Urinary Leakage During Sexual Activity: A Narrative Review of an Underdiagnosed Female Pelvic Floor Disorder

Abstract

Coital urinary incontinence is a frequently underdiagnosed manifestation of female pelvic floor dysfunction, characterized by involuntary urine leakage during sexual activity, particularly during vaginal penetration or orgasm. Although interest in this condition has increased in recent years, it remains insufficiently investigated in clinical practice and is often underreported by patients because of stigma, emotional distress, and the negative impact on intimate relationships and quality of life. Current evidence supports the existence of distinct pathophysiological mechanisms depending on the timing of urinary leakage. Leakage occurring during vaginal penetration is more commonly associated with stress urinary incontinence, urethral hypermobility, and pelvic support defects, whereas orgasm-associated urinary incontinence appears to be more closely related to detrusor overactivity and complex pelvic neurophysiological mechanisms. Hormonal changes associated with the peri- and postmenopausal period may further contribute to symptom progression through alterations in urethral and vaginal trophicity, local vascularization, and pelvic neuromuscular function. Clinical evaluation remains challenging because many affected women do not voluntarily report symptoms due to embarrassment or social stigma, therefore it requires targeted questioning regarding urinary leakage during sexual activity, associated lower urinary tract symptoms, and the impact on female sexual health. Therapeutic management should be individualized and tailored to the predominant underlying mechanisms, including pelvic floor rehabilitation, behavioral interventions, pharmacological treatment, local hormonal therapy, and surgical management of stress urinary incontinence or pelvic support defects. Minimally invasive and regenerative therapies, such as vaginal laser therapy, platelet-rich plasma, cellular therapies, and neuromodulation, represent promising therapeutic approaches. Greater awareness and proactive screening during urogynecological evaluation are essential for improving diagnosis, individualized treatment, sexual health, and overall quality of life in affected women.