Bariatric surgery improves urinary incontinence in morbidly obese individuals

Does Significant Weight Loss After Bariatric Surgery Affect Sexual Function and Urinary Symptoms? An Iranian Study

INTRODUCTION

For sexual dysfunction and lower urinary tract symptoms (LUTS), obesity is identified as an independent risk factor. The current study aimed to evaluate the effect of significant rapid weight loss by bariatric surgery on LUTS and sexual function among men and women with class III obesity.

METHOD

A group of patients who were planned to undergo bariatric surgery was enrolled in the study. Male patients were given the International Index of Erectile Function (IIEF) and the International Prostate Symptom Score (IPSS) questionnaires. In the female group, they filled in the female sexual function index (FSFI) and the International Consultation on Incontinence Questionnaire short form (ICIQ-SF) questionnaires. Patients were followed up 1 year after their bariatric surgery.

RESULTS

All questionnaires were completed by eighty-one patients. (mean age ± SD: 39.4 ± 9.2 years; mean body mass index (BMI) ± SD: 47.15 ± 5.4 kg/m2). The total score of the IPSS questionnaire decreased from 5.83 ± 3.01 preoperatively to 2.37 ± 1.66 postoperatively. The weight loss caused significant improvement in the storage phase of LUTS domains, but there were no considerable changes in the voiding phase. In the IIEF questionnaire, domains of sexual desire, overall satisfaction, and orgasmic function improved significantly. There was not a significant change in any FSFI domains after bariatric surgery. Mean ICIQ-SF decreased, but it was not substantial.

CONCLUSION

Bariatric surgery can significantly improve the storage phase in men, but not the voiding phase. Sexual desire, orgasmic function, and overall satisfaction were significantly improved in men. No significant improvement in sexual function and UI in women was observed.

Impact of bariatric surgery on urinary incontinence in morbidly obese individuals

BACKGROUND

There is scanty evidence on the impact of bariatric surgery on urinary incontinence (UI) in the Asian population.

METHODOLOGY

Patients who underwent bariatric surgery from June 2018 to June 2019 were screened using the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) questionnaire. Patients having UI were identified and followed until 1 year of surgery using the ICIQ-UI-SF. These were classified as having stress, urge, or mixed type of UI. The prevalence, change in scores, and the number of pads used were compared at baseline and at follow-up.

RESULTS

A total of 148 patients underwent bariatric surgery of whom, 41 patients (M = 2, F = 39) had UI. Stress incontinence was seen in 70.7%, 19.5% had urge incontinence, and rest had the mixed type. Using logistic regression, it was found that female gender was the most important predictor of having UI (OR: 8.33). The prevalence of UI decreased from 27.7% at baseline to 8.1% at 6 months and 3.4% at 12 months. The mean ICIQ-UI-SF score improved from 8.76 (SD = 3.2) at baseline to 0.66 (SD = 2.1) at 12 months of follow-up. The proportion of patients with UI using any number of pads decreased from 92.7% at baseline to 9.8% at 12 months. There was a decrease in the number of patients having moderate to very severe UI from 35 (85.4%) at baseline to 2 (4.9%) at 12 months. Proportion of patients showing resolution was highest among the stress incontinence group at 96.5%. Presence or absence of comorbidities did not significantly influence the ICIQ-UI-SF scores.

CONCLUSION

Bariatric surgery leads to profound improvement in UI in obese individuals which is well sustained until 1 year of follow-up. Resolution rates might be higher in Asian population.

Treating the Chronic Disease of Obesity

Obesity is a treatable chronic disease. Primary care providers play an essential role in diagnosis, treatment, and comprehensive care of patients with obesity. In recent years, treatment approaches have rapidly evolved, increasing effective and safe therapies. In this review, we provide practical information on the care of patients with obesity with a focus on antiobesity pharmacotherapy within the context of currently available therapeutic modalities such as intensive lifestyle interventions and bariatric surgery.

Weight loss with bariatric surgery or behaviour modification and the impact on female obesity-related urine incontinence: A comprehensive systematic review and meta-analysis

Women with obesity are at risk of pelvic floor dysfunction with a 3-fold increased incidence of urge urinary incontinence (UUI) and double the risk of stress urinary incontinence (SUI). The National Institute for Health and Care Excellence (NICE) and European Association of Urology (EAU) recommend that women with a body mass index ≥30 kg/m² should consider weight loss prior to consideration for incontinence surgery. This systematic review and meta-analysis will assess this recommendation to aid in the counselling of women with obesity-related urinary incontinence (UI). Medical Literature Analysis and Retrieval System online (MEDLINE), EMBASE, Cochrane, ClinicalTrials.gov, and SCOPUS were systematically and critically appraised for all peer reviewed manuscripts that suitably fulfilled the inclusion criteria established a priori and presented original, empirical data relevant to weight loss intervention in the management of urinary incontinence. Thirty-three studies and their outcomes were meta-analysed. Weight loss interventions were associated in a decreased prevalence in UI (OR 0.222, 95% CI [0.147, 0.336]), SUI (OR 0.354, 95% CI [0.256, 0.489]), UUI (OR 0.437, 95% CI [0.295, 0.649]) and improved quality of life (PFDI-20, SMD -0.774 (95% CI [-1.236, -0.312]). This systematic review and meta-analysis provide evidence that weight loss interventions are effective in reducing the prevalence of obesity-related UI symptoms in women. Bariatric surgery in particular shows greater sustained weight loss and improvements in UI prevalence. Further large scale, randomized control trials assessing the effect of bariatric surgery on women with obesity-related UI are needed to confirm this study's findings.

Impact of bariatric surgery in patients with stress urinary incontinence

Objective:

To examine epidemiologic, anthropometric and clinical variables associated with stress urinary incontinence in obese women, before and after bariatric surgery, and to identify predictive factors of stress urinary incontinence resolution.

Methods:

Prospective observational study with women enrolled in a bariatric surgery program between 2015 and 2016. Patients were assessed prior to and 6 months after bariatric surgery using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, the Patient Global Impression of Improvement and the Visual Analogue Scale. Patient assessment also included physical examination and bladder stress tests.

Results:

A total of 43 women completed the study. There was a 72.7% reduction in stress urinary incontinence (p=0.021). Predictive factors for preoperative diagnosis of stress urinary incontinence included age (p=0.024) and abdominal waist circumference (p=0.048). Urinary symptoms improved after weight loss, especially nocturia (p=0.001) and stress urinary incontinence (p=0.026). Menopause was the most significant predictive factor for persistence of stress urinary incontinence within six months of bariatric surgery (p=0.046). Self-reported outcomes and scores obtained in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, the Patient Global Impression of Improvement and the Visual Analogue Scale were associated with significant improvement (p=0.012, p=0.025, and p=0.002 respectively).

Conclusion:

Older women with larger waist circumference have a higher risk of developing stress urinary incontinence prior to bariatric surgery. Menopausal women are highly prone to persistent stress urinary incontinence, even after weight loss. Weight loss achieved through bariatric surgery improved stress urinary incontinence symptoms and mitigated related impacts on quality of life in the vast majority of women.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

The impact of bariatric surgery on urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Obesity and overweight are strongly associated with stress and urgency urinary incontinence, and weight loss has been associated with improvement in urinary incontinence. We aimed to measure pooled effect sizes for different weight loss procedures on incontinence-specific quality of life and incontinence cure rate in a systematic review and meta-analysis.

METHODS

MEDLINE, Embase and the Cochrane library were searched using a pre-defined strategy for relevant cohort studies. Random effects meta-analyses were conducted for the weighted mean difference for urinary quality of life scores and weighted overall pooled estimates for proportions of women cured. We explored heterogeneity using meta-regression, testing the type of bariatric surgery and change in BMI as predictors of effect size. The studies were categorised as either low or high risk of bias using a novel instrument specifically designed for longitudinal symptom research studies.

RESULTS

Twenty-three studies (n = 3,225) were included. Incontinence-specific quality of life scores were improved by 14% (weighted mean difference = -14.79; CI = -18.47 to -11.11; I² = 87.1%); the proportion of women cured of any urinary incontinence was 59% (95% CI = 51 to 66%) and the proportion of women cured of stress urinary incontinence was 55% (95% CI = 40 to 70%).

CONCLUSIONS

Bariatric surgery results in clinically meaningful improvements in incontinence-specific quality of life. Current data are limited by both short-term follow-up and unexplained heterogeneity among studies.

Quality of life in obese women with symptoms of urinary incontinence

Abstract Introduction: Obesity is a contributing factor to the development of urinary incontinence (UI). Objective: The objective of this study was to evaluate the prevalence of UI symptoms in women with morbid obesity and their impacts on quality of life (QOL), correlating the influence of age and body mass index (BMI) with the presence of UI. Method: Sixty-five women undergoing preoperative bariatric surgery, aged 35.8 ± 9.97 years, with an average BMI of 45.04 ± 6.79 kg/m2 were asked about the presence of UI symptoms; when they answered positively, the King’s Health Questionnaire (validated into Portuguese) was applied. The questionnaire was self-administered and all answers were assigned numerical scores. These scores were distributed according to quartiles and correlated with age and BMI. The level of hypothesis rejection was 5%, and analyses were performed using BioEstat software version 5.3. Results: Among 65 interviewees, 19 (29.23%) had symptoms of UI and went on to answer the questionnaire. The highest-scoring areas were “incontinence impact” (36.8) and “general health perception” (32.9). There was no significant correlation between questionnaire scores and BMI. In the association with age, the “incontinence impact” domain showed a significant, positive and moderate correlation (r = 0.52; p = 0.02). Conclusion: The prevalence of UI symptoms in the sample had a slight negative effect on QOL; however, UI associated with older ages significantly affected the QOL of the studied volunteers.

Quality of life and sexual functıon in obese women with pelvic floor dysfunction

This prospective study was conducted in the urogynecology and gynecology outpatient clinics of Istanbul Faculty of Medicine from December 2014 to March 2015. The objective was to identify the association between obesity and sexual function and quality of life in women with pelvic floor dysfunction (PFD). A total of 387 sexually active women diagnosed with urinary incontinence and/or pelvic organ prolapse were included and categorized as obese (n = 200) or nonobese (n = 187). Mean body mass indexes were 25.7 ± 2.41 kg/m² for nonobese women and 34.9 ± 3.92 kg/m² for obese women. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 total score was significantly lower in obese (27.66 ± 7.12) than in nonobese women (30.18 ± 6.54) (p < .05). Quality of life mean scores were higher in obese women for both the Incontinence Impact Questionnaire total score (67.24 ± 26.8 versus 49.12 ± 27.5) and Urogenital Distress Inventory total score (65.02 ± 21.4 versus 55.07 ± 24.7) (p < .001). Obese women with PFD had symptoms for longer durations, had more frequent urinary incontinence, and worse sexual function and quality of life than nonobese women. Health-care professionals caring for obese women should be aware of the coexistence of obesity and PFD. Future studies should evaluate whether obesity-associated PFD can be reduced through successful weight reduction interventions.

Effect of Bariatric Surgery on Urinary Incontinence in Obese Women: A Meta-analysis and Systematic Review

OBJECTIVES

The aim of this study was to explore the effectiveness of bariatric surgery in obese women with urinary incontinence (UI) through meta-analysis.

METHODS

Searches of PubMed, the Cochrane Library, and EMBASE databases were performed using "weight loss surgery/bariatric surgery/gastric bypass surgery" and "incontinentia urinae/uracratia/urinary incontinence/uroclepsia" in the title/abstract before January 2018. Then, meta-analysis was analyzed by Review Manager 5.3 (Cochrane Collaboration, Oxford, United Kingdom). The standardized mean difference (SMD) and odds ratio (OR) were used to describe results of continuous variables and dichotomous variables, respectively.

RESULTS

Pooled data showed that bariatric surgery reduced the incidence of UI in obese women at the follow-up of 6 months (OR, 3.27; 95% confidence interval [CI], 2.55-4.21; P < 0.00001) and 12 months (OR, 4.04; 95% CI, 2.62-6.22; P < 0.00001) and significantly reduced the body mass index at 6 months (SMD, 1.86; 95% CI, 1.19-2.53; P < 0.00001) and 12 months (SMD, 2.04; 95% CI, 1.44-2.64; P < 0.00001). In addition, bariatric surgery could also significantly increase the quality of life (SMD, 0.53; 95% CI, 0.27-0.80; P < 0.00001) and improve the function of pelvic floor disorders (SMD, 0.55; 95% CI, 0.38-0.72; P < 0.00001) based on quality-of-life questionnaires and Pelvic Floor Distress Inventory 20, respectively.

CONCLUSIONS

This meta-analysis demonstrated that bariatric surgery is an effective choice for obese women with UI. However, more randomized controlled trials are required to confirm this result.

Metabolic and Bariatric Surgery: An Effective Treatment Option for Obesity and Cardiovascular Disease

Obesity is a chronic and debilitating disease that has become a global epidemic. Especially severe in the Unites States, obesity currently affects almost 40% of the population. Obesity has a strong causal relationship with numerous serious comorbidities that impair quality of life, shorten life expectancy, and carry a major economic burden. Obesity has particular relevance to cardiologists because it contributes directly to several major cardiovascular diseases and, consequently, increases overall cardiovascular mortality. Multiple treatment options are available, but metabolic and bariatric surgery offers the most effective and durable treatment for obesity. Moreover, metabolic and bariatric operations alleviate and often completely eliminate numerous comorbidities, particularly type 2 diabetes and other cardiovascular risk factors, such as hypertension and dyslipidemia. With their low risk of complications and morbidity, metabolic and bariatric operations significantly improve quality of life and overall survival, particularly reducing death due to cardiovascular disease.

Obesity and Stress Urinary Incontinence: Impact on Pathophysiology and Treatment

PURPOSE OF REVIEW

Obesity is highly prevalent and is associated with stress urinary incontinence (SUI). The purposes of this review are to assess the pathophysiology of SUI in the obese female and review the outcomes of weight loss and anti-incontinence surgery in this population.

RECENT FINDINGS

While increased intra-abdominal pressure appears to be the common pathophysiologic link between obesity and SUI, neurogenic and metabolic pathways have been proposed. Both surgical and non-surgical weight loss continue to have beneficial effects on SUI; however, long-term outcomes are largely absent. Midurethral sling (MUS) surgery is largely effective in the obese population, with a complication profile similar to that in non-obese women. Obesity has been shown to be a risk factor for failure of MUS. While weight loss should be the primary modality to improve SUI in the obese woman, MUS remains an effective and safe option in those women undertaking surgery.

Path of translational discovery of urological complications of obesity and diabetes

Diabetes mellitus (DM) is a prevalent chronic disease. Type 1 DM (T1DM) is a metabolic disorder that is characterized by hyperglycemia in the context of absolute lack of insulin, whereas type 2 DM (T2DM) is due to insulin resistance-related relative insulin deficiency. In comparison with T1DM, T2DM is more complex. The natural history of T2DM in most patients typically involves a course of obesity to impaired glucose tolerance, to insulin resistance, to hyperinsulinemia, to hyperglycemia, and finally to insulin deficiency. Obesity is a risk factor of T2DM. Diabetes causes some serious microvascular and macrovascular complications, such as retinopathy, nephropathy, neuropathy, angiopathy and stroke. Urological complications of obesity and diabetes (UCOD) affect quality of life, but are not well investigated. The urological complications in T1DM and T2DM are different. In addition, obesity itself affects the lower urinary tract. The aim of this perspective is to review the available data, combined with the experience of our research teams, who have spent a good part of last decade on studies of association between DM and lower urinary tract symptoms (LUTS) with the aim of bringing more focus to the future scientific exploration of UCOD. We focus on the most commonly seen urological complications, urinary incontinence, bladder dysfunction, and LUTS, in obesity and diabetes. Knowledge of these associations will lead to a better understanding of the pathophysiology underlying UCOD and hopefully assist urologists in the clinical management of obese or diabetic patients with LUTS.

Comprehensive evaluation of the effect of bariatric surgery on pelvic floor disorders

BACKGROUND

The association of pelvic floor disorders (PFD) with obesity is well documented. The spectrum of PFD includes stress urinary incontinence (SUI), urge urinary incontinence (UUI), pelvic organ prolapse (POP), and fecal incontinence (FI). Resolution or improvement of SUI after bariatric surgery has been previously reported. However, the data regarding UUI and other forms of PFD with objective testing are sparse.

OBJECTIVES

Prospectively evaluate the effects of bariatric surgery on the prevalence and severity of pelvic floor disorders.

SETTING

U.S. Academic Hospital.

METHODS

From December 2008 to December 2012, patients who screened positive on a screening questionnaire were asked to participate in the study. Participants completed 3 validated condition-specific questionnaires before surgery and 6-12 months after. A subgroup consented to gynecologic examination (Pelvic Organ Prolapse Quantification [POP-Q] test) and urodynamic testing at similar time points.

RESULTS

Seventy-two study patients underwent laparoscopic gastric bypass (n = 65), sleeve gastrectomy (n = 5), and gastric banding (n = 2). Mean BMI decreased from 47.5 to 32.7 kg/m(2) 1 year after surgery (P<.001). Based on questionnaires, the most prevalent PFD was SUI, identified in 60 (83.3%) patients at baseline and 32 (44.4%, P<.001) at follow-up. There was significant improvement in PFD-related symptoms, quality of life, POP, and sexual function at follow-up. Decrease in prevalence of SUI after surgery was also confirmed with urodynamic testing (from 76.9% to 30.8%, P = .01). There was no significant change in prevalence and severity of POP based on POP-Q exam.

CONCLUSIONS

Bariatric surgery is associated with a decrease in prevalence and severity of diverse forms of urinary incontinence as well as improvement in quality of life and sexual function of morbidly obese women.

Urinary Incontinence Before and After Bariatric Surgery

IMPORTANCE

Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking.

OBJECTIVES

To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery.

DESIGN, SETTING, AND PARTICIPANTS

The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012).

INTERVENTION

Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter.

MAIN OUTCOMES AND MEASURES

The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up.

RESULTS

Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation.

CONCLUSIONS AND RELEVANCE

Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.

The effect of non-surgical weight loss interventions on urinary incontinence in overweight women: a systematic review and meta-analysis

Although the aetiology of urinary incontinence can be multifactorial, in some cases weight loss could be considered as a part of the therapeutic approach for urinary incontinence in people who are overweight. The objective of this study was to review and meta-analyse the effect of non-surgical weight loss interventions on urinary incontinence in overweight women. Web of Science, PubMed, Pedro, SPORTDiscus and Cochrane were systematically searched for clinical trials that met the a priori set criteria. Data of women who participated in non-surgical weight loss interventions (diet, exercise, medication or a combination) were included in the meta-analysis. After removing duplicates, 62 articles remained for screening on title, abstract and full text. Six articles (totalling 2,352 subjects in the intervention groups) were included for meta-analysis. The mean change in urinary incontinence (reported as frequency or quantity, depending on the study) after a non-surgical weight loss intervention, expressed as standardized effect size and corrected for small sample sizes (Hedges' g), was -0.30 (95%CI = -0.47 to -0.12). This systematic review and meta-analysis shows evidence that a non-surgical weight loss intervention has the potential to improve urinary incontinence and should be considered part of standard practice in the management of urinary incontinence in overweight women.

Bariatric surgery improves urinary incontinence but not anorectal function in obese women

BACKGROUND

While the association between obesity and urinary incontinence (UI) in women has been clearly documented, the relationship with anal incontinence (AI) is less well defined; moreover, while bariatric surgery has been shown to improve UI, its effect on AI is still unclear.

METHODS

A total of 32 obese women were studied by means of PFDI-20 and PFIQ-7 questionnaires and anorectal manometry before and after bariatric surgery and compared with 71 non-obese women.

RESULTS

Obese women showed worse overall questionnaire results (OR 5.18 for PFDI-20 and 2.66 for PFIQ-7). Whereas obese women showed worse results for urinary sub-items and a higher urge UI incidence (43.8 vs 18.3 %, p = 0.013), they did not show worsening in colorecto-anal symptoms. Post-operatively, median PFDI-20 total score did not change (24.2 vs 26.6, p = ns), while there was an improvement in urinary score (14.6 vs 8.3, p < 0.001); median PFIQ-7 improved (4.8 vs 0.0, p = 0.044), but while the urinary score improved (2.4 vs 0.0, p = 0.033), the colorecto-anal score did not change significantly. Although after surgery urge UI decreased from 43.8 to 15.6 % (p = 0.029), the incidence of any AI increased from 28.1 to 40.6 % (p = ns) and flatus incontinence increased from 18.8 to 37.5 % (p = ns). Anorectal manometry did not show significant changes after surgery.

CONCLUSIONS

Obese women had worse questionnaire results, but while showing a higher incidence of UI, they did not experience anorectal function worsening. After bariatric surgery, there was a slight improvement in PFD symptoms related to UI, but anorectal function did not change significantly and flatus incontinence increased.

Prevalence and risk factors of urinary incontinence and bladder retention in gastric bypass surgery: a cross-sectional study

Morbid obesity is a known risk factor for developing symptoms of urinary incontinence. However, it is not known if this leads to a high prevalence of perioperative incontinence and bladder retention after bariatric surgery because routine use of bladder catheterization is usual during this kind of surgery. The study was conducted at a general hospital in the Netherlands. Sixty morbidly obese female patients undergoing laparoscopic gastric bypass surgery were included in the present study. Preoperative urinary incontinence and risk factors were investigated by use of questionnaires. The following perioperative parameters were collected: operation time, total amount of intravenous fluids, preoperative urinary retention on the ward measured by bladder scan, postoperative urinary incontinence on the recovery room, postoperative urinary retention on the ward after passing urine measured by bladder scan, and observed urination on the ward. The prevalence of preoperative incontinence was 43 %. Nine patients (15 %) had postoperative urinary incontinence including four patients with known incontinence and five patients without. There were no differences between the patients with and without postoperative incontinence with relation to age, body mass index, diabetes mellitus, operation time, received amount of intravenous fluids and pre- and postoperative bladder scan residual volumes. Although the prevalence of urinary incontinence is high among morbidly obese female patients seeking bariatric surgery, postoperative incontinence was only present in 15 % of patients, and there was no need for catheterization for bladder retention. Preoperative risk factors for developing this kind of complications could not be identified.

Urogenital complications of obesity

We performed a critical review focused on the main non-oncologic disorders that have a strong, direct association with obesity: chronic kidney disease, kidney stones and female and male lower urinary tract symptoms/disorders. We discuss the epidemiology, pathogenesis and therapeutic aspects regarding the association between obesity and non-diabetic and non-hypertensive forms of chronic kidney disease directly caused or worsened by weight excess, with particular attention on obesity-related glomerulopathy (ORG), which is typical of severe obesity, and the consequences of intentional weight loss on proteinuria and glomerular filtration rate. The associations of obesity with kidney stones and lower urinary tract conditions are also discussed from the epidemiological, physiopathological and therapeutical points of view, with emphasis on the principal concerns raised by the heterogeneity of study designs and outcome definitions typical of research in these fields. We also call attention to important clinical and scientific questions that should be addressed by future research.

Efeitos da cirurgia bariátrica na função do assoalho pélvico

RACIONAL: A incontinência urinária é bem documentada como comorbidade da obesidade. Estudos demonstram resolução ou atenuação da incontinência após a perda de peso. Porém, os mecanismos pelos quais isso ocorre ainda não estão claros. OBJETIVO: Avaliar os efeitos da cirurgia bariátrica na função do assoalho pélvico em mulheres. MÉTODOS: Foram avaliadas 30 mulheres que estavam em lista de espera para realizar a operação. Foi verificada a prevalência de incontinência urinária no pré e no pós-operatório e seu impacto na qualidade de vida através do King's Health Questionnaire. A qualidade da contração muscular do assoalho pélvico foi avaliada através da Escala de Oxford Modificada e da perineometria. RESULTADOS: Vinte e quatro mulheres finalizaram o estudo. O índice de massa corporal passou de 46,96±5,77 kg/m2 no pré-operatório para 29,97±3,48 kg/m2 no pós-operatório, e a perda percentual do excesso de peso média foi de 70,77±13,26%. A prevalência de incontinência urinária passou de 70,8% no pré-operatório para 20,8% no pós-operatório. Após um ano da cirurgia bariátrica, houve redução do impacto da incontinência urinária na qualidade de vida em sete dos nove domínios avaliados no questionário. A mediana da Escala de Oxford Modificada aumentou de três no pré-operatório para quatro no pós-operatório. A perineometria apresentou aumento significativo na média das três contrações solicitadas, passou de 21,32±12,80 sauers para 28,83±16,17 sauers na comparação pré e pós-operatória. O pico de contração também aumentou significativamente no pós-operatório em relação ao pré-operatório, passou de 25,29±14,49 sauers para 30,92±16,20 sauers. CONCLUSÃO: A perda massiva de peso através da cirurgia bariátrica repercute positivamente na função do assoalho pélvico e na qualidade de vida das mulheres com obesidade mórbida.

[Urinary incontinence and obesity]

Obesity, defined as a body mass index (BMI) more than or equal to 30kg/m(2), promotes pelvic floor disorders such as urinary incontinence (UI) and genital prolapse. Datas from cohort studies found an association between high BMI and the onset of UI. This association seems to be predominant with for mixed UI and stress UI. For the urge UI and overactive bladder syndrome, the analysis of the literature found a weaker association. The weight is therefore the only modifiable risk factor. Thus, the weight loss by a hypocaloric diet associated with pelvic floor muscle training should be the front line treatment in the obese patient suffering from UI. Bariatric surgery can be discussed in the most obese patient, even if the risk/benefit balance should be weighed because of significant morbidity of this surgery. The results of sub urethral sling (by retropubic tension-free vaginal tape or transobturator sling) in obese patients appear to be equivalent to those obtained in patients of normal weight. Datas on per- and postoperative complications for suburethral slings are reassuring.

Psychosocial correlates of pelvic floor disorders in women seeking bariatric surgery

BACKGROUND

Women who struggle with obesity are at a significant risk for pelvic floor disorders (PFDs), defined as urinary incontinence, pelvic organ prolapse, and/or fecal incontinence. The association between PFDs and reduced quality of life has been demonstrated; however, the psychosocial correlates of PFDs in women undergoing bariatric surgery have yet to be examined. The present study explored the potential psychosocial correlates of PFD. The setting was an academic medical center.

METHODS

Data were analyzed from 421 female patients evaluated for bariatric surgery. Based upon a screening questionnaire, participants were dichotomized as women with PFDs (n = 121) and women without PFDs (n = 300). Patients completed the "Minnesota Multiphasic Personality Inventory, 2nd ed., Restructured Form (MMPI-2-RF)," and medical records were reviewed for demographic data, body mass index, substance abuse/dependence history, history of physical and/or sexual abuse, psychiatric medication usage, and psychiatric diagnoses. MMPI-2-RF scales measuring depression, anxiety, somatic symptoms, and social support were examined.

RESULTS

Women with PFDs were significantly older (F(1,420) = 3.87, P < .05) and more likely to evidence a history of substance abuse/dependence (chi-square = 4.53, P < .05) and depression (chi-square = 4.31, P < .05) than women without PFDs. There also was a trend for previous inpatient hospitalization (chi-square = 2.93, P < .09), outpatient behavioral health treatment (chi-square = 2.89, P < .09), and psychotropic medication usage (chi-square = 3.32, P < .07). No differences were found in the objective psychological testing.

CONCLUSION

Women with PFDs may be more psychiatrically vulnerable than other bariatric surgery candidates. Additional research on the association among PFDs, substance abuse, and depression is warranted. Future research should consider whether this potential relationship changes postoperative bariatric surgery.

Clinical and instrumental evaluation of pelvic floor disorders before and after bariatric surgery in obese women

BACKGROUND

Obesity, well known as a risk factor for several diseases, can also lead to pelvic floor dysfunction (PFD). However, scant data are available regarding PFD in obese individuals. Our study was designed to assess the prevalence, severity, and the quality of life (QOL) effect of PFD in obese women before and after bariatric surgery at a university hospital in Italy.

METHODS

A total of 100 obese (body mass index [BMI] ≥30 kg/m(2)) women completed 6 validated specific and QOL questionnaires about PFD. The patients were evaluated by physical examination, endoanal ultrasonography, rectal balloon distension test, and dynamic magnetic resonance imaging. Of the 100 patients, 87 were reassessed 12 months after bariatric surgery.

RESULTS

The prevalence of PFD was 81%, and 49% of patients reported that their symptoms adversely affected their QOL. Urinary incontinence (UI) was the most common disorder (61%) and was associated with the BMI (P = .04). Fecal incontinence and pelvic organ prolapse symptoms were reported by 24 and 56 patients, respectively. Urogenital prolapse and rectocele was documented in 15% and 74% of patients, respectively. After a mean BMI reduction of 10 kg/m(2), the prevalence of PFD decreased to 48% (P = .02), with a significant improvement in QOL. The prevalence of UI decreased to 9.2% (P = .0001) and was associated with the decrease in postoperative BMI (P = .04). The rate of resolution of the symptoms was 84%, 85%, and 74% for UI, fecal incontinence, and pelvic organ prolapse, respectively.

CONCLUSION

In the present sample of obese women, PFD was common and adversely affected their QOL. A clear association was found between the BMI and UI. Weight loss resulted in improved UI, fecal incontinence, and symptoms of pelvic organ prolapse.

Confronting the challenges of postmenopausal urogenital health

The global population is aging, especially in Western industrialized nations. In the USA, 38% of adults are over the age of 45 and 13% of adults are over the age of 65 years. Moreover, postmenopausal women now comprise 60% of adults aged over 65 years of age, a proportion that will rise as the population ages. This article reviews some of the more common urogenital health issues among older women. Changes to urogenital morphology and physiology are discussed, highlighting the impact on tissue atrophy, sexuality, prevalence of certain vulvar dermatoses, susceptibility to infection and urinary continence. We review treatment approaches, challenge some of the current paradigms and discuss the need for future research.

Urinary and fecal incontinence after bariatric surgery

BACKGROUND

Morbidly obese women have markedly high rates of urinary and fecal incontinence. Weight loss reduces prevalence and severity of urinary incontinence; however, the effect of weight loss on fecal incontinence is unknown.

AIMS

The aim of this study was to document the prevalence of urinary and fecal incontinence in subjects who underwent bariatric surgery and associated weight loss.

METHODS

We mailed a detailed survey to all 404 adults who underwent bariatric surgery at the University of Wisconsin prior to May 2006. Type and severity of urinary and fecal incontinence was obtained using previously validated questionnaires. Perceived effect of surgery on bowel and bladder function was also assessed.

RESULTS

Forty-eight percent (193) of the surveys were returned. Urinary incontinence was reported in 72% of the women, 39% of whom perceived improvement after surgery. Only 21% of the men reported urinary incontinence. In contrast, fecal incontinence was common in both men and women; 48% of the women and 42% of the men reported liquid stool incontinence and 21% of the women and 30% of the men reported solid stool incontinence. Fifty-five percent of the women and 31% of the men with fecal incontinence perceived worsening after surgery. Women with diarrhea were four times more likely to report fecal incontinence (P<0.0001). Furthermore, women who perceived worsening of diarrhea after surgery were significantly more likely to have fecal incontinence (P=0.003).

CONCLUSIONS

Both fecal and urinary incontinence were common after bariatric surgery. Risk factors for fecal incontinence in women after bariatric surgery include diarrhea and worsening of diarrhea; we suggest that such surgery may uncover prior weaknesses in the continence mechanism.

Effect of surgically induced weight loss on pelvic floor disorders in morbidly obese women

OBJECTIVE

To evaluate the effect of surgically induced weight loss on pelvic floor disorders (PFD) in morbidly obese women.

SUMMARY BACKGROUND DATA

Although bariatric surgery may lead to the improvement of some obesity-related comorbidities, the resolution of global PFD has not been well described.

METHODS

Women with a body mass index (BMI) of 35 kg/m(2) or more who were considering bariatric surgery were asked to complete 2 validated condition-specific questionnaires assessing the distress/quality of life impact of PFD, total and by domain (pelvic organ prolapse, colorectal-anal, and urogenital). Women who achieved a > or =50% excess body weight loss after surgery were asked to complete the same questionnaires for comparison.

RESULTS

Of the 178 women who underwent surgery, 46 completed the postoperative questionnaires. Mean age of this group was 45 years (range, 20-67), and mean preoperative BMI was 45 kg/m(2) (range, 35-75). The prevalence of PFD symptoms improved from 87% before surgery to 65% after surgery (P = 0.02, 95% CI: 0.05%-53%). There was a significant reduction in total mean distress scores after surgery (P = 0.015, 95% CI: 3.3-32.9), which was attributed mainly to the significant decrease in urinary symptoms (P = 0.0002, 95% CI: 8.2-22.7). Reductions in the scores were noted for the other PFD domains as well. Quality of life total scores improved (P = 0.002, 95% CI: 4.8-27.1), as did scores in the urinary domain (P = 0.0005, 95% CI: 3.8-13.5) and the pelvic organ prolapse domain (P = 0.015, 95% CI: 0.6-9.5). Age, parity, history of complicated delivery, percent excess body weight loss, BMI, type of weight loss procedure and presence of diabetes mellitus and hypertension had no predictive value for postoperative outcomes.

CONCLUSION

Surgically induced weight loss has a beneficial effect on symptoms of PFD in morbidly obese women.

Prevalence and degree of bother from pelvic floor disorders in obese women

We aimed to determine the prevalence and bother from pelvic floor disorders (PFD) by obesity severity, hypothesizing that both would increase with higher degrees of obesity. We performed a secondary analysis of 1,155 females enrolled in an epidemiologic study that used a validated questionnaire to identify PFD. Prevalence and degree of bother were compared across three obesity groups. Logistic regression assessed the contribution of degree of obesity to the odds of having PFD. Prevalence of any PFD was highest in morbidly (57%) and severely (53%) obese compared to obese women (44%). Regression models demonstrated higher prevalence of pelvic organ prolapse, overactive bladder, stress urinary incontinence, and any PFD in morbidly compared to obese women and higher prevalence of stress urinary incontinence in severely obese compared to obese women. Degree of bother did not vary by degree of obesity. Prevalence of PFD increases with higher degrees of obesity.