Urinary and sexual functional outcomes in female patients following elective lumbar spine surgery: a systematic review and meta-analysis

Urinary and sexual functional changes are associated with spine surgery, with reported incidences of approximately 20% for postoperative urinary retention (POUR) and 5-38% for sexual functional changes in mixed-sex cohorts, but sex-disaggregated outcomes are poorly characterized in females. We aimed to synthesize the available evidence on postoperative urinary and sexual functional outcomes in female patients undergoing elective lumbar fusion or disc replacement and to quantify pooled incidence rates, sex-based differences, and variation by surgical approach. We systematically searched PubMed, Embase, and Scopus in accordance with PRISMA guidelines for studies reporting postoperative urinary or sexual functional outcomes in female patients undergoing lumbar spine surgery. Both study sets were restricted to elective lumbar fusion or disc replacement for the primary analyses; decompression-only, mixed, and adolescent scoliosis cohorts were retained as sensitivity analyses. POUR was defined by each study's own criteria, and analyses were stratified by definition and by surgical approach (posterior fusion versus anterior or lateral interbody fusion or disc replacement). Impaired sexual function was defined as a pathological score on a validated instrument or a patient-reported decline in sexual frequency, satisfaction, or comfort. Pooled proportions were estimated with random-effects models, with meta-regression on publication year and procedure category. Seventeen studies were included in the POUR review and 12 in the sexual functional outcome review. Seven cohorts (1,758 female patients) undergoing lumbar fusion or disc replacement contributed to the primary POUR meta-analysis: pooled incidence 14% (95% CI, 7-26; I², 89%). Six posterior fusion cohorts gave 12% (95% CI, 7-21); only one anterior or lateral interbody cohort reported POUR (41%; 95% CI, 29-54), so that stratum could not be pooled. Surgical approach accounted for 60% of the between-study variance (p = 0.007). Adding decompression-only and mixed cohorts (13 cohorts, 15,741 patients) gave 12% (95% CI, 7-18). Multivariable odds ratios comparing males with females ranged from 1.04 to 3.05. An exploratory estimate of impaired postoperative sexual function, from six cohorts and 283 patients assessed largely with non-validated instruments, was 23% (95% CI, 12-38; I², 56%). Neither temporal trend was statistically significant. All POUR studies were at low risk of bias; seven sexual-function studies were low risk and the remainder unclear. In female patients undergoing elective lumbar fusion or disc replacement, postoperative urinary and sexual functional changes are present and probably underrecognized rather than rare. Because the evidence is observational, heterogeneous, and largely without baseline functional assessment, it does not establish causality or support definitive clinical recommendations. Surgeons may consider sex-specific counseling and monitoring of urinary and sexual function in follow-up. The sexual function estimate is exploratory; prospective, female-focused studies with validated instruments and preoperative baselines are needed.