Midurethral Sling Surgery and Weight Loss in Women

Does effective treatment of urinary incontinence improve soldier

readiness? Alan P. Gehrich MD COL, MC

Assistant Chief, Dept. OB/GYNChief, FPMRS

Tripler Army Medical Center

Disclaimer

The views expressed in this presentation are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

US Marines Female Engagement Team in Afghanistan

Female F-15 Pilots at Elmendorf AFB

First Female Army RangerAUG 2015

Defense Policy Change

• All combat positions should be opened to female soldiers.

• Defense Secretary Ashton Carter said “Women should have the chance to meet the standards of combat jobs currently closed to them.”

The Way Forward

• To determine the prerequisites for success in these positions

• To determine how best to select and prepare female soldiers for combat roles

Pelvic Floor Disorders

Incontinence

Prolapse

Pelvic pain

Recurrent UTI

FSD

Background• 15 % of AD personnel are women

– 16% Officers– 14% Enlisted

• Urinary Incontinence is the most common pelvic floor complaint among women

• Risk Factors– Age– Parity– Body Mass Index– Socioeconomic background – Race– Diet– Hysterectomy– Comorbid diseases

Prevalence of Urinary Incontinence by Age in Civilian Cohort

Age No. of Women Prevalence of UI Confidence Interval

Overall 7142 17.1% (15.8-18.4)

Age 20-29 1,128 3.5% (2.6-4.9)

Age 30-39 1,117 9.2% (7.5-11.2)

Age 40-49 1,318 15.0% (12.7-17.6)

Age 50-50 1,085 22.4% (19.1-26.1)

Wu, J et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women OB GYN 2014;123:141-8

Non-Modifiable Risk Factors

Variable OR ( 95% CI) P value

Age (decade) 1.2 (1.2-1.3) <.001

Race (Non- Hispanic white compared with all other racial groups)

1.3(1.1-1.5) .009

Comorbid Diseases

0 1.0 .001

1 1.3(1.3-1.5) <.001

2 1.6(1.4-2.0) <.001

3 or greater 2.1(1.6-2.6) <.001

Wu, J et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women OB GYN 2014;123:141-8

Modifiable Risk FactorsVariable OR ( 95% CI) P value

BMI (kg/m2)

Less than 25 1.0

25-29.9 1.3(1.1-1.6) .004

30.0 and greater 1.6(1.2-2.0) <.001

Parity

O 1.0

1 1.6(1.2-2.1) .004

2 1.5(1.1-2.0) .009

3 1.8(1.3-2.5) <.001

4 or greater 2.0(1.5-2.6) <.001

Hysterectomy 1.5(1.3-1.7) <.001

Mode of delivery (CS vs VD)

NO SIGNIFICANT DIFFERNCE

Pelvic Floor Complaints among AD Women

• AD are exposed to: – Increased physical stressors– Pregnancy Rates comparable to civilian counterparts

• Pelvic Floor complaints may have greater impact on AD than civilian women– 31% of women modify physical training and field training

to prevent urinary incontinence (Davis et al. 1999)• Is there also a potential of aggravating pelvic floor

disorders with increasing physical demands on women?

Percentage of Soldiers Reporting Urinary Incontinence by Age

AGE

%

Davis G et al. Urinary Incontinence Among Female Soldiers Mil Med 164 3:182 1999

<20 yoa 20-29yoa 30-39yoa 40-49yoa0

5

10

15

20

25

30

35

40

45

CivilianAD

Activities during which Urinary Incontinence becomes a Social or Hygienic Factor

Physica

l Trai

ning

Field Exe

rcise

Regular

Duty

Daily A

ctivit

y

Recreati

onal Exe

rcise

0

5

10

15

20

25

30

<25% of time 25-50% of time > 50% of time

Davis G et al. Urinary Incontinence Among Female Soldiers Mil Med 164 3:182 1999

Weight Issues for AD Women

• Over the past 15 years 3x increase in number of soldiers that do not make height/weight standards

• Increasing number of Medical Board procedures based on the overweight status

Weight Issues for AD female troops

• Increase in overweight and obese AD females– From 1999 to 2006

• Pre-pregnancy BMI increased 24.3-25.4• Demonstrated among all ethnicities

– Obesity in pregnancy was associated with adverse obstetric outcomes

Hill, CC et al. Military maternal weight trends and perinatal outcomes Mil Med 2013 AUG 178 :880-6

Effects of Pregnancy on the Army Physical Fitness Test

• 52 healthy AD women who participated in pregnancy and post partum physical fitness regimens

• Weight gain during pregnancy - 15-80lbs• Mean 40 point decrease in Army Physical

Fitness Test scores (11 months post partum)• For every 10lb weight gain during pregnancy,

decrease of 6.8 points

Weina S et al. Effects of Pregnancy on the Army Physical Fitness Test MilMed 171 :534-537 (2006)

Thesis

• Physical training (PT) clearly precipitates Urinary Incontinence (UI) in AD women

• UI inhibits full participation of women in PT• UI also leads to unhealthy behavior such as

dehydration prior to PT

• EFFECTIVE TREATMENT OF SUI SHOULD IMPROVE LEVEL OF FITNESS AND THEREBY EFFECT A DECREASE IN WEIGHT/ BMI

Treatment Options for SUI• Weight loss – very effective in obese women but questionably so in

overweight women (BMI 25-30)– Suback LL et al. Weight Loss to treat Urinary Incontinence in Overweight and Obese women NEJM 360:481-490 (2009)

• Pelvic Floor Physical Therapy- 40-60% @ 3 months but markedly deteriorates at 12 months

– Richter et al. Conservative Therapy for Stress Incontinence Obstet Gynecol (2010) 115: 609-617– Doumolin C et al. Pelvic floor muscle training versus no treatment or inactive control treatment for urinary incontinence in women. Cochrane

Database Syst Rev 2010

• Pessary – 40 % effective @ 1 year – Richter et al. Conservative Therapy for Stress Incontinence Obstet Gynecol (2010) 115: 609-617

• Mid urethral sling surgery- 80-90% effective– Appropriate First Line Therapy for SUI– Longevity 5-10 years (70%)– Surgery vs. Physiotherapy for SUI NEJM 2013: 369:1124-33

Midurethral Sling and Weight Loss (MUSAWL) study

• Primary objective - to determine if MUS surgery is associated with a change in postoperative weight and/or BMI

• Retrospective cohort study– AD females– Civilian beneficiaries

• WEIGHT/BMI from 3 distinct time periods:– 1year prior to operation– At time of surgery– 1 year after surgery

Methods

• Any patient who underwent MUS procedures performed between 2006-2013 @ Tripler Army Medical Center were eligible

• Utilized EMR System to obtain data • Paired t-tests - assess change in Weight/BMI

between time points• P<0.05 = Significant

Results

• 130 Patients with adequate data• 22 AD females• Age (mean)

– AD - 42.1 years– CIV - 47.0 years

• Parity – 2.4• 30 % menopausal (1 AD)• Race Caucasian (62%) African American (4%)

Asian (14%) Other (20%)

Perioperative BMI Change with MUS surgery

0

5

10

15

20

25

30

1 year PreopAt Surgery1 year postop

BMI (

Kg/

m2)

BMI CHANGE FOLLOWING Midurethral Sling Surgery

MUSAWL Conclusion

• MUS surgery for treatment of SUI does not appear to lead to weight loss

• AD women seeking surgical treatment for symptomatic SUI are more likely to be:– Overweight– Significantly older than the average soldier

Weaknesses

• Inadequate Numbers– initiating multicenter research

• Retrospective– Future research needs to be prospective

• Weight/BMI is only one marker of soldier readiness

Future Research

• Big Data– APFTs Scores now recorded on central database– Corroborate physical fitness with SUI treatment

• Intervention– Pregnancy/Postpartum Physical Fitness Regimens– Allowing more time for post partum recovery

• Measure success of interventions for UI by APFT scores, retention, and promotion

Conclusion

The assessment and maintenance of pelvic floor physical health in addition to musculoskeletal and psychological health will be keys to further integrate women in to active combat roles in the US Army.