In this podcast, experienced urogynaecologist Dr Deepa Gopinath will be discussing the topic of obesity and pelvic floor disorders, including how obesity contirbutes to pelvic floor disorders, the major risks of this, the treatment options available, warning signs to look out for, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Deepa Gopinath
Deepa Gopinath is a urogynaecologist with dual subspecialist qualifications from Australian and United Kingdom. She is the lead clinician for Urogynaecology at the Nepean Hospital in Western Sydney and treats women with pelvic floor problems.
She has several special interests, including recurrent prolapse and incontinence, but is passionate about the pelvic floor problems in women at the end of the spectrum from post-partum to frail elderly. She is actively involved in creating multidisciplinary team models, improving access to health information to the women and shared decision making. She has also published and presented widely.
Today, we’ll be discussing the topic of obesity and pelvic floor disorders.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Deepa, thanks for talking with us on PodMD today.
Deepa : Thank you for having me.
The topic of today’s discussion is obesity and pelvic floor disorders. Deepa, Can you give us a brief overview about obesity and pelvic floor disorders?
Deepa: Absolutely. So as you know, obesity is the new epidemic of the world and every 3rd or 4th patient that might be coming to see you is likely to be a. East, especially in the western world and especially in this in Australasia, you’ll find that in the Pacific Islander group it’s actually even higher than that and it’s perhaps one to two. Now we we do know quite well the impact of obesity on general health and conditions like diabetes etcetera. But what is not so well known is its impact on the pelvic floor, and I can tell you that this is a risk factor for pelvic floor disorders.
How does obesity contribute to the development of pelvic floor disorders?
Deepa: And so as you can imagine. If there is excessive weight gain, there is going to be a proportionate strain on the pelvic flow structures, which includes the muscles, the connective tissue and the nerves, and that can cause damage and weakness and as. A result of. This you can get symptoms like urinary and faecal incontinence. As for less pelvic organ prolapse, now it’s not just the weight and. Itself, and there is also a metabolic element that you see with obesity due to the abnormal glucose metabolism, the atherosclerotic changes, which can cause ischemia and that can cause a direct impact on the nerve and the muscle function of the bladder or the pelvic floor structures in general. And predisposing you to pelvic floor disorder. So it’s not just the weight in it.
What are the risks associated with obesity and pelvic floor disorders?
Deepa: So as we just said, obesity is a risk factor for pelvic floor disorders and if you, if you were to look at pelvic floor disorders, we want to sort of divide them into four different domains like the bladder, the prolapse, the bowel. And also the sexual function. So what respect to the bladder? Once the body mass index, which is a measure of, you know, weight in health, once the body body mass index is over 30, which is when it’s classed as obesity, you are four to five times more likely to experience urinary leakage.
Even a small increase in BMI. From 30 to 35, for example, can increase your urinary leakage by 20 to 70%. So it’s a it’s like a geometric relationship, and this applies not only to the stress urinary incontinence, which is the leakage with physical exertion like coughing, sneezing, etc. But also with urgency, incontinence, which is the leakage with urgent urination. And it’s not only that this is this increases your risk for the leakage.
If you did choose a surgical procedure to improve the incontinence, there will be city still has an impact. And reduces your success rate from surgery compared to the non obese. So that was that was on the bladder and in terms for in terms of prolapse which? Is where there is. A A protrusion or a vaginal lump, which is the commonest symptoms described by patients having obesity increases your chances of having a prolapse and also. The chance of this worsening over time now, interestingly, with bowels. There is it, it’s. It’s slightly conflicting, but overall the consensus seems to be that it doesn’t really have a huge impact with either difficulty with bowel movement or leakage and the last, but the you know an important function of the vagina which is sexual function.
It’s again quite tricky to measure the direct. Impact of obesity itself, because obesity itself can cause mental health problems or, you know, a different body image, and all of that can have impact with sexual function. So it’s it’s difficult to know how much of that is due to the obesity in itself. But overall, as she can? Yeah, just say it has got impact on the bladder and the vagina predominantly.
What are the treatment options?
Deepa: So generally the treatment options remain more or less the same without you are obese or nonobese, so most of the time when a patient you know comes to see you in clinic, you’re looking to. See what other? Reversible factors here that I can improve and also the non surgical or conservative options. That you can advocate for the patient to. Improve the pelvic floor. Health. So most of the time this includes pelvic floor exercises, medications, especially if it’s overactive bladder or pessaries. If they have pelvic organ prolapse. But the most important thing is managing the weight which has got an important role in the treatment strategy. And this is where a GP can be incredibly helpful in terms of health education, because it’s not just the pelvic floor or the other outcomes from weight loss in itself and also supporting the patient’s journey with their weight loss.
Can you explain further how weight loss helps in the treatment of pelvic floor disorders?
Deepa: Absolutely so.Often with weight class, we’re not talking about getting their body mass index back to normal BMI. We’re talking about a small drop in their weight. It could be anywhere from 5 to 10% and we know that a 5% weight loss. Can lead lead to 50% improvement in their stress urinary incontinence symptoms and this can be achieved by just managing their weight with diet, exercise and medication and similarly for overactive bladder. We found that weight loss can lead to up to 70% improvement of symptoms.
So it just shows that with respect to bladder. This weight loss itself is a good treatment option that can improve their symptoms by 50% and also perhaps avoid surgical. Management now when it comes to prolapse, it’s slightly different. If it is in the early stages of prolapse, we know that it does prevent progression of prolapse symptoms. However, if they are in the advanced stages. So for example stage 3 and four where there is protrusion of the prolapse beyond the. Entrance to the vagina. You often find that it doesn’t really achieve in reversing the anatomical changes. However, these are the patients you would consider for surgery. So in terms of managing the surgical risks, these patients would take, while class is certainly helpful in reducing complications related to the surgery, the recovery and also the anaesthetic.
What are the specific issues you worry about considering surgery for these patients?
Deepa: So I would think the main concern with any surgery or main difference you want to see is an improved treatment outcome and generally for if you take stress in Conan surgery as an example and if you chose the gold standard, would you say retropubic midurethral sling which is a synthetic sling? So another way mesh vaginal mesh. We find an 80 to 90% improvement occurs of stress incontinence, you know in an average patient. However, if you add obesity into this equation, we find that this outcome is reduced.
It can be as low as 50 to 70%, especially in the long term. So we know that generally pelvic floor disorders get, you know, get worse as patients get older. So especially in the long term, these patients are more likely to come back to you with recurrent urinary incontinence than somebody else who is known obese. So. So the success of treatment is lower than average. But also when you have obesity, they also come with. Other medical comorbidities that needs to be managed appropriately prior to considering surgery and also there are anaesthetic challenges with you know intubation and ventilation and and also postoperatively they’re more at risk of wound infection or blood clots etcetera. They are challenging patients with higher risk for surgery and not necessarily get the same outcome as somebody else with the normal weight.
What specific strategies do you propose for weight loss?
Deepa: So weight management is always a sensitive topic and often the ladies that come and see me share stories about their different diets. And you know the exercises and everything that they have tried to help in reducing their way. They often feel that medical practitioners especially are quite judgmental when it comes to weight. It’s often implied that it’s because of their lifestyle factors and their lack of exercise. You know, poor, poor diet, etcetera. Whereas we know that this is not the case and there is a genetic predisposition.
Which is why majority of the ladies are that way. You know, in the 1st place. So it’s acknowledging that and and not being judgmental and being very sympathetic with with your approach. And and often the place to start is by reassuring them that we’re not looking to achieve a normal BMI here. And you know, we wanna achieve a 5 to 10% weight loss, which is often enough to improve their symptoms and is is giving them a weight as a target, which they also feel. Is realistic and giving them some time frames to to achieve that. Now. Once they do achieve the weight. To we do want them to maintain it and not gain further, which is easier said than done and and that is again another challenge with obesity because your body is set to in a certain I forget the term for it, but in a certain way that it always tries to achieve the previous weight as normal rather than. The new newly gained normal. Wait and and often just just telling a patient that you’ve got to lose certain amount of weight alone doesn’t really work.
And most of the time it’s best achieved with multi disciplinary care and that is where the GP is. Again very important being the link and the one who constantly reviews. Their weight loss journey. Obviously you want your dieticians who can help support the diets that you will prescribe, exercise physiologists who can support with the exercise and a lot of the time they need some mental support as well. And that is where a psychologist or a life coach is helpful in giving them. Cable strategies. I could see some of the programmes like noon and that comes up on social media where they specifically target the this aspect of weight
What role does the GP play in the treatment of the condition?
Deepa: So as we said before, we would have started the conversational weight class in the clinic and just explaining to them how it impacts on their pelvic floor symptoms and what happens if you did consider surgery that is not going to. Achieve the ideal success rate that I would want to see in a patient, so they’re often engaged and interested in that journey to support their own good outcomes. And we would then ask them to go and discuss this further with their GP practitioner.
So often the things we would have discussed, the various diets so. And there are the I mean I I won’t go into the details of it, but the one that we specifically discussed with them in terms of acute weight loss prior to surgical procedure. Would be the very low energy diets now. Again, this may not be practical or ideal for somebody with medical conditions, so we often ask them to discuss that with the GP further or seek the help of a dietitian and certainly medical therapy. We mentioned the names, but again we ask them to explore. That further with their GP, with their that is the asymptotic or other appetiser presents, etc. And also the cost barriers that the patient has so.
So we asked them to discuss that further with you exercise. We often find it’s like a double edged sword for our patients because a lot of these patients with public health problems cannot exercise due to the problems themselves. Whether that’s the leakage or the the prolapse. So and also a lot of them are elderly and have limited mobility. You know, by the age factor itself, so we sometimes have to be more realistic in terms of the strenuous exercise. You would want them to carry out for their weight loss. And you know re reset that at the level where you just want to preserve the muscle mass and strength rather than have that as a weight loss strategy.
So those are the conversations that we would have had with the patient, but we do know in the long term medical therapy. It’s inferior to surgical therapy, so weight loss surgery certainly has got a better long term success rate in terms of reducing weights and maintaining weight. But again, this is not something we would be discussing with them and we would feel that it will be more appropriate at the level. Of a GP setting in liaison with a metabolic clinic to to make these discussions happen and to support the weight gain. Sorry, the weight loss journey.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on obesity and pelvic floor disorders?
Deepa: So I think I’ve summarised the impact of obesity on pelvic floor symptoms and the fact that some of these changes are reversible. And so I feel patient education clearly has a role in achieving realistic targets, thereby getting good outcomes. And also maintaining this in the long run. And clearly this has to be achieved in a multidisciplinary way with the the specialist, the GP and all the other light health specialists and perhaps some layers on with the metabolic clinic as well.
Thanks for your time and the insights you’ve provided.
Deepa: Thank you