Purpose of Review
Obesity is highly prevalent and is associated with stress urinary incontinence (SUI). The purposes of this review are to assess the pathophysiology of SUI in the obese female and review the outcomes of weight loss and anti-incontinence surgery in this population.
While increased intra-abdominal pressure appears to be the common pathophysiologic link between obesity and SUI, neurogenic and metabolic pathways have been proposed. Both surgical and non-surgical weight loss continue to have beneficial effects on SUI; however, long-term outcomes are largely absent. Midurethral sling (MUS) surgery is largely effective in the obese population, with a complication profile similar to that in non-obese women. Obesity has been shown to be a risk factor for failure of MUS.
While weight loss should be the primary modality to improve SUI in the obese woman, MUS remains an effective and safe option in those women undertaking surgery.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/adult/defining.html. Accessed October 4, 2017.
Ogden CL, Carroll MD, Fryar CD, Flegal KM. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS Data Brief, No. 219, November 2015. https://www.cdc.gov/nchs/data/databriefs/db219.pdf. Accessed October 4, 2017.
Centers for Disease Control and Prevention. Nutrition, Physical Activity and Obesity Data, Trends and Maps website. https://www.cdc.gov/obesity/data/prevalence-maps.html. Accessed October 4, 2017.
The State of Obesity. Louisiana State obesity data, rates, and trends. https://stateofobesity.org. Accessed October 4, 2017.
Obesity in America: a growing concern. Endocrine Web. https://www.endocrineweb.com/conditions/obesity/obesity-america-growing-concern Accessed October 4, 2017.
Dee A, Kearns K, O'Neill C, et al. The direct and indirect costs of both overweight and obesity: a systematic review. BMC Res Notes. 2014;7(1):242. https://doi.org/10.1186/1756-0500-7-242.
Johnson SC, Packiam VT, Golan S, Cohen AJ, Nottingham CU, Smith ND. The effect of obesity on perioperative outcomes for open and minimally invasive prostatectomy. Urology. 2017;100:111–6. https://doi.org/10.1016/j.urology.2016.11.028.
Coyne KS, Wein A, Nicholson S, Kvasz M, Chen CI, Milsom I. Economic burden of urgency urinary incontinence in the United States: a systematic review. J Manag Care Pharm. 2014;20(2):130–40. https://doi.org/10.18553/jmcp.2014.20.2.130.
Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence: epidemiology and clinical research update. J Urol. 2009;182(6):S2–7. https://doi.org/10.1016/j.juro.2009.08.071.
Cummings JM, Rodning CB. Urinary stress incontinence among obese women: review of pathophysiology therapy. Int Urogynecol J Pelvic Floor Dysfunct. 2000;11(1):41–4. https://doi.org/10.1007/s001920050008.
Yarnell JW, Voyle GJ, Sweetnam PM, Milbank J, Richards CJ, Stephenson TP. Factors associated with urinary incontinence in women. J Epidemiol Commun Health. 1982;36(1):58–63. https://doi.org/10.1136/jech.36.1.58.
Mommsen S, Foldspang A. Body mass index and adult female urinary incontinence. World J Urol. 1994;12(6):319–22.
Sugerman H, Windsor A, Bessos M, Wolfe L. Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity. J Intern Med. 1997;241(1):71–9. https://doi.org/10.1046/j.1365-2796.1997.89104000.x.
Lambert DM, Marceau S, Forse RA. Intra-abdominal pressure in the morbidly obese. Obes Surg. 2005;15(9):1225–32. https://doi.org/10.1381/096089205774512546.
Noblett KL, Jensen JK, Ostergard DR. The relationship of body mass index to intra-abdominal pressure as measured by multi-channel cystometry. Int Urogynecol J. 1997;8(6):323–6. https://doi.org/10.1007/BF02765589.
Bai SW, Kang JY, Rha KH, Lee MS, Kim JY. Relationship of urodynamic parameters and obesity in women with stress urinary incontinence. J Reprod Med. 2002;47(7):559–63.
Richter HE, Creasman JM, Myers DL, Wheeler TL, Burgio KL, Subak LL. Urodynamic characterization of obese women with urinary incontinence undergoing a weight loss program: the Program to Reduce Incontinence by Diet and Exercise (PRIDE) trial. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12):1653–8. https://doi.org/10.1007/s00192-008-0694-8.
Nathan PA, Keniston RC, Myers LD, Meadows KD. Obesity as a risk factor for slowing of sensory conduction of the median nerve in industry. A cross-sectional and longitudinal study involving 429 workers. J Occup Med. 1992;34(4):379–83.
Hanewinckel R, Ikram MA, Franco OH, Hofman A, Drenthen J, van Doorn PA. High body mass and kidney dysfunction relate to worse nerve function, even in adults without neuropathy. J Peripher Nerv Syst. 2017;22(2):112–20. https://doi.org/10.1111/jns.12211.
Yadav RL, Sharma D, Yadav PK, Shah DK, Agrawal K, Khadka R, et al. Somatic neural alterations in non-diabetic obesity: a cross-sectional study. BMC Obes. 2016;3(1):50. https://doi.org/10.1186/s40608-016-0131-3.
Callaghan BC, Xia R, Reynolds E, Banerjee M, Rothberg AE, Burant CF, et al. Association between metabolic syndrome components and polyneuropathy in an obese population. JAMA Neurol. 2016;73(12):1468–76. https://doi.org/10.1001/jamaneurol.2016.3745.
Heliovaara M. Body height, obesity, and risk of herniated lumbar intervertebral disc. Spine. 1987;12(5):469–72. https://doi.org/10.1097/00007632-198706000-00009.
• Subak LL, King WC, Belle SH, Chen JY, Courcoulas AP, Ebel FE, et al. Urinary incontinence before and after bariatric surgery. JAMA Intern Med. 2015;175(8):1378–87. Large study of > 1500 patients undergoing bariatric surgery. At 3 years of follow-up, urgency urinary incontinence improved similarly to stress incontinence. https://doi.org/10.1001/jamainternmed.2015.2609.
Phelan S, Kanaya AM, Subak LL, Hogan PE, Espeland MA, Wing RR, et al. Weight loss prevents urinary incontinence in women with type 2 diabetes: results from the Look AHEAD trial. J Urol. 2012;187(3):939–44. https://doi.org/10.1016/j.juro.2011.10.139.
Wing RR, Creasman JM, West DS, Richter HE, Myers D, Burgio KL, et al. Program to reduce incontinence by diet and exercise. Improving urinary incontinence in overweight and obese women through modest weight loss. Obstet Gynecol. 2010;116(2, Part 1):284–92. https://doi.org/10.1097/AOG.0b013e3181e8fb60.
Subak LL, Wing R, West DS, Franklin F, Vittinghoff E, Creasman JM, et al. Weight loss to treat urinary incontinence in overweight and obese women. N Engl J Med. 2009;360(5):481–90. https://doi.org/10.1056/NEJMoa0806375.
Auwad W, Steggles P, Bombieri L, Waterfield M, Wilkin T, Freeman R. Moderate weight loss in obese women with urinary incontinence: a prospective longitudinal study. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(9):1251–9. https://doi.org/10.1007/s00192-008-0616-9.
Brown JS, Wing R, Barrett-Connor E, Nyberg LM, Kusek JW, Orchard TJ, et al. Lifestyle intervention is associated with lower prevalence of urinary incontinence: the diabetes prevention program. Diabetes Care. 2006;29(2):385–90. https://doi.org/10.2337/diacare.29.02.06.dc05-1781.
Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. Weight loss: a novel and effective treatment for urinary incontinence. J Urol. 2005;174(1):190–5. https://doi.org/10.1097/01.ju.0000162056.30326.83.
Subak LL, Johnson C, Whitcomb E, Boban D, Saxton J, Brown JS. Does weight loss improve incontinence in moderately obese women? Int Urogyn J Pelvic Floor Dysfunct. 2002;13(1):40–3. https://doi.org/10.1007/s001920200008.
Leshem A, Shimonov M, Amir H, Gordon D, Groutz A. Effects of bariatric surgery on female pelvic floor disorders. Urology. 2017;105:42–7. https://doi.org/10.1016/j.urology.2017.03.003.
Bulbuller N, Habibi M, Yuksel M, Ozener O, Oruc MT, Oner OZ, et al. Effects of bariatric surgery on urinary incontinence. Ther Clin Risk Manag. 2017;13:95–100. https://doi.org/10.2147/TCRM.S125781.
Romero-Talamás H, Unger CA, Aminian A, Schauer PR, Barber M, Brethauer S. Comprehensive evaluation of the effect of bariatric surgery on pelvic floor disorders. Surg Obes Relat Dis. 2016;12(1):138–43. https://doi.org/10.1016/j.soard.2015.08.499.
Knepfler T, Valero E, Triki E, Chilintseva N, Koensgen S, Rohr S. Bariatric surgery improves female pelvic floor disorders. J Visc Surg. 2016;153(2):95–9. https://doi.org/10.1016/j.jviscsurg.2015.11.011.
O'Boyle CJ, O'Sullivan OE, Shabana H, Boyce M, O'Reilly BA. The effect of bariatric surgery on urinary incontinence in women. Obes Surg. 2016;26(7):1471–8. https://doi.org/10.1007/s11695-015-1969-z.
Shimonov M, Groutz A, Schachter P, Gordon D. Is bariatric surgery the answer to urinary incontinence in obese women? Neurourol Urodyn. 2017;36(1):184–7. https://doi.org/10.1002/nau.22909.
Scozzari G, Rebecchi F, Giaccone C, Chiaro P, Mistrangelo M, Morino M. Bariatric surgery improves urinary incontinence but not anorectal function in obese women. Obes Surg. 2013;23(7):931–8. https://doi.org/10.1007/s11695-013-0880-8.
Cuicchi D, Lombardi R, Cariani S, Leuratti L, Lecce F, Cola B. Clinical and instrumental evaluation of pelvic floor disorders before and after bariatric surgery in obese women. Surg Obes Relat Dis. 2013;9(1):69–75. https://doi.org/10.1016/j.soard.2011.08.013.
Whitcomb EL, Horgan S, Donohue MC, Lucacz ES. Impact of surgically induced weight loss on pelvic floor disorders. Int Urogynecol J. 2012;23(8):1111–6. https://doi.org/10.1007/s00192-012-1756-5.
Ranasinghe WK, Wright T, Attia J, et al. Effects of bariatric surgery on urinary and sexual function. BJU Int. 2011;107(1):88–94. https://doi.org/10.1111/j.1464-410X.2010.09509.x.
Srinivasa S, Hill LS, Sammour T, Hill AG, Babor R, Rahman H. Early and mid-term outcomes of single-stage laparoscopic sleeve gastrectomy. Obes Surg. 2010;20(11):1484–90. https://doi.org/10.1007/s11695-010-0267-z.
Laungani RG, Seleno N, Carlin AM. Effect of laparoscopic gastric bypass surgery on urinary incontinence in morbidly obese women. Surg Obes Relat Dis. 2009;5(3):334–8. https://doi.org/10.1016/j.soard.2008.12.003.
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(1):72–6. https://doi.org/10.1097/SLA.0b013e31818c7082.
Burgio KL, Richter HE, Clements RH, Redden DT, Goode PS. Changes in urinary and fecal incontinence symptoms with weight loss surgery in morbidly obese women. Obstet Gynecol. 2007;110(5):1034–40. https://doi.org/10.1097/01.AOG.0000285483.22898.9c.
Kuruba R, Almahmeed T, Martinez F, Torrella TA, Haines K, Nelson LG, et al. Bariatric surgery improves urinary incontinence in morbidly obese individuals. Surg Obes Relat Dis. 2007;3(6):586–90. https://doi.org/10.1016/j.soard.2007.08.007.
Ahroni JH, Montgomery KF, Watkins BM. Laparoscopic adjustable gastric banding: weight loss, co-morbidities, medication usage and quality of life at one year. Obes Surg. 2005;15(5):641–7. https://doi.org/10.1381/0960892053923716.
Bump RC, Sugerman HJ, Fantl JA, DK MC. Obesity and lower urinary tract function in women: effect of surgically induced weight loss. Am J Obstet Gynecol. 1992;167(2):392–7. https://doi.org/10.1016/S0002-9378(11)91418-5.
Deitel M, Stone E, Kassam HA, Wilk EJ, Sutherland DJ. Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. J Am Coll Nutr. 1988;7(2):147–53. https://doi.org/10.1080/07315724.1988.10720232.
Osborn DJ, Strain M, Gomelsky A, Rothschild J, Dmochowski R. Obesity and female stress urinary incontinence. Urology. 2013;82(4):759–63. https://doi.org/10.1016/j.urology.2013.06.020.
Tchey DU, Kim WT, Kim YJ, Yun SJ, Lee SC, Kim WJ. Influence of obesity on short-term surgical outcome of the transobturator tape procedure in patients with stress urinary incontinence. Int Neurourol J. 2010;14:13–9.
Liu PE, Su CH, Lau HH, Chang RJ, Huang WC, Su TH. Outcome of tension-free obturator tape procedures in obese and overweight women. Int Urogynecol J. 2011;22(3):259–63. https://doi.org/10.1007/s00192-010-1311-1.
Miranda V, Pineda R, Lovatsis D, Alarab M, Drutz H. Efficacy and safety of tension-free vaginal tape compared with transobturator tape among obese women with stress urinary incontinence: a retrospective cohort study. J Obstet Gynaecol Can. 2012;34(8):755–9. https://doi.org/10.1016/S1701-2163(16)35339-7.
Meschia M, Rossi G, Bertini S, Sommacal A, Foina S, Sandretti F, et al. Single incision mid-urethral slings: impact of obesity on outcomes. Eur J Obstet Gynecol Reprod Biol. 2013;170(2):571–4. https://doi.org/10.1016/j.ejogrb.2013.08.007.
Frohme C, Ludt F, Varga Z, Olbert PJ, Hofmann R, Hegele A. TOT approach in stress urinary incontinence (SUI)—outcome in obese female. BMC Urol. 2014;14(1):20. https://doi.org/10.1186/1471-2490-14-20.
Jeong SJ, Lee HS, Lee JK, Jeong JW, Lee SC, Kim JH, et al. The long-term influence of body mass index on the success rate of mid-urethral sling surgery among women with stress urinary incontinence or stress-predominant mixed incontinence: comparisons between retropubic and transobturator approaches. PLoS One. 2014;9(11):e113517. https://doi.org/10.1371/journal.pone.0113517.
Brennand EA, Tang S, Williamson T, Birch C, Murphy M, Robert M, et al. Twelve-month outcomes following midurethral sling procedures for stress incontinence: impact of obesity. BJOG. 2015;122(12):1705–12. https://doi.org/10.1111/1471-0528.13132.
Yonguc T, Degirmenci T, Bozkurt IH, Aydogdu O, Gunlusoy B, Sen V, et al. Effectiveness of transobturator tape procedure in obese and severely obese women: 3-year follow-up. Urology. 2015;86(2):244–8. https://doi.org/10.1016/j.urology.2015.03.048.
Berger AA, Zhan T, Montella JM. The role of obesity in success and complications in patients undergoing retropubic tension-free vaginal tape surgery. Female Pelvic Med Reconstr Surg. 2016;22(3):161–5. https://doi.org/10.1097/SPV.0000000000000241.
JB MK, Parkin K, Cheng Y, Moore KH. Objective efficacy of the tension-free vaginal tape in obese/morbidly obese women versus non-obese women, at median five year follow up. Aust N Z J Obstet Gynaecol. 2016;56:628–32.
Pereira I, Valentim-Lourenco A, Castro C, Martins I, Henriques A, Riberinho AL. Incontinence surgery in obese women: comparative analysis of short- and long-term outcomes with a transobturator sling. Int Urogynecol J. 2016;27(2):247–53. https://doi.org/10.1007/s00192-015-2820-8.
Tommaselli GA, Napolitano V, Di Carlo C, Formisano C, Fabozzi A, Nappi C. Efficacy and safety of the trans-obturator TVT-Abbrevo device in normal weight compared to overweight patients affected by stress urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2016;197:116–9. https://doi.org/10.1016/j.ejogrb.2015.11.014.
•• Brennand EA, Tang S, Birch C, Murphy M, Ross S, Robert M. Calgary Women’s Pelvic Health Research Group. Five years after midurethral sling surgery for stress incontinence: obesity continues to have an impact on outcomes. Int Urogynecol J. 2017;28(4):621–8. Long-term follow-up in RCT of TVT and TOT showing significantly lower objective and subjective success rates in the obese population. https://doi.org/10.1007/s00192-016-3161-y.
Karaman U, Campbell KJ, Frilot CF 2nd, Gomelsky A. The impact of obesity on outcomes and complications after top-down retropubic midurethral sling. Neurourol Urodyn. 2017;36(5):1330–5. https://doi.org/10.1002/nau.23098.
Aigmueller T, Trutnovsky G, Tamussino K, et al. Ten-year follow-up after the tension-free vaginal tape procedure. Am J Obstet Gynecol. 2011;205(496):e1–5.
Serati M, Ghezzi F, Cattoni E, Braga A, Siesto G, Torella M, et al. Tension-free vaginal tape for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 10-year follow-up. Eur Urol. 2012;61(5):939–46. https://doi.org/10.1016/j.eururo.2012.01.038.
Serati M, Sorice P, Bogani G, Braga A, Cantaluppi S, Uccella S, et al. TVT for the treatment of urodynamic stress incontinence: efficacy and adverse effects at 13-year follow-up. Neurourol Urodyn. 2017;36(1):192–7. https://doi.org/10.1002/nau.22914.
Haverkorn RM, Williams BJ, Kubricht WS 3rd, Gomelsky A. Is obesity a risk factor for failure and complications after surgery for incontinence and prolapse in women? J Urol. 2011;185(3):987–92. https://doi.org/10.1016/j.juro.2010.10.064.
• Rodrigues CA, Bianchi-Ferraro AMHM, Zucchi EVM, Sartori MGF, Girao MJBC, Jarmy-Di Bella ZIK. Pelvic floor 3D ultrasound of women with a TVT, TVT-O, or TVT-S for stress urinary incontinence at the three-year follow-up. Rev Bras Ginecol Obstet. 2017;39(9):471–9. TVT appears to remain at midurethra more frequently compared to TVT-O or TVT-S. MUS more often located in the distal urethra in obese women. https://doi.org/10.1055/s-0037-1606125.
Majkusiak W, Pomian A, Tomasik P, et al. Does the suburethral sling change its location? Int J Urol 2017 Sep 20. [Epub aheead of print].
•• Weltz V, Guldberg R, Lose G. Efficacy and perioperative safety of synthetic mid-urethral slings in obese women with stress urinary incontinence. Int Urogynecol J. 2015;26(5):641–8. Systematic review of pooled data from 13 studies, showing no significant difference in rates of postoperative urinary retention or sling excision between obese and non-obese women after MUS surgery. https://doi.org/10.1007/s00192-014-2567-7.
Chen CC, Collins SA, Rodgers AK, Paraiso MF, Walters MD, Barber MD. Perioperative complications in obese women vs normal-weight women who undergo vaginal surgery. Am J Obstet Gynecol. 2007;197(1):98.e1–8. https://doi.org/10.1016/j.ajog.2007.03.055.
Dunivan GC, Connolly A, Jannelli ML, Wells EC, Geller EJ. Body mass index as a risk factor for cystotomy during suprapubic placement of mid-urethral slings. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(9):1127–31. https://doi.org/10.1007/s00192-009-0915-9.
Revicky V, Mukhopadhyay S, de Boer F, Morris EP. Obesity and the incidence of bladder injury and urinary retention following tension-free vaginal tape procedure: retrospective cohort study. Obstet Gynecol Int. 2011;2011:746393.
Zyczynski HM, Albo ME, Goldman HB, Wai CY, Sirls LT, Brubaker L, et al. Urinary incontinence treatment network. Change in overactive bladder symptoms after surgery for stress urinary incontinence in women. Obstet Gynecol. 2015;126(2):423–30. https://doi.org/10.1097/AOG.0000000000000929.
Cadish LA, Hacker MR, Modest AM, Rogers KJ, Dessie S, Elkadry EA. Association between body mass index and pain following transobturator sling. J Obstet Gynaecol. 2017;37(6):766–9. https://doi.org/10.1080/01443615.2017.1292226.
Hunskaar S. A systematic review of overweight and obesity as risk factors and targets for clinical intervention for urinary incontinence in women. Neurourol Urodynam. 2008;27(8):749–57. https://doi.org/10.1002/nau.20635.
Conflict of Interest
Alex Fuselier, Jordan Hanberry, J. Margaret Lovin, and Alex Gomelsky each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Female Urology
About this article
Cite this article
Fuselier, A., Hanberry, J., Margaret Lovin, J. et al. Obesity and Stress Urinary Incontinence: Impact on Pathophysiology and Treatment. Curr Urol Rep 19, 10 (2018). https://doi.org/10.1007/s11934-018-0762-7
- Stress urinary incontinence
- Weight loss