomy, regardless of the technique (vaginal, abdominal, laparoscopic, or with sacrospinous hysteropexy), generally does not negatively impact overall sexual function, and can even improve it by resolving prolapse-related issues.Radical hysterectomy may have a more detrimental effect on sexual function and pelvic floor issues compared to simple hysterectomy. While vaginal length may be affected by the surgical approach, it doesn’t seem to have a significant impact on sexual function [41–44].

Weight loss surgery also demonstrates a positive impact on both pelvic floor disorders and sexual performance in a single study [45].

Collectively, surgical interventions remain a cornerstone for severe UI, offering robust anatomical correction and symptom resolution. Nevertheless, the potential for adverse sexual outcomes underscores the importance of meticulous patient selection, individualized counseling, and consideration of less invasive alternatives where appropriate.

Comparative outcomes of surgical vs. non-surgical approaches

Comparative analyses demonstrate a clear dichotomy between surgical and non-surgical interventions for urinary incontinence (UI), with each approach offering distinct advantages and limitations. Surgical interventions [23,32,46,47] consistently demonstrate superior efficacy in anatomical restoration and reduction of coital incontinence, with emerging techniques such as mini-slings and autologous transobturator tape (TOT) showing improved safety profiles compared to traditional midurethral slings (MUTs). These procedures often provide durable, long-term benefits, making them particularly suitable for patients with severe symptoms or those who have failed conservative management. In contrast, non-surgical modalities—including pelvic floor muscle training (PFMT) [23], pulsed magnetic stimulation (PMS) [26], and cognitive-behavioral therapy (CBT) [27]—achieve comparable improvements in sexual function while avoiding surgical risks. These approaches are particularly advantageous for patients with milder symptoms or those prioritizing minimally invasive treatment. Pessary use [28] demonstrates efficacy similar to minor surgical interventions in preserving sexual function, whereas anticholinergic therapy [23] shows limited benefits, underscoring its condition-specific limitations. Further examination of surgical techniques [48] suggests that native tissue repairs may offer an optimal balance between efficacy and safety compared to mesh-based alternatives. These findings support a stepped-care approach, with non-surgical interventions serving as first-line therapy, followed by surgical options for non-responders or severe cases. However, the current evidence base is constrained by a paucity of direct head-to-head comparative trials, necessitating individualized treatment decisions based on symptom severity, patient comorbidities, and personal preferences. (Table 2 shows the pros and cons of interventions for improving the sexual health of women with UI.)

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Table 2. Pros and Cons of Interventions for Improving Sexual Health in Women with UI.

https://doi.org/10.1371/journal.pone.0346256.t002

Partner sexual function

Only three studies assessed partner-related sexual outcomes following interventions for urinary incontinence. Across these studies, with partner sample sizes that were either small and evaluated using heterogeneous outcome measures. Due to the limited number of studies, small sample sizes, and variability in outcome assessment, findings related to partner sexual outcomes should be interpreted with caution.

The impact of UI interventions on partners’ sexual function remains inadequately investigated in the current literature. Available evidence suggests that while treatment yields significant improvements in female sexual function [29,49–52], these benefits appear largely patient-specific, with no corresponding enhancement in male partners’ sexual satisfaction or function as measured by standardized instruments (MSHQ, IIEF-5).

Notably, Jha et al. [23] observed higher rates of partner avoidance in cases of pelvic organ prolapse (POP) compared to SUI, suggesting condition-specific variations in relational dynamics. However, detailed assessments of partner outcomes were not reported. Similarly, while one study [25] implied improved couple-level satisfaction following pulsed magnetic stimulation (PMS), it lacked specific metrics evaluating partners’ sexual function.

The limited focus on partner outcomes reflects a broader gap in understanding sexual mutuality, where both partners’ experiences shape relational satisfaction. Jha et al. [23] noted higher partner avoidance in POP compared to SUI, suggesting that condition-specific symptoms influence interpersonal dynamics differently. The absence of validated partner-focused metrics, such as the International Index of Erectile Function (IIEF-5), in most studies limits conclusions about mutual sexual satisfaction. Qualitative insights, though scarce, suggest that shame and avoidance behaviors in women with UI may indirectly affect partner intimacy, warranting further exploration.

These findings collectively indicate that UI interventions primarily address female sexual dysfunction, with any partner benefits likely being indirect (e.g., through enhanced intimacy) rather than reflecting measurable improvements in sexual function. The current research landscape reveals a significant gap in understanding the interpersonal consequences of UI—including shame, avoidance behaviors, and altered relationship dynamics—which may substantially influence overall relationship quality. Future studies should incorporate comprehensive partner assessments to better elucidate these multidimensional effects.

Strengths of the review

The review’s robust methodology, grounded in Arksey and O’Malley’s framework and enhanced by JBI recommendations, ensures a systematic and transparent approach. The comprehensive search strategy, spanning PubMed, Scopus, Web of Science, and gray literature from 2015 to 2025, captures a broad evidence base, including diverse interventions and populations. The inclusion of validated tools like the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12) and Female Sexual Function Index (FSFI) strengthens the reliability of sexual health outcomes. The narrative synthesis approach effectively accommodates the heterogeneity of study designs, providing a cohesive overview of a complex field.

Limitations

Despite its strengths, the review faces limitations that temper its generalizability.

Considerable heterogeneity existed across studies regarding study design, urinary incontinence subtypes, interventions, and outcome measures, which limited direct comparison and precluded conclusions about treatment effectiveness. However, this heterogeneity also reflects fundamental gaps in the current evidence base.

Sexual dysfunction was not consistently assessed or reported at baseline, and many studies included sexually active women without clearly defining the presence or severity of dysfunction. Consequently, changes in sexual function scores may not necessarily indicate improvement from a clinically defined condition.

In addition, the application and interpretation of sexual function questionnaires (e.g., FSFI, PISQ) varied widely, with limited clarity regarding clinically meaningful change. Grouping biologically distinct conditions such as stress urinary incontinence, urgency urinary incontinence, and pelvic organ prolapse further complicates interpretation of sexual health outcomes and limits the validity of comparisons between surgical and non-surgical interventions.

Finally, evidence on partner-related sexual outcomes was scarce and based on small samples, highlighting an important gap in the literature. Despite these limitations, this review clarifies methodological inconsistencies and identifies priorities for future sexual health–focused research in women with urinary incontinence.

Future research directions

Most interventions included in this review primarily targeted urinary incontinence management rather than sexual well-being directly. However, many of them produced secondary benefits on sexual health. Future interventions should explicitly integrate couple-based or partner-inclusive strategies to address both physiological and relational domains of sexual health.

Future research should prioritize head-to-head comparative trials of surgical versus non-surgical interventions, standardizing outcome measures (e.g., PISQ-12) and extending follow-ups to assess long-term durability. Investigating partner sexual function using validated tools (e.g., IIEF-5) and qualitative methods could elucidate relational dynamics, addressing the current patient-centric bias. Exploring novel modalities, such as laser therapy or nerve-sparing surgical techniques, may further minimize adverse sexual outcomes. Larger, multicenter studies in diverse populations are needed to ensure broadly applicable findings, particularly in underrepresented regions. Integrating psychological interventions like CBT with physiotherapy could enhance holistic care, especially for urgency UI, where pharmacological options underperform.

A stepped-care model, starting with non-surgical interventions (e.g., PFMT, PMS) for mild to moderate UI and escalating to surgical options (e.g., MUT) for severe cases, can optimize sexual health outcomes while minimizing risks.