Genital self-image, sexual function and pelvic floor discomfort in COVID-19 pandemic scenario

Introduction: Sexual health is an important area of women's health, comprising aspects that can be affected by stressors, such as in the COVID-19 pandemic scenario. Objective: To investigate genital self-image, sexual function and pelvic floor discomfort in young female university students during the COVID-19 pandemic, comparing these factors with their sexual activity. Methods: This study is a quantitative and cross-sectional survey of young female university students during the COVID-19 pandemic period, carried out through an online form. To assess the variables, the Female Sexual Function Index, Pelvic Floor Distress Inventory, and Female Genital Self-Image Scale were used. Results: 182 women participated in the study, and the general mean age was 22.06 ± 2.75 years. Sexually active women (n = 128) had significantly better genital self-image compared to inactive women (22.87 ± 2.92 vs. 20.85 ± 4.41; p = 0.004). Likewise, better genital self-image was also observed in women without sexual dysfunction (23.36 ± 2.72 vs. 21.11 ± 2.96; p < 0.001) and in those who reported fewer symptoms of pelvic floor discomfort (p = 0.014). Conclusion: A positive genital self-image was associated with fewer sexual dysfunctions, better sexual function, and fewer symptoms of pelvic floor discomfort. Furthermore, sexual activity is associated with a better genital self-image.


Introduction
Coronavirus disease 2019 (COVID-19) is a severe acute respiratory syndrome, which may initially show symptoms such as fever, cough, myalgia and fatigue.
In March 2020, after spreading across continents with a high number of victims, the World Health Organization declared a pandemic situation. 1 In the same way as countries in other continents, Brazil has also adopted strategies to contain the pandemic, such as distance and social isolation, quarantine, masks wearing, reduction of agglomerations, and other strategies. 2 Several universities have modified their teaching methods to avoid agglomerations and reduce contagion, as was the case at the Universidade Federal de Santa Maria, which instituted a special home exercise scheme through Resolution N. 24/2020. 3 However, these strategies, along with the chaotic scenario of the pandemic, are aspects that can directly affect the individual's mental health. In the study by Pedrozo-Pupo et al. 4 carried out in Colombia, 15% of the participants reported high levels of stress associated with the COVID-19 pandemic. Among students, the impact of the pandemic also seems to have consequences, and there are studies that already point to a negative impact on the mental health of university students, with worsening levels of stress, anxiety, sleep quality, loneliness and depression. 5,6 In addition, some studies carried out among university students have observed that female participants had higher levels of stress, and which is associated with worse levels of mental health in this pandemic period. 7,8 Linked to mental health, sexual health is an important and delicate area that is also being affected and needs attention in this pandemic moment. As a complex area, sexual health seems to be affected by the psychosocial effects of the pandemic, especially female university students. Studies developed in this period already show a direct impact of the COVID-19 pandemic on sexual health and quality of life, with decreased desire and frequency of sexual intercourse. [9][10][11] However, even before the effects of the pandemic, sexual dysfunction already had negative impacts on sexual health. These conditions also interfere with the individual's quality of life, acting on physical, emotional and social aspects, which are associated with their well-being. 12,13 Female sexual dysfunction is linked, among other causes, to dysfunctions of the pelvic floor muscles. 14 Bezerra et al. 15 observed that even young and female university students -with access to current information and notions about female anatomy and physiology -may have difficulty in fully and effectively performing their own sexuality, with a high prevalence of sexual dysfunction.
In addition, factors such as anxiety, stress and depression seem to be closely associated with the dysfunctions of this musculature, including conditions of hypertonia, urinary incontinence and painful symptoms of pelvic myofascial disorders. 16,17 As already mentioned, these factors are symptoms that have become common and are part of the routine of many students in this pandemic period. The FSFI consists of 19 questions that have five to six response options, two of which are related to desire, four to arousal and four to lubrication, three to orgasm, three to satisfaction and, finally, three questions about pain.
The score for each dimension varies between 1.2 and 6 or between 0 and 6, and the total FSFI score varies between 2 and 36, indicating better sexual function at high scores.
The cut-off point of the FSFI was adopted as a score of 26.55, in order to predict sexual dysfunction for scores below this value. The following cut-off points were used to analyse the domains: desire (4. rho < 0.30 as low correlation; 0.30 ≤ rho ≤ 0.60 as a moderate correlation; and rho > 0.60 as a high correlation. 28 To measure the effect of the correlation, the determination coefficient (R²) was used. For all tests p < 0.05 was adopted. All statistical analyses were performed using the SPSS 22.0 program.

Results
At the end of the data collections, 202 responses were obtained from the participants, and 182 responses were analysed using the eligibility criteria.
For data analysis, the participants were divided into years. Table 1 shows the characterization of the study participants.
The Female Genital Self-Image Scale (FGSIS) offers an effective means of assessing genital self-image. 19  The Table 4 shows the values of the correlations between the total FGSIS score and the FSFI domains, the PFDI-20 subscales and the total PFDI-20 score of sexually active university students in the last four weeks.
The total FGSIS score showed a significant and positive correlation with orgasm (rho = 0.225), pain (0.247) and with the total FSFI score (0.216). The variation in the total FGSIS score can be explained by, The values referring to the analysis of the FGSIS between the groups are shown in Table 2. When comparing the overall score of each group, sexually active women had a better genital self-image compared to the group of sexually inactive women (p < 0,004). The same occurred when analysing the items security (p = 0,016), appearance (p = 0,021), comfort (p = 0,007), smell (p = 0,023) and shame (p = 0,003), which showed significantly higher values in sexually active women.

Discussion
In accordance with our objectives, the analysis of genital self-image and sexual function showed interesting results when compared. In each domain of sexual function, women without dysfunction had better genital self-image, except for the sexual desire domain.
At this point, consequently, women with some sexual dysfunction have a worse self-image about their genitals.
Furthermore, it is observed that the better women's genital self-image, the better their sexual function in the orgasm domain and less pain dysfunction. Good genital self-image was associated with better overall sexual function.
Sexual function is only analysed in sexually active women. We defined sexually active women as those who had some sexual activity (penetrative or not) with a partner in the last four weeks before participating in the survey. Thus, sexually inactive women are those who did not have sexual activity during the same period. In our study, sexually active women had better genital selfimage, with a significantly higher mean total score than sexually inactive women.
Sexual activity, when compared to the relationship status, shows a significant number of sexually active women with a partner. However, a part of women with a partner were not sexually active, which may have been influenced by social distance for those who do not cohabit with their partner, which is culturally common for younger women. The presence of UI was also a relevant point, and, although without statistical significance between the groups, there was a predominance of UUI symptoms in both. Regarding genital self-image, sexually active women had a mean total score significantly higher than sexually inactive.
Improved genital self-image was associated with fewer symptoms related to colorectal and urinary disorders, as well as pelvic floor discomfort in general.