Cath Lab Digest

Trends in Urinary and Obesity
It seems that everyone is talking about weight and weight issues these days. There are reality shows, newspaper articles, TV documentaries, and sidewalk debates devoted to obesity, which affect many lives in many ways. Weight loss surgery (WLS) is also receiving lots of attention, and this is probably because we see some great data about the improvement or resolution of type 2 diabetes, hypertension, high cholesterol and sleep apnea after bariatric surgery. However, other aggravating conditions are showing improvement, too. Stress urinary incontinence (SUI), which is not usually talked about outside of healthcare circles, is one such problem where WLS seems to make a huge improvement in quality of life. SUI is the most common type of incontinence and we generally see it in women, especially after pregnancy and vaginal birth. According to the Agency for Healthcare Policy Research, 13 million Americans suffer from urinary incontinence and 85% (11 million) are women. Based on the results of a 2002 Gallup survey, 70% of women with incontinence have symptoms of SUI. Simply defined, SUI is the sudden, involuntary loss of urine that happens with laughing, sneezing, heavy lifting, coughing or exercise. It occurs because of damage to the pelvic muscles and supporting structures. It can be exacerbated by estrogen loss that accompanies menopause; yet SUI affects women of all ages. The average age of onset is 48 years old. Women tell us SUI can be an embarrassing, unpredictable condition. As a result, many women avoid an active lifestyle and social situations—especially problematic for your obese female clients—from a physical and emotional perspective. When they do participate socially, it is not uncommon for them to explain that they feel they must constantly search for the nearest bathroom or carry around a change of clothing and underwear. SUI may be underreported, as women are too embarrassed to talk to us or other healthcare providers about their incontinence, especially if they believe obesity is a contributing factor.

Morbid obesity is a well-documented risk factor for SUI. It is believed that stress urinary incontinence in obesity happens because of elevated intraabdominal pressure caused by excess fatty tissue in the abdomen and pelvis. Nerves and circulation can be affected by this pressure as well as direct pressure to the musculature and supporting structures. Obesity is not only a major contributor to stress incontinence, but there are other problems with obesity and SUI. Surgical repair is technically more difficult because of obesity and this could lead to early failure and recurrence of incontinence. Non-surgical treatment is just as challenging because diagnostic and therapeutic equipment is not always size-sensitive. So WLS looks even more promising in some cases. However, do we really have research to back up the common belief that SUI may improve or resolve after bariatric surgery? Several studies say, yes, at least to some extent. For example, a recent study from the Weight Management and Metabolic Health Center, in Tampa, Florida by Kurubam and others collected data from 201 candidates for bariatric surgery. They found that 32% of the patients reported urinary incontinence. Of those 65 patients, 45 underwent bariatric surgery. Of the 38 patients who had complete postoperative follow-up for at least 6 months, 50% reported resolution of urinary incontinence while 37% indicated residual slight-to-moderate incontinence. Residual severe urinary incontinence was reported by 13%. In general, patients reported improvement within 4 months or after losing 50 pounds. In a study by Dudley and others, 100% of participants (WLS candidates who were morbidly obese) reported SUI, and 89% found resolution of incontinence at one year following WLS (massive weight loss). And a final study to report, presented 12 subjects who reported incontinence prior to WLS surgery. Three subjects reported some degree of incontinence after surgery and only one subject requested treatment. The remaining eight subjects had resolution of their incontinence.

While the findings of these studies and others are certainly encouraging, each author concludes that their findings warrant additional investigation with urodynamic studies and patient follow-up. Regardless, the message to clinicians is clear: when we talk to obese clients about health and health promotion we must recognize the threat of SUI and obesity along with problems inherent in traditional diagnostic and treatment modalities. Additionally, WLS is long recognized for its value in issues such as metabolic syndrome and other cardiometabolic issues; however, other subtle quality of life concerns can be just as important to the day to day struggles of our clients. Imagine the findings of Kurubaum’s study: 32% of his morbidly obese candidates reported incontinence! We probably need to think about the ways that this impacts care of the morbidly obese patients across practice settings…but that’s a topic for another day.

Susan Gallagher Camden, RN, MSN, MA, WOCN, PhD is a certified bariatric nurse, licensed healthcare manager, and a wound ostomy continence nurse (WOCN). She can be contacted at susangallagher@hotmail.com.