Battle of the bulge: is your weight impacting your pelvic floor function?

By: Sigourney Cross, DPT, PHRC Walnut Creek

If you’re anything like me, you’ve probably spent the last couple of months eating everything in sight. With Thanksgiving, Christmas and New Year’s back to back, it’s hard to say no to all those delicious side dishes and homemade desserts. But now that the holidays have come to an end, it’s back to reality. Did you know year after year, losing weight makes it into one of the top three most common news years resolutions? This is why you see tons of new people at the gym the first few weeks in January. By February the crowds get smaller as people lose motivation to stick to their goals. Of course we all know the many health benefits of maintaining a healthy weight. A healthy weight is also an important factor in optimal pelvic floor function. As the incidence of obesity increases, so does the incidence of pelvic floor disorders. This post will outline the role obesity has in pelvic floor function and hopefully motivate you to stick to those new year’s resolutions.  

What is considered overweight or obese?

You may have heard of the obesity epidemic plaguing America. That’s because Obesity affects nearly 60 million Americans, and this number is steadily increasing. To determine whether or not a person is overweight or obese, clinicians measure a person’s BMI (body mass index). BMI is an estimate of body fat based on a person’s weight to height ratio. A high BMI indicates that a person’s weight is above the healthy range. A person is considered overweight with a BMI ranging from 25-29.9, while obesity is defined as a BMI over 30.2 I will note that if you are a professional athlete, say a football player with an extreme amount of muscle mass and low body fat percentage, the BMI score is often swayed and not a true indicator of the athletes overall health. For us non superstar athletes, a BMI measurement is a much more accurate tool. Obesity has been linked to a multitude of medical conditions including pelvic floor disorders such as incontinence, overactive bladder, pelvic organ prolapse, and chronic pelvic pain. With more than half of people with a BMI >30 reporting pelvic floor dysfunction compared to approximately 30 percent in those with a normal range BMI, obese person’s are disproportionately affected to their normal weight peers.⁴

How does being overweight directly impact the pelvic floor?

As you’ll see throughout this post, there is a good amount of evidence to demonstrate the damaging effect obesity has on the pelvic floor. There is however limited research on the actual neurophysiological and pathophysiological mechanisms through which this happens. A study by Jain et al, lists six plausible mechanisms by which obesity can be affecting the pelvic floor. These mechanisms include:

1. Chronic increase in intra-abdominal pressure
2. Damage to pelvic musculature
3. Nerve damage and associated conduction abnormalities
4. Obesity-related comorbidities
5. Diabetic neuropathy
6. Intervertebral disc herniation

More research is needed to objectively quantify the actual strain obesity puts on the pelvic floor.

Obesity and Incontinence

Overweight and obese women and men are at higher risk for developing lower urinary tract symptoms such as overactive bladder, and urinary incontinence. Stress urinary incontinence (SUI) or the involuntary loss of urine on effort or exertion, is the most common. To maintain continence, urethral pressure must exceed vesical pressure at all times except during urination. Vesical pressure is the sum of abdominal and detrusor pressure.³ It has been proven that obese persons have a significantly elevated intra-abdominal pressure, therefore surpassing urethral pressure which leads to incontinence.

One of the most common complaints I hear from my patients is SUI when going from a sitting position to a standing position. If abdominal bracing and kegels don’t work with transferring from a sit to stand position, I’ll have my overweight patients manually hold their tummies up with their hands before and while they stand. Most of my patients feel less leakage using this technique. This technique mechanically helps take the pressure off of their bladders. Research shows that overweight people who lose as little as 5-8 percent of their body weight can decrease their incontinence frequency by 50 percent.⁷

Obesity and Overactive Bladder

Overactive bladder syndrome is characterized by urgency, frequency and nocturia. These symptoms are frequently associated with detrusor overactivity. Detrusor overactivity is seen with urodynamic testing which shows involuntary detrusor contractions, during the filling phase while the person is trying to inhibit urination. In a study by Pomian et al, it was found that detrusor overactivity was significantly increased in obese women when compared to non-obese women. Obese women in this study also reported a significantly increased prevalence of urinary frequency, urgency and nocturia compared with non-obese women.     

Obesity and Pelvic Organ Prolapse

Prolapse occurs when the tissue that supports our pelvic organs, such as the bladder or uterus, are stretched leading to the organs dropping down and pressing against the wall of the vagina. Learn more about pelvic organ prolapse here. A study by Giri et al, showed that women with excessive weight are at higher risk of prolapse. It was also found that the risk of prolapse progression in overweight women when compared to women with a normal BMI increased by 48 percent for a bladder prolapse, 58 percent for rectal prolapse and by 69 percent for a uterine prolapse. When it comes to pregnant women, women who start their pregnancies with higher BMI’s are also more likely to have prolapse than women who start their pregnancies at lower weights.¹ Unfortunately weight loss does not appear to be significantly associated with regression of pelvic organ prolapse. One study demonstrated that with 10 percent weight loss the regression of bladder and rectal prolapse was insignificant. With that being said, these women did however subjectively report decreased discomfort related to their prolapse after weight loss.⁸

Obesity and Chronic Pelvic Pain/Sexual Dysfunction

Obesity has long been correlated with chronic pain syndromes due to increases in inflammation and added stress to joints. This does not exclude the pelvic floor. If you look back to our mechanisms of injury list, all of these mechanisms can lead to pelvic pain and sexual dysfunction. One study looked at the relationship between woman’s BMI and sexual function using the sexual function index score, which is a questionnaire that measures how well women are functioning sexually. This study found an inverse correlation between BMI and the female sexual function index score.The higher the woman’s BMI the lower her sexual function index score.⁹  Even a little excess weight can impact women’s hormone levels. The altered hormone profile of obese women, can have an impact on their reproductive health. Treatment of obesity can have a positive effect on women’s sexual health and decrease risk factors related to menopause, pregnancy and infertility.

What you can do?

As you can see obesity can have a profound negative impact on a person’s pelvic health and quality of life. Fortunately, even losing just a few pounds can have a significant impact on your chronic pain and pelvic floor dysfunction. While pelvic floor physical therapy is the first line of treatment for pelvic floor dysfunction, I always encourage my overweight patients to lose weight as a part of their treatment plan.

There are many resources out there to help people achieve their weight loss goals. It is ideal to find a weight loss group or partner to help provide structure and accountability. You can also start by making small changes to your daily routine. Take the stairs instead of the elevator, park further away from the entrance, etc. It’s also important to find activities you enjoy, whether it be a daily walk, or swimming for example, so you’ll be more motivated to stick with it.

Surgical weight loss is also an option if diet, exercise, and lifestyle modifications prove to be too difficult. Not only will weight loss improve pelvic floor symptoms and prevent further progression of symptoms, it will have major positive effect on your overall health and well being. I hope this post has inspired you to get started and make 2019 a year of either obtaining or maintaining a healthy weight. Your pelvic floor will thank you for it.

 

References:

1. Giri A, et al. Obesity and pelvic organ prolapse: a systematic review and meta-analysis of observational studies. American Journal of Obstetrics & Gynecology. 2017;(1):11-26
2. Jain P, Parsons M. A review. The effects of obesity on the pelvic floor. Royal College of Obstetricians and Gynecologists. 2011;13:133-142.
3. Lambert DM, et al. Intra-abdominal pressure in the morbidly obese. Obesity surgery. 2005;15:1225-1226
4. Lazaro S, et al. Obesity and pelvic floor dysfunction: battling the bulge. Obstetrical & Gynecological Survey. 2016;71(2):114-125.
5. Marsha Guess, MD. How a Healthy BMI helps keep the urogynecologist away. https://urogyn.coloradowomenshealth.com/blog/healthy-bmi. January 30, 2018.
6. Pomian A, et al. Obesity and pelvic floor disorders. A review of the literature. Medical Science Monitor. 2016;22:1880-1886.
7. Subak LL, Johnson C, Whitcomb E, Boban D, Saxton J, Brown JS. Does weight loss improve incontinence in morbidly obese women? Int. Urogynecol Journal of Pelvic Floor Dysfunction. 2002;13:40–3.
8. Wasserberg N, Petrone P, Haney M, Crookes PF, Kaufman HS. Effect of surgically induced weight loss on pelvic floor disorders in morbidly obese women. Ann Surg 2009;249:72–6.
9. Esposito K, Ciotola M, Giugliano F, Bisogni C, Schisano B, Autorino R, et al. Association of body weight with sexual function in women. Int J Impot Res 2007;19:353–7