Obesity and incontinence
Obesity is defined as excessive weight or fat accumulation in the body that has an adverse affect on health, according to the World Health Organization (WHO). (1) Obesity can be measured by using The Body Mass Index (BMI) which is defined as the ratio of body weight to height. Obesity, according the BMI is defined as an index score of over 30 kg/m2. (2)
Continence is a fine balance between urethral closure and detrusor muscle activity (the muscle which contracts when urine is pushed out). Normally, the pressure in the urethra is larger than the pressure in the bladder, keeping urine inside the bladder. Under the condition of incontinence the pelvic floor muscles (or Pubococcygeus muscles) are weakened and the brain no longer has sole control over the muscle. As the muscle tone is diminished, it leads to less pressure in the urethra than in the bladder, causing urine to trickle from the urethra. (3)
How does obesity increase the likelihood of incontinence?
Urethral incontinence (UI) is twice as likely in women (especially older women) as in men, and affects millions of Americans. Age and abdominal weight are two large factors in the prevalence of incontinence. Up to 35% of the over-60 population has suffered or is suffering from incontinence. More than 50% of the elderly who are admitted to nursing homes suffer from incontinence. (4)
While the body is obese it has to carry a large amount of excess weight. This puts pressure on the pelvic muscles. Due to a lack of exercise all muscle tone is weakened. Inter-abdominal pressure is also increased with obesity, with age and the effects of gravity. The muscles weaken and balloon out or bulge. Once the muscles have lost their tightness they never fully go back, but exercise can help regain tautness. (5) (6) A study conducted on 403 women found that those who regularly used pelvic floor muscle training exercises reported a decrease in the frequency of incontinence, usually one episode less of incontinence daily. The effects are more prevalent in younger women, when used as a preventive measure as opposed to a cure. (7)
Obesity and bladder control issues are highly co-morbid. Difficulty with this issue can lead to depression, and decreased work capacity, which leads to an inactive lifestyle, which leads to more weight gain. A never-ending catch 22 cycle. (8)
In a study of 368 incontinent women 232 (63%) of them were diagnosed as having genuine stress incontinence (urinary leaking during laughing, coughing or strain from heavy lifting), and 136 (27%) suffering from detrusor instability. Stress incontinence was found to be significantly more prevalent in obese women. A larger abdominal cavity has been shown to have an adverse affect on the muscles that control the urinary tract opening, therefore there is a higher risk of incontinence developing. (9)
The importance of losing the weight; exercise as a prevention of incontinence
Research has found that women who have lost weight experience a lowering in the frequency of episodes of incontinence. The 10 women in the study experienced incontinence at least 13 times a week, and had a baseline BMI index of 38 kg/ m2, which is determined to be extremely obese by the WHO. Even a weight-loss of less than or equal to 5% reduced the number of incontinence episodes from 13 to 8 per week. (10)
A sedentary lifestyle may also cause urethral incontinence and is firmly related to obesity. Even in occupations where people sit for most of the day, they put excess pressure on the pelvic region. The fatigue associated with carrying around the excess weight leads to a more inactive lifestyle associated with obesity.
Additionally, a lack of exercise is also a major contributing factor to both obesity and incontinence. Exercising the muscles makes them able to take more strain and this is true also for the Pubococcygeus muscle.
Sitting on a fitness ball is an effective method to counter-act sitting for hours on a chair, as it not only strengthens the pelvic muscles, helping to fight incontinence, but also helps to straighten the posture, strengthen the back, gluteus and thigh muscles as well as being an effective cardiovascular workout.
With Pilates or Kegel exercises (named after Dr. Arnold Kegel), an exercise regime of how to contract and relax the pelvic floor muscles like any other muscle of the body is learned, strengthening and toning them. These exercises are effective in the prevention of incontinence and may also be effective in the strengthening of the muscles if incontinence is already a problem. (11)
Bio-feedback theory states that during exercise the brain also teaches itself a new routine, and keeps the muscles contracted tighter, not allowing sagging or bulging. A study conducted on 135 erderly women found that exercise and bio-feedback together showed a larger significance with the decrease of incontinence episodes, than in the control group, who did not use an exercise regime. (12)
Treatments depend on the frequency and severity of incontinence. They can range anywhere from: symptom control (adult diapers), lifestyle choice changes (exercise and weight loss), external incontinence treatment devices (externally worn devices that protect the skin from the constant leakage of urine), incontinence medication and surgery (colposuspension or silastic sling insertion). It also must be noted that obesity diminishes the effects of surgery. (13) 190 patients were studied after they had received colposuspension or silastic sling insertion operations due to a genuine stress incontinence diagnosis. 91 patients were normal weight (BMI = 18.5 kg/m2 to less than 25 kg/m2), 66 were overweight (BMI = 25 kg/m2 to less than 30 kg/m2), while 33 were obese (BMI = more than 30 kg/m2). A larger body mass index correlated significantly with a negative outcome of operations, as it diminished the effectiveness of the operations. (14)
If obesity is a major cause of incontinence it goes without saying that prevention is better than a cure, losing the weight (even a 5% loss) allows for a drop in not only the frequency of incontinence, but also helps those recovering from surgery.