Introduction Obesity is one of the well-documented risk factors of pelvic floor disorders (PFDs). The PFDs include urinary and fecal incontinence (UI, FI) and pelvic organ prolapse (POP). Surgery-induced weight loss improves different kinds of inconti- nence as well as POP symptoms. However, there is a lack of evidence how bariatric surgery influences pelvic floor anatomy and function in women without previous PFDs and whether it may be concerned as PFD prophylaxis tool. Materials and Methods The present analysis is a prospective, non-randomized case-control study from January 2014 to September 2017. Participants underwent pelvic floor ultrasound examination with bladder neck position estimation at rest, during levator ani tension, and at Valsalva maneuver before surgery and 12–18 months after. Pelvic organ prolapse quantification (POPQ) > 2 stage and PFD complaints were the exclusion criteria. Results Fifty-nine patients underwent bariatric surgery (57 sleeve gastrectomy and 2 gastric bypass). Mean BMI decreased from 43.8 ± 5.9 to 29 ± 4.6 kg/m after surgery (p < 0.001). Statistically significant higher position of the bladder neck at rest, during tension, and at Valsalva maneuver (p < 0.05) was shown after surgery. We did not demonstrate differences in bladder neck mobility and bladder neck elevation at tension after weight loss. Conclusions Bariatric surgery is associated with a betterment of bladder neck position at rest, tension, and Valsalva maneuver in women without PFDs. We postulate that bariatric surgery may be a tool for PFD prevention. It does not improve levator ani function and does not limit bladder neck mobility, which implicates that it has no influence on preexisting pelvic dysfunction. . . . . . Keywords Bariatric surgery Pelvic organ prolapse Pelvic floor disorders Urethral mobility Female incontinence Obesity Introduction is a risk for many chronic diseases (metabolic syn- drome, musculoskeletal disorders, and certain types of Obesity is defined as a body mass index (BMI) greater than cancer). The prevalence of obesity has doubled within 30 kg/m . It is a worldwide public health problem as it the last three decades and currently almost 15% of the has a negative impact on the individual’s well-being and world population is obese . * Ewa Barcz Aneta Zwierzchowska email@example.com firstname.lastname@example.org Andrzej Pomian email@example.com Jacek Kociszewski firstname.lastname@example.org Wojciech Majkusiak email@example.com 1st Department of Obstetrics and Gynecology, Medical University of Wojciech Lisik Warsaw, Pl. Starynkiewicza 1/3, 02-015 Warsaw, Poland firstname.lastname@example.org Paweł Tomasik Department of General and Transplantation Surgery, Medical email@example.com University of Warsaw, Warsaw, Poland Edyta Horosz firstname.lastname@example.org Evangelisches Krankenhaus Hagen-Haspe, Hagen, Germany 1654 OBES SURG (2018) 28:1653–1658 Pelvic floor disorders (PFDs) encompass a broad spectrum parameter may serve as an indirect indicator of its function. of health problems, including different types of urinary incon- The aim of the present study was to evaluate whether BMI tinence (UI), pelvic organ prolapse (POP), fecal incontinence reduction after bariatric surgery influences bladder neck posi- (FI), and defecatory and sexual dysfunctions. PFDs influence tion as well as its mobility and levator ani function in obese medical, emotional, social, and economic issues of women all women without previous history of pelvic floor dysfunction. over the world. It is estimated that different conditions con- nected with pelvic floor disorders concern approximately 30% of adult women population worldwide with increased inci- Material and Methods dence in elderly and obese population . There are many risk factors for developing pelvic floor The present analysis is a prospective non-randomized single- disorders including vaginal and instrumental deliveries, age, center case-control study, approved by local ethic committee race, family history, and last but not least, overweight and before initiation. obesity . Women with obesity are at much higher risk as Fifty-nine adult obese women (BMI > 35) who were sched- compared to normal-weight individuals for developing differ- uled for bariatric surgery were included in the trial. The inclu- ent types of incontinence and POP. It is estimated that over sion criteria were obesity, no PFD symptoms, and POPQ ex- 50% of women with a BMI greater than 35 kg/m report a amination < 2 within all compartments. All patients PFD, compared with approximately 30% of women with a underwent pelvic floor ultrasound examination with evalua- normal body mass index . tion of three parameters: bladder neck position at rest, during There are strong evidences that reducing weight improves levator ani tension, and during maximum Valsalva maneuver. urinary incontinence. It was shown that after bariatric surgery, The control examination took place minimum 1 year after there were significant improvements in voiding status bariatric surgery. assessed by voiding questionnaires , as well as in objective Bladder neck position was measured in a standardized tests such as pad test . Additionally, it was confirmed that manner, with the patient on the gynecological chair in a semi weight loss after surgery improves various lower urinary tract sitting position with the bladder filled to 200–400 ml (the symptoms such as stress urinary incontinence, urge inconti- association between the bladder filling and bladder neck po- nence, and dysuria, as well as quality of life in the above sition in the volume range of 200–400 ml was not statistically aspect . It was also shown on the basis of patients’ ques- significant). Three diameters of the bladder was measured in tionnaires that bariatric surgery improves different symptoms order to estimate the bladder volume at the beginning of the related to pelvic floor disorders connected with POP (pro- examination. The probe (a 3.6–8.3-MHz vaginal transducer lapse, lower urinary tract, colorectal symptoms, and sexual with a beam angle of 160°) was placed in the vaginal introitus dysfunctions) [8, 9]. at the level of the external urethral orifice. With the probe in Most current studies on the influence of bariatric surgery this position, the bladder neck (BN), urethra (U), and pubic on PFDs focus on subjective improvement of symptoms, bas- symphysis (PS) with the interpubic disc were visualized in the ing on different kinds of questionnaires and rarely rate objec- median sagittal plane, according to Interdisciplinary S2k tive signs of pelvic floor anatomy and function. Moreover, Guideline: Sonography in Urogynecology . authors usually concentrate on already existing symptoms of Bladder neck position at rest was measured as the shortest PFDs. Till now, there is no data if and how weight loss may distance between the point of urethral-bladder junction and the influence pelvic floor anatomy and/or function in women horizontal line running through the lower edge of symphysis without PFDs and whether it may serve as a prophylaxis for pubis and was shown in millimeters. Accordingly, bladder future possible failure. neck position was measured in maximal descent point during The urethro-vesical junction (bladder neck) is a point that Valsalva maneuver (Fig. 1) and in maximal elevation point at corresponds to point Aa in POPQ (pelvic organ prolapse contracting levator ani muscle (Fig. 2). quantification scale) on the anterior vaginal wall 3 cm from Bladder neck mobility was defined as the difference be- the vaginal vestibule. Lowering of its position is connected tween its position at rest and during Valsalva maneuver and with anterior vaginal wall descent as well as with higher risk was shown in millimeters. Bladder neck elevation during con- of urinary incontinence. Bladder neck hypermobility (the dif- traction was shown as the difference between bladder neck ference between bladder neck positions at rest vs during position at rest and during levator ani muscle tension. Valsalva maneuver) is connected with higher incidence of Descriptive statistical analysis and statistical tests were per- stress UI  whereas the levator ani injury may be the cause formed using the R version 3.4.0 (by the R Foundation for of bladder neck descent and future pelvic floor dysfunctions Statistical Computing). Normality was tested using Lilliefors and prolapse . Elevation of the bladder neck during ten- and Shapiro-Wilk W tests. We associated the degree and type sion is realized by contraction of the most important muscle of of non-adherence using the Wilcoxon signed-rank test and the pelvic floor—levator ani. The measurement of the above multivariate variance analysis (MANOVA) and multiple OBES SURG (2018) 28:1653–1658 1655 Fig. 1 Measurement of bladder neck position at rest: the shortest distance between the point of urethral-bladder junction and the horizontal line running through the lower edge of symphysis pubis (marked with white line) and bladder neck position measurement in maximal descent point during Valsalva maneuver (marked with the red line). SP symphysis pubis, U urethra, BN bladder neck regression for multivariable analysis. We established a signif- 20.3 ± 5.7 vs 22.9 ± 5.1 mm as well as during Valsalva ma- icance level of p <0.05. neuver (p = 0.03) 3.0 ± 7.9 vs 5.1 ± 7.7 mm was observed after weight loss (Fig. 3). Age, parity, mode of delivery, and hormonal status Results did not influence the observed changes in bladder neck position at rest, tension, and Valsalva maneuver in multivari- Fifty-nine women without PFDs were enrolled in the study. able analysis. Demographic features of the study group are shown in The calculation of absolute value of change of the bladder Table 1. neck position at rest vs at levator ani tension showed no dif- In all the examined cases, significant weight loss was ob- ferences in muscle function following weight lost after bariat- served after bariatric surgery (43.7 ± 5.8 vs 29 ± 4.6 kg/m ). ric surgery 5.1 ± 3.8 vs 5.4 ± 3.8 (n/s, p = 0.94) (Fig. 4). We showed statistically significant elevation of the bladder Similarly, we did not show changes in bladder neck mobil- neck position at rest in patients who underwent bariatric sur- ity after bariatric surgery shown in absolute values as the dif- gery (p = 0.004) 15.2 ± 5.4 vs 17.6 ± 4.0 mm. Significantly ference of bladder neck position at rest vs Valsalva maneuver higher position of the bladder neck at tension (p = 0.004) 12.2 ± 6.7 vs 12.4 ± 6.6 (n/s, p = 0.34) (Fig. 5). Fig. 2 Measurement of bladder neck position at rest: the shortest distance between the point of urethral-bladder junction and the horizontal line running through the lower edge of symphysis pubis (marked with the white line) and bladder neck position measurement in maximal elevation point at contracting levator ani muscle (marked with the red line). SP symphysis pubis, U urethra, BN bladder neck 1656 OBES SURG (2018) 28:1653–1658 Table 1 Demographic features of examined group induced weight loss might become one of the important issues in patients’ counseling. Before surgery After surgery In the current study, for the first time, it was shown that Age 42.2 ± 11.8 43.5 ± 11.5 BMI reduction results in the betterment of bladder neck posi- BMI 43.7 ± 5.8 29 ± 4.6 tion in patients without clinically manifested POP—one of the %EWL 81.3 ± 22.9% objective and measurable features of the pelvic floor anatomy. %total body weight loss 33.9 ± 8.7% At the same time, we showed higher position of the bladder neck during tension of levator ani as well as during Valsalva Parity 1.5 ± 1.3 Nulliparas 32.2% maneuver. Most of current studies draw the conclusion about PFD improvement on the basis of patients’ questionnaires Menopause 32.2% showing positive subjective results of bariatric surgery on Surgery type 57 patients—SG 2 patients—RYGB the pelvic floor anatomy and function and they seem to be in agreement with our observations, which may be an objective BMI body mass index, %EWL %excess weight loss, SG sleeve gastrec- explanation of such subjective improvement . tomy, RYGB Roux-en-Y gastric bypass On the basis of the above observations, we postulate that weight loss may be a prophylaxis tool in the prevention of pelvic Discussion floor disorders probably in the mechanism of lowering of the intra-abdominal pressure. The above results might be an impor- Obesity is considered as one of the most important risk factors tant argument when counseling patients before bariatric surgery. of pelvic floor disorders. It is suggested that increased intra- On the other hand, we did not show any improvement in abdominal pressure causes weakening of pelvic floor muscles levator ani function measured as absolute value of the difference and destruction of the fascia leading to pelvic organ prolapse between bladder neck position at rest vs at levator ani tension. It and incontinence . Moreover, obesity is associated with may suggest that weight loss itself does not restore muscle func- impairment of the quality of life (QOL) as far as pelvic floor tion and other medical options should be considered. symptoms are concerned . The present work has also shown that bladder neck mobil- Among pelvic floor disorders’ risk factors, only several are ity measured as the difference of the bladder neck position at modifiable. There has been ongoing discussion to what extent rest vs Valsalva maneuver was not restricted after bariatric delivery mode or elective cesarean section may prevent PFDs surgery. It suggests that bladder neck hypermobility and de- in high-risk subjects . There are also strong evidences that scent that are often connected with urinary incontinence and pelvic floor muscle training improves POP and incontinence POP do not change, and therefore, all abnormalities connected . As far as the influence of weight loss on PFDs is con- with pelvic floor injuries or weakening do not restore to- cerned, it has been shown that bariatric surgery improves gether with BMI normalization. It stays in agreement QOL and self-reported prolapse symptoms . However, till with observations showing no improvement of already now, there have been no reports concerning the influence of existing POP symptoms after bariatric surgery . bariatric surgery on the anatomical and functional features of In the current literature, there are strong evidences that pelvic floor in patients without PFD. The questions seem to be weight loss results in at least partial resolution of incontinence of a great importance as possible protective effect of surgery- symptoms. Nevertheless, it has been suggested that urinary Fig. 3 Bladder neck position at rest, tension, and during Valsalva maneuver before and after bariatric surgery with marked values density and 0.95 confidence interval (n =59) OBES SURG (2018) 28:1653–1658 1657 Fig. 4 Scatterplot of bladder neck position at rest vs at tension before and after surgery with marked 0.95 confidence interval. The degree of inclination of the trend line corresponds to the levator ani function before (red) and after surgery (green) and does not differ significantly incontinence in obese women is dependent rather on higher functional conditions. Therefore, it should be emphasized in intra-vesical pressure than urethral hypermobility . The the process of patients’ counseling that weight loss should above observation may explain incontinence improvement af- result in betterment of pelvic floor anatomy as long as there ter bariatric surgery despite lack of restoration of bladder neck is no serious impairment, but it will not restore muscle func- mobility that has been demonstrated in the current study. tions and preexisting fascia injuries resulted from, i.e., labors All the above observations suggest that weight normaliza- and obesity. Therefore, it should be taken into consideration tion after bariatric surgery improves anatomical features of the that the sooner surgery-induced weight loss is obtained, the pelvic floor but at the same time does not change preexisting greater the chance for preserving pelvic floor wellness. Fig. 5 Scatterplot of bladder neck position at rest vs at tension before and after surgery with marked 0.95 confidence interval. 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Published: Dec 18, 2017