13.1

Introduction

• 1.
  

  Pelvic Organ Prolapse (POP) prevalence rates range from 10% in younger women and up to 50% in postmenopausal women.

  
  
• 2.
  

  Nearly 1 in 10 women will undergo surgical correction for POP in their lifetime.

  
  
• 3.
  

  This can be defined as descend into the vaginal space prolapse of >1 intrapelvic organ (uterus, bladder, rectum, and the urethra), presumably due to deficiencies in the pelvic support system that normally provides sustained support.

  
  
• 4.
  

  There are many known and unknown variables that affect the severity of POP and its symptoms.

  
  
• 5.
  

  Epidemiological studies have identified age, race, parity, size of infant, and body mass index (BMI) as independent risk factors for POP.

  
  
• 6.
  

  Aging and parity have been most consistently associated with POP; however, these factors are not modifiable. Obesity is a modifiable risk factor that may be influenced on a population level to reduce the public health and economic burden of POP.

  
  
• 7.
  

  As the population ages, the prevalence of POP is likely to increase, and more women will undergo surgical procedures to treat prolapse.

  
  
• 8.
  

  These two factors—increasing obesity rates and the aging population—will most likely increase the rates of POP beyond what is predicted.

  
  
• 9.
  

  Data from published cross-sectional and prospective studies suggest that being overweight or obese is associated with prevalent and incident POP as well as progression of POP; however, few studies have evaluated the impact of weight loss on subjective or objective POP or symptom severity

13.2

Obesity as risk factor for pelvic organ prolapse

• 1.
  

  POP is defined as the descent of the anterior vaginal wall, the posterior vaginal wall and/or the apex of the vagina (cervix or vault after hysterectomy).

  
  
• 2.
  

  For clinical and research purposes, the Pelvic Organ Prolapse Quantification (POP-Q) scale is used for an objective quantification of degree of the prolapse.

  
  
• 3.
  

  The prevalence of POP varies depending on the used definition. The subjective diagnosis of POP is mostly defined by the sensation of vaginal bulging. The reported prevalence range is 6%–11%. The subjective presence of a POP is strongly associated with a prolapse beyond the level of the hymen.

  
  
• 4.
  

  Risk factors for developing a POP can be divided into obstetric, lifestyle, comorbidity, nonmodifiable (e.g., age), social, pelvic floor, and surgical factors. Parity and aging are the strongest risk factors of POP. The most important lifestyle factor is a higher BMI.

  
  
• 5.
  

  The most probable mechanism of POP development among obese women is the increase in intraabdominal pressure that causes weakening of pelvic floor muscles and fascia. However, studies evaluating the association between obesity and POP have reported inconsistent conclusions.

  
  
• 6.
  

  Study showed symptomatic POP increased by 3% with each unit increase in current BMI. Recent published systematic review and meta-analysis showed that, compared with normal-weight women, women in the overweight and obese categories had risk ratios of at least 1.36 (95% CI, 1.20–1.53) and 1.47 (95% CI, 1.35–1.59), respectively, of developing POP.

  
  
• 7.
  

  A large US study that analysed data from 16,608 women showed progression of POP with increasing body weight. The excess risks for anterior vaginal prolapse were 32% and 48% in overweight and obese women, respectively, for posterior prolapse 37% and 58%, and for uterine prolapse it was 43% and 69%. However, weight loss did not significantly reduce degree of POP and suggested that damage to the pelvic floor associated with obesity may be irreversible.

13.3

Weight loss and the effects upon pelvic organ prolapse

• 1.
  

  Data on whether weight loss alters prolapse severity are also scarce. A large prospective study found that weight loss had only minimal effects upon anatomical prolapse.

  
  
• 2.
  

  The role of weight reduction on POP symptoms is an important clinical question as weight loss is an action that the patient can initiate through diet, exercise, and/or in some cases weight-loss surgery.

  
  
  
  
  • a.
    

    Weight loss in an overweight or obese person is a positive action toward improving one’s general health.

    
    
  • b.
    

    Obesity is thought to cause increased intraabdominal pressure, which then transfers strain to supporting pelvic floor structures.

    
    
  • c.
    

    Obesity may coexist with other comorbidities, such as diabetes, which are thought to contribute to poor tissue quality.

    
    
  • d.
    

    Studies on this topic shed light on the complexity of POP as a disease process and how to appropriately counsel patients who are interested in weight loss as a treatment option.

  
  
  
  
• 3.
  

  There are limited studies on women who present specifically with symptomatic POP and underwent a weight loss program to treat their weight and prolapse symptoms.

  
  
• 4.
  

  Studies of the impact of obesity have focused on other pelvic floor disorders (PFDs) such as incontinence and overactive bladder, so weight loss has not directly been shown to decrease prolapse symptoms in these subset populations.

  
  
  
  
  • a.
    

    One study looked at weight reduction on UI and pelvic floor anatomy, and found that in 378 women, the weight loss group with a mean weight reduction of 9.4%, only genital hiatus, perineal body, and Ap measurement were lower in the weight-loss group compared to the control group at 6 months. The authors concluded that there was little to no change in significant POP-Q variables after weight reduction.

    
    
  • b.
    

    A study from Egypt assessed 400 women and found vaginal prolapse in 65% of the sample, although symptoms were much less common.

    
    
  • c.
    

    In a group of women who underwent bariatric surgery, POP symptoms were reported by 56 women, and 15 women had documented anatomical prolapse. After surgery, 74% of the affected women had resolution of their prolapse symptoms.

  
  

13.4

Prolapse surgery in the obese woman

The obese woman with pelvic prolapse is a challenge for the pelvic surgeon.

For prolapse surgery, data on the relationship between obesity and the outcomes and complications are extremely limited.

Weight loss should be considered the primary option in obese women for its salutary effects on multiple organ systems and reducing PFD symptoms.

• 1.
  

  A very important question is how obesity influences the risk of intraoperative and postoperative complications as well as the outcome of surgical management of POP.

  
  
• 2.
  

  Laparoscopic or vaginal route may reduce the incidence of thromboembolic events associated with obesity.

  
  
• 3.
  

  The vaginal approach is also beneficial because it has been shown that obese women undergoing vaginal hysterectomy sustained fewer perioperative complications.

  
  
• 4.
  

  Irrespective of the type of surgery, the operation time in obese women is significantly longer than in healthy weight women.

  
  
• 5.
  

  Intraoperative surgery complications of the different vaginal surgeries (vaginal hysterectomy, anterior and posterior colporrhaphy, iliococcygeal hitch or posterior intravaginal sling), no differences are observed between obese and nonobese patients.

  
  
• 6.
  

  Complication rate of laparoscopic sacrocolpopexy is not different in obese and nonobese patient.

  
  
• 7.
  

  It seems that obese women are not at higher risk for perioperative and postoperative complications. Data from larger studies with longer follow-up are needed to be confident of this conclusion.

13.5

Recurrence of pelvic organ prolapse

Impact of obesity on surgical outcomes and the data regarding whether obesity is a risk factor for recurrence after POP surgery are controversial

• 1.
  

  The retrospective cohort study shows that after total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension, overweight or obese women have a similar overall risk of 20% prolapse recurrence (composite outcome definition of any anatomic prolapse beyond the hymen or pessary or repeat surgery).

  
  
• 2.
  

  Overweight and obese women are, however, more prone to recurrence in the anterior wall compared with normal-weight women.

  
  
  
  
  • a.
    

    After anterior colporrhaphy, the risk of recurrence is relatively high in the short term and obesity is associated with increased odds of anatomic recurrence of anterior vaginal wall prolapse

    
    
  • b.
    

    Five-year analysis of a prospective observational study where 376 women were followed after surgery for POP and/or UI showed no association was found with BMI in these surgical failures.

    
    
  • c.
    

    A prospective study evaluated the development of POP in patients who underwent Burch colposuspensions. At 8-year follow-up, 38% had developed symptomatic prolapse and another 38% had asymptomatic prolapse but BMI was not found to have a significant association with surgical failure.

    
    
  • d.
    

    In a secondary analysis at 2 years postoperatively of the Colpopexy and Urinary Reduction Efforts (CARE) trial, obese women were found to have significantly more prolapsed posterior vaginal wall, compared to healthy-weight women. The obese group reported more colorectal symptoms and related functional impact, but no differences were found in subjective prolapse symptoms and patient satisfaction outcomes.

  
  

Native tissue repair is the standard method for POP surgery, whereas the use of mesh in POP surgery has become controversial .

• 1.
  

  It is stated that the use of mesh should be reserved for high-risk individuals in whom the benefit of the use of mesh may justify the risks, such as individuals with recurrent POP.

  
  
• 2.
  

  In general, the population in studies on POP recurrence after mesh surgery often consist of a selected, high-risk group of women, which cannot be compared with the population in studies on POP recurrence after native tissue repair.

  
  
• 3.
  

  Looking at the outcomes of obese patients with the use of anterior trans-obturator mesh and vaginal sacrospinous ligament fixation, the surgical outcomes are not inferior compared to outcomes in nonobese women.

In an obese population with POP, no significant differences in the recurrence of POP after sacral colpopexy versus vaginal mesh colpopexy are noted, with better anatomical outcome of sacral colpopexy.

13.6

Conclusion

• 1.
  

  Worldwide, the number of women with overweight, obesity, or morbid obesity is impressive with prevalence of obesity ranging from 4% to 36%.

  
  
• 2.
  

  Overweight and obese women are more likely to have POP than normal weight women. This association is larger for clinically significant POP.

  
  
• 3.
  

  Weight loss (either by diet and exercise or by BS) is associated with large improvements in prolapse symptoms. Achieving a target weight loss between 5% and 10% of baseline weight will bring about complete resolution of prolapse symptoms in up to 70% of women.

  
  
• 4.
  

  Where surgery is deemed necessary, women should be advised that prolapse surgery appears equally safe in the obese patient but that the long-term failure rate after prolapse surgery is greater in the obese.

  
  
• 5.
  

  Obesity does not seem to be a strong risk factor for recurrence of POP in the short term. However, an increase in intra-abdominal pressure may have a negative impact on postoperative results in the long term.

  
  
• 6.
  

  Patients should be counselled on maintaining a healthy weight for their overall health and its impact on pelvic floor symptoms.

  
  
• 7.
  

  There are many gaps in the literature related to obesity and POP.

Key points

• 1.
  

  The most probable mechanism of POP development among obese women is the increase in intraabdominal pressure that causes weakening of pelvic floor muscles and fascia.

  
  
• 2.
  

  Obesity is associated with significant pelvic floor symptoms and impairment of QOL. Weight loss is likely not associated with anatomic improvement but may be associated with prolapse symptom improvement.

  
  
• 3.
  

  Weight loss should be considered a primary option in obese women for its beneficial effects on multiple organ systems and reducing PFD symptoms.

  
  
• 4.
  

  Although the operation time in obese women is longer than in healthy weight women, the complication rate of surgery has not been shown to be increased compared to nonobese patients, regardless of route of surgery.