Objective
To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women.
Study Design
Prospective cohort study of 44 women undergoing bariatric surgery.
Results
Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (−34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193).
Conclusion
Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.
Obesity has reached epidemic proportions in the United States, and is known to be a risk factor for pelvic floor dysfunction. There is a paucity of data regarding how obesity affects a woman’s pelvic and sexual health. Previous studies evaluating the effect of weight loss in this cohort of women were of short-term follow-up, or used nonvalidated questionnaires as assessment tools. Bump et al evaluated 13 patients that underwent bariatric surgery for morbid obesity and followed them an average 14.5 months postoperatively. Subjective improvement in both stress and urge incontinence was documented using nonvalidated questionnaires.
A pilot study published by Kapoor et al evaluated 20 morbidly obese women planning to undergo gastric bypass surgery and compared them with 20 age-matched female controls. Analysis of their data using nonvalidated sexual function questionnaires showed that obese women were 20% less sexually active compared with controls, but there was no statistically significant difference in sexual function between these 2 groups.
Assimakopoulos et al assessed the sexual function of 60 obese women scheduled to undergo bariatric surgery and 60 healthy matched controls by age, education, and marital status. Analysis of their data revealed that obese women who were expected to undergo bariatric surgery reported significant impairment on most domains of sexual function including desire, arousal, lubrication, orgasm, and satisfaction, compared with healthy controls.
The aim of our study was to investigate the impact of significant weight loss in women undergoing bariatric surgery on pelvic floor mediated quality of life (QOL).
Materials and Methods
Institutional review board approval was obtained at Mount Sinai School of Medicine and all women gave written informed consent. We hypothesized that surgically induced weight loss would be associated with a significant improvement in quality of life and sexual function in this cohort using validated assessment tools. Subjects were recruited from Aug. 20, 2007, through May 28, 2008, from the colorectal surgery department at Mount Sinai hospital. All women completed baseline questionnaires when they presented for preoperative counseling. Postoperatively, women completed questionnaires by either returning to the office, returning a questionnaire, which had been mailed to them, or by telephone interview. Postoperative data were collected over a range of 2.76–3.83 years with a mean of 3.152 years. The inclusion criteria were morbidly obese females scheduled to undergo bariatric surgery for weight loss who were at least 45 kg above ideal body weight (using Metropolitan Life—Insurance Tables), and/or body mass index (BMI) >35 with comorbidities, or BMI >40 without comorbidities. We excluded women less than 18 years of age, those who were not eligible for bariatric surgery, those unwilling to participate in the study or give written consent, those who did not speak and read English, and those unable or unwilling to follow-up. All women underwent surgery with either a Roux-en-Y gastric bypass, a laparoscopic adjustable gastric band (Lap Band; Allergan, Irvine, CA), or a laparoscopic sleeve gastrectomy, for weight loss.
The primary outcome was the summary score of the Pelvic Floor Impact Questionnaire (PFIQ). This instrument incorporates the urinary incontinence questions of the validated Incontinence Impact Questionnaire (IIQ), and adds colorectal-anal and pelvic organ prolapse subscales. In the long form, each subscale has 31 questions for a total of 93 questions; lower scores indicate less impact of pelvic floor dysfunction on QOL. Secondary outcome measures were the summary score of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the Female Sexual Function Index (FSFI). The PISQ-12 is a condition-specific validated 12 question instrument that evaluates sexual function in women with pelvic floor dysfunction, and includes questions about sexual desire, pain, orgasm, and urinary incontinence. Higher scores indicate better sexual function. The FSFI is a 19-item multiple choice instrument that measures sexual desire, arousal (both subjective and physiologic), lubrication, orgasm, satisfaction, and pain. The 6 domain scores of the FSFI are summed to produce a full-scale score. For all FSFI domains, higher values indicate a better level of sexual function, and scores less than or equal to 26 represent sexual dysfunction. Data collected included demographic data as well as PFIQ, PISQ-12, and FSFI summary scores. Thirty-six subjects were needed to provide 80% power to find a 30-point difference on the PFIQ, the primary outcome. Estimating a 20% dropout rate, we enrolled 44 subjects. Descriptive statistics was provided for all variables. Alpha level was set at .05. Data were analyzed with a paired t test, and linear regression models using SAS software version 9.2.
Results
We recruited 44 women; 36 women gave follow-up data. Women who gave follow-up data were not different than those who did not follow-up (all P > .05, data not shown). Mean age at baseline was 41.28 ± 12.28 years, mean follow-up was 3.152 ± 0.55 years with a range of 2.76-3.83 years. Women who underwent bariatric surgery had a mean BMI at baseline of 45.76 ± 6.48, which decreased at follow-up to 31.55, P < .0001 ( Table 1 ). Ethnicity, race, marital status, hormonal status, and surgical history demographic data is represented in Table 2 . PFIQ scores are summarized in Table 3 . Mean difference in Urinary Impact Questionnaire (UIQ) preoperative (143.41 ± 66.56) and postoperative (108.49 ± 18.12) scores showed significant improvement in total score, (−34.92) P = .0020, and all 4 subscale scores: travel (−9.03) P = .0020, social (−7.01) P = .0027, emotional (−8.93) P = .0116, and physical (−9.95) P = .0015, when evaluated postoperatively. Overall Colorectal-Anal Impact Questionnaire (CRAIQ) scores did not change, although the CRAIQ social subscale was significantly improved (−5.11) P = .0250. Likewise overall Pelvic Organ Prolapse Impact Questionnaire (POPIQ) scores did not show improvement although there was improvement in the physical subscale (−4.40) P = .0491, and social subscale (−3.79) P = .0365. PISQ-12 scores improved from 35.78 ± 6.06 at baseline to 38.22 ± 6.03 at follow-up ( P = .0193). For every 1 unit decrease in BMI there was a mean significant increase in PISQ-12 score of 0.32 points in our linear regression model P = .0198. FSFI total scores were low at baseline and did not improve with weight loss at follow-up. This was true in all domains including desire (0.20) P = .4385, arousal (−0.15) P = .6795, lubrication (−0.21) P = .4007, orgasm (−0.04) P = .8811, satisfaction (−0.27) P = .5104, and pain (−0.32) P = .0973 ( Table 4 ). This relationship was also true in our linear regression model P = .5167.
| Variable | (n = 36) | Standard deviation (n = 36) |
|---|---|---|
| Age (mean y) | 41.28 | 12.28 |
| Years of follow-up | 3.152 | 0.55 |
| Parity | 1.36 | 1.31 |
| BMI at baseline | 45.76 | 6.48 |
| Delta BMI | −14.21 | 7.31 |
| Characteristic | Frequency (n = 36) | Percentage (%) |
|---|---|---|
| Ethnicity | ||
| Hispanic/Latino | 15/36 | 41.67 |
| Race | ||
| Black or African American | 9/36 | 25 |
| White | 12/36 | 33.33 |
| Marital status/relationship | ||
| Single | 13/36 | 36.11 |
| Married | 15/36 | 41.67 |
| Committed relationship | 8/36 | 22.22 |
| Hormonal status | ||
| Premenopausal | 27/36 | 75 |
| Postmenopausal no HRT | 7/36 | 19.44 |
| Postmenopausal with HRT | 1/36 | 2.78 |
| Surgical history | ||
| Prior incontinence surgery | 2/36 | 5.56 |
| Prior prolapse surgery | 0/36 | 0 |
| Prior hysterectomy | 0/36 | 0 |
| Prior salpingo-oophorectomy | 1/36 | 2.78 |
