Bariatric Surgery and Urinary Incontinence

About one-quarter of adults in the United States are obese.1 Among itsmyriadadverseeffectsonhealth, obesity affects the support and function of the pelvic floor. As obesity increases, the pelvic floor disorders of urinary incontinence, anal incontinence, and (forwomen) pelvic organ prolapse become more prevalent. More than half of the women who are morbidly obese have pelvic floor disorders.2 Obesity may cause or aggravate pelvic floor disorders throughmechanisms such as chronic strain on ligaments and nerves, leading to excessive stretch and increased abdominal pressure. Using an indwelling urinary catheter in 63morbidly obese patients about to undergo bariatric surgery, Varela and colleagues3 demonstrated elevated intra-abdominal pressure in 48 patients (77.0%). Increased intra-abdominal pressure has also been found in obese women with stress urinary incontinence, which is involuntary leakage on effort or exertion, sneezing, or coughing, and in urge urinary incontinence, which is involuntary leakage accompanied by or immediately preceded by urgency.4 Epidemiological investigationshave shown that obesity is a strong independent risk factor for urinary incontinence.5 Obesewomen undergoing surgery for stress incontinence report more incontinence episodes, greater symptom distress, andworsequalityof lifecomparedwithnormal-weightwomen. Formen andwomen, the probability of having urinary incontinence increases with increasing weight.5 Although urinary incontinence ismore common in severely obesewomen than men, it occurs frequently in both sexes. Thewide rangeof treatments forurinary incontinenceand other pelvic floor disorders include pelvic muscle exercises, vaginal devices knownas continence rings or dishes, anticholinergicandbeta-agonistmedications, andbehavioral changes. Weight loss is one of the best-studied behavioral treatments. In the 2009 PRIDE (Program to Reduce Incontinence by Diet and Exercise) study,6 a total of 338 overweight and obese womenwith urinary incontinencewere randomized to an intensive intervention to lose weight or to a control intervention. The intensive weight loss program met in groups of 10 to 15personsweekly for 6months for 1-hour sessions. The sessions were led by experts in nutrition and exercise. The control interventionwasa structurededucationprogram inwhich groups met monthly for 4 months. All participants received self-help information on pelvic muscle exercises and methods for improving bladder control. The intensive group had a greater reduction in the mean weekly number of urinary incontinence episodes than the control group. The effects of bariatric surgery on pelvic floor disorders have also been studied, but typically with small cohorts or in single-site studies.Outcomeshavebeenassessedwithin 1year after surgery and are assessed with a proxy measure of urinary incontinence such as International Classification of Diseases, Ninth Revision, codes.7 In this issue of JAMA Internal Medicine, Subak et al8 report a large multicenter observational cohort study of urinary incontinencebefore andafter bariatric surgerywithmultiple direct assessments of incontinence symptoms and longtermfollow-up.Amongwomenandmen,bariatric surgerywas associated with substantial reductions in urinary incontinence over 3 years. For both sexes, the largest improvements occurred in the first year after surgery. Men and women had reductions in any typeof urinary incontinence, aswell as urge urinary incontinence. Forwomen, the study founda trend toRelated article page 1378 Urinary Incontinence Before and After Bariatric Surgery Original Investigation Research