Abstract
Objectives
There is a paucity of data on postoperative exercise and how it relates to surgical failure, specifically following midurethral sling (MUS) surgery. We aimed to assess if women with higher self-reported activity levels as measured by strenuous exercise, are more likely to experience stress urinary incontinence (SUI) symptoms after MUS than women with lower self-reported activity.
Methods
This is a secondary analysis of Operations and Pelvic Muscle Training in the Management of Apical Support Loss: the OPTIMAL Trial, a randomized trial comparing sacrospinous ligament suspension versus uterosacral ligament suspension, both with concomitant retropubic MUS. Participants completed a validated assessment of activity pre- and postoperatively. Women in the upper quartile for strenuous exercise (≥90 minutes per week) were compared to the remaining participants. Symptomatic SUI was defined as retreatment or reoperation for SUI and/or any positive response to Pelvic Floor Disorders Inventory (PFDI) stress incontinence questions 20–22.
Results
A total of 351 participants in the OPTIMAL study received MUS along with their prolapse repair and had postoperative exercise and PFDI data. At 2 years, 87/305 (29%) exercised strenuously for at least 90 minutes per week, and 63/277 (23%) experienced SUI. Women who were less active at 2 years were significantly more likely to experience SUI than women who were more active (26.6% vs 12.8%, p= 0.0138).
Conclusions
In this study, symptomatic SUI occurred more frequently in women with lower self-reported exercise levels 2 years after MUS surgery.
Keywords: Stress Urinary Incontinence, Activity, Exercise, Midurethral Sling
Introduction
Female pelvic floor disorders are common, with a recent estimated 12.6% lifetime risk of undergoing surgery and over 300,000 surgical procedures for prolapse and 200,000 for stress urinary incontinence (SUI) performed each year1. Many women seeking surgical correction of prolapse are concomitantly affected by SUI 2,3. Outcomes assessed after pelvic floor surgery commonly include functions of the urinary, intestinal and gynecological tracts, that may impact activities of daily living, and quality of life 1,4–6. The goals of surgery for prolapse and incontinence are generally to improve these activities and quality of life in women limited by their condition. The midurethral sling (MUS) is a gold standard operation with high success rates and low morbidity performed to treat SUI, incontinence that occurs during increases in intraabdominal pressure such as cough, sneeze, laugh, and/or physical activity 7. Its mechanism of action is achieved by increasing outflow resistance during increases in intraabdominal pressure 8,9; however, there are likely limits to the amount of pressure the sling and supported urethra can withstand. Despite existing long-term outcome data for women undergoing MUS surgery, it remains unclear how exercise level varies among women after MUS and how level and degree of exercise after surgery are associated with the patient reported success of the procedure and symptoms. We aimed to assess if women with higher self-reported activity, as measured by strenuous exercise, are more likely to experience SUI symptoms after MUS than women with lower self-reported activity. Given the provocation of SUI by physical activity, we hypothesized that more active women may have greater strain and force exerted on the system resulting in higher rates of SUI symptoms (i.e. failure) than those who are less active. Because exercise is not static and amount of exercise might affect SUI symptoms and vice versa, we also aimed to compare SUI symptoms at varying postoperative time points by exercise level. We hypothesized that earlier increased postoperative exercise may result in more SUI symptoms at a later postoperative time point.
Materials and Methods
We conducted a secondary analysis of the participants in the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) Trial. The (OPTIMAL) Trial was a 2×2 factorial randomized trial comparing 2-year outcomes in women undergoing apical prolapse repair, sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (ULS), with concomitant MUS for SUI 10. The primary aims of the trial were: 1) to compare surgical outcomes following SSLF to ULS in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and SUI and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. The design and primary results of the OPTIMAL trial have been published previously 10,11.
All participants in OPTIMAL had a planned retropubic MUS for SUI. Those women who underwent the MUS procedure and had complete activity and Pelvic Floor Disorders Inventory (PFDI) questionnaire data at a minimum of one of the postoperative visits at 6, 12 or 24 months were included in this analysis. PFDI data were collected by phone.
We compared symptomatic SUI among women of varying activity levels. A validated assessment of activity which asked the subjects about strenuous exercise performed in a week was administered at baseline, 3, 6, 12 and 24 months12,13. Women were asked “During the past month, on average, on how many days in each week did you do strenuous or very hard exercise; that is, exercise that caused you to work up a sweat and made your heart beat fast. For example, aerobics, dancing, jogging, or tennis?” and “How many minutes each day did you do this exercise?”. More active women were defined as those who performed strenuous exercise for at least 90 minutes per week at the point of interest. This was based on the upper quartile of participants’ exercise minutes. Extremely active women were defined as those who performed strenuous exercise for at least 300 minutes per week at the point of interest. Participants in OPTIMAL were given standardized postoperative instructions allowing them to perform light physical activities while refraining from activities which caused the feeling of pressure in the pelvis for 6 weeks after surgery.
The primary outcome of symptomatic SUI was assessed at 6, 12 and 24 months and was defined as either reoperation or retreatment for SUI or any positive response to PFDI questions 20–22: Do you usually experience urine leakage related to coughing, sneezing or laughing? Do you usually experience urine leakage related to physical exercise such as walking, running, aerobics, or tennis? Do you usually experience urine leakage related to lifting or bending over? Retreatment included anti-incontinence surgery, treatment with an anti-incontinence device, periurethral bulking agents or behavioral treatment. Urinary symptoms were assessed by Urogenital Distress Inventory (UDI) subscale of the PFDI scores and were compared between activity groups postoperatively up to 24 months.
Baseline characteristics of women with and without postoperative symptomatic SUI were compared using Wilcoxon rank-sum tests or chi-square tests. SUI at 6 months, 1 year, and 2 years was compared between women who were more active versus less active at time points from baseline through 2 years using chi-square tests. Because exercise is not static, symptomatic SUI at each discrete postoperative time point was compared to women’s activity levels at baseline, 6 months, 1 and 2 years. UDI scores at 6 months through 2 years were compared between women performing more versus less strenuous exercise at 2 years using t tests. Generalized linear mixed models were constructed to predict SUI symptoms over time based on baseline and concurrent activity level (90+ minutes vs <90 minutes per week), age, parity, visit (6 months, 1 year, or 2 years), education, public insurance, race, ethnicity, and OPTIMAL surgical assignment; covariates were selected based on clinical importance. Correlations between repeated measures on the same participant were modeled with a compound symmetry covariance structure.
Results
Of the 374 women randomized in the OPTIMAL study, 351 were included in this analysis and 338 had baseline activity data. At 6, 12 and 24 months, 323, 319 and 305 patients were available for analysis respectively. Those included were similar in demographics to those excluded. The median (P25, P75) age was 57 years (49,66) with a parity of 3 (2,4), BMI of 28 (25,32) and baseline strenuous exercise minutes per week of 0 (0,60).
Overall, 21% (72/338) of women exercised strenuously at least 90 minutes per week at baseline. Table 1A displays the baseline characteristics of women who were more active versus less active at baseline. Those women who were less active were on average older and more likely to be diabetic and postmenopausal with lower rates of estrogen use. They also were less likely to have 4 or more years of college education or to have private insurance. Greater than 90% of women in both groups had SUI symptoms at baseline with less active women having higher UDI scores indicating greater urinary incontinence bother (Table 1A). When looking at baseline characteristics of women who were active at 2 years (Table 1B), less active subjects were older, had a higher median BMI, were more likely to have had a prior hysterectomy and be postmenopausal and less likely to have 4 or more years of college and have private insurance, but those who were less active at 2 years no longer had a significant difference in UDI scores at baseline when compared to more active women at 2 years. Contrary to our hypothesis, women who were more active had lower rates of symptomatic SUI at 2 years than those who were less active (Table 2). Physical activity rates remained relatively stable over 2 years: at 6 months 29% (n=97) were more active, while 26% (n=82) and 29% (n=87) were more active at 12 and 24 months postoperatively, respectively. Fewer women who were more active at baseline had SUI symptoms at 24 months (8.9% vs 28.4% p=0.0025) (Table 2). Similarly, fewer women who were more active at 24 months had symptomatic SUI at that time point (12.8% vs 26.6%, p=0.0138). No other time points showed a statistically significant difference in symptomatic SUI between more versus less active women (Table 2). Minutes of strenuous activity at each visit, stratified by persistence of SUI at 24 months are shown in Figure 1. Women who were less active at 24 months also had higher (worse) scores on the UDI (mean ± SD) at 6 months (33.5 ± 45.1 vs 23.4 ± 27.0, p=0.0200), 12 months (31.4± 41.7 vs 23.7 ± 31.1, p=0.0862) and 24 months (43.9 ± 54.3 vs 31.0 ± 37.4, p=0.0233).
Table 1A:
Baseline Characteristics by Activity Level 1 at Baseline
| Baseline Characteristics | More Active 1 at Baseline N=72 | Less Active 1 at Baseline N=266 | P-value 2 |
|---|---|---|---|
| Minutes of Strenuous Exercise per week, N | 72 | 266 | |
| Median (P25, P75) | 180 (120, 240) | 0 (0, 15) | <.0001 |
| Race: White, n/N (%) | 65/72 (90.3) | 220/266 (82.7) | 0.1176 |
| Ethnicity: Hispanic, n/N (%) | 9/72 (12.5) | 61/266 (22.9) | 0.0530 |
| Insurance: Public, n/N (%) | 12/72 (16.7) | 84/266 (31.6) | 0.0129 |
| Insurance: Private, n/N (%) | 55/72 (76.4) | 169/266 (63.5) | 0.0410 |
| Education: 4 years or more of college, n/N (%) | 41/72 (56.9) | 68/262 (26.0) | <.0001 |
| Marital Status: Married, n/N (%) | 54/71 (76.1) | 175/262 (66.8) | 0.1358 |
| Age at Randomization (years), N | 72 | 266 | |
| Median (P25, P75) | 53 (45, 59) | 58 (50, 66) | 0.0002 |
| Body Mass Index (kg/m2), N | 72 | 265 | |
| Median (P25, P75) | 27 (24, 30) | 28 (25, 32) | 0.0846 |
| Parity, N | 72 | 266 | |
| Median (P25, P75) | 3.0 (2.0, 3.5) | 3.0 (2.0, 4.0) | 0.7056 |
| Post-Menopausal, n/N (%) | 32/67 (47.8) | 187/252 (74.2) | <.0001 |
| Estrogen Use 3, n/N (%) | 29/72 (40.3) | 75/266 (28.2) | 0.0491 |
| Current Smoker, n/N (%) | 4/72 (5.6) | 23/266 (8.6) | 0.3915 |
| Diabetes Mellitus, n/N (%) | 4/71 (5.6) | 39/261 (14.9) | 0.0386 |
| Connective Tissue Disease, n/N (%) | 0/71 (0.0) | 4/262 (1.5) | 0.2956 |
| Prior Hysterectomy, n/N (%) | 13/72 (18.1) | 75/266 (28.2) | 0.0824 |
| Prior Prolapse Surgery, n/N (%) | 6/72 (8.3) | 15/266 (5.6) | 0.4015 |
| Prior Stress Urinary Incontinence Surgery, n/N (%) | 2/72 (2.8) | 9/266 (3.4) | 0.7975 |
| Randomized Vault Suspension Group: ULS, n/N (%) | 30/72 (41.7) | 143/266 (53.8) | 0.0690 |
| Randomized PMT Group: PMT, n/N (%) | 33/72 (45.8) | 131/266 (49.2) | 0.6076 |
| Stress Urinary Incontinence Symptoms, n/N (%) | 72/72 (100.0) | 240/266 (90.2) | 0.0058 |
| Hunskaar Score, N | 68 | 252 | |
| Median (P25, P75) | 4 (3, 8) | 4 (3, 8) | 0.7954 |
| UDI Score, N | 68 | 253 | |
| Median (P25, P75) | 107 (69, 148) | 122 (88, 164) | 0.0281 |
More active is defined as strenuous exercise at least 90 minutes per week at the point of interest. Less active is defined as strenuous exercise less than 90 minutes per week at the point of interest.
P-values were obtained using Wilcoxon rank-sum test for continuous measures, and Chi-square tests for categorical measures. All tests were conducted at a significance level of 0.05.
Estrogen use is defined as the use of oral, vaginal cream, tablets or cream, or skin patch.
Table 1B:
Baseline Characteristics by Activity Level 1 at 2 Years
| Baseline Characteristics | More Active 1 at 2 Years N=87 | Less Active 1 at 2 Years N=218 | P-value 2 |
|---|---|---|---|
| Minutes of Strenuous Exercise per week, N | 83 | 211 | |
| Median (P25, P75) | 60 (0, 180) | 0 (0, 30) | <.0001 |
| Race: White, n/N (%) | 76/87 (87.4) | 180/218 (82.6) | 0.3047 |
| Ethnicity: Hispanic, n/N (%) | 15/87 (17.2) | 45/218 (20.6) | 0.5006 |
| Insurance: Public, n/N (%) | 18/87 (20.7) | 68/218 (31.2) | 0.0661 |
| Insurance: Private, n/N (%) | 65/87 (74.7) | 137/218 (62.8) | 0.0482 |
| Education: 4 years or more of college, n/N (%) | 49/87 (56.3) | 55/214 (25.7) | <.0001 |
| Marital Status: Married, n/N (%) | 64/86 (74.4) | 140/215 (65.1) | 0.1194 |
| Age at Randomization (years), N | 87 | 218 | |
| Median (P25, P75) | 53 (46, 63) | 58 (50, 68) | 0.0051 |
| Body Mass Index (kg/m2), N | 87 | 217 | |
| Median (P25, P75) | 27 (24, 30) | 28 (25, 32) | 0.0203 |
| Parity, N | 87 | 218 | |
| Median (P25, P75) | 3.0 (2.0, 4.0) | 3.0 (2.0, 4.0) | 0.5975 |
| Post-Menopausal, n/N (%) | 49/83 (59.0) | 153/206 (74.3) | 0.0108 |
| Estrogen Use 3, n/N (%) | 24/87 (27.6) | 71/218 (32.6) | 0.3970 |
| Current Smoker, n/N (%) | 7/87 (8.0) | 16/218 (7.3) | 0.8332 |
| Diabetes Mellitus, n/N (%) | 7/86 (8.1) | 27/214 (12.6) | 0.2694 |
| Connective Tissue Disease, n/N (%) | 0/85 (0.0) | 5/215 (2.3) | 0.1569 |
| Prior Hysterectomy, n/N (%) | 14/87 (16.1) | 63/218 (28.9) | 0.0203 |
| Prior Prolapse Surgery, n/N (%) | 2/87 (2.3) | 17/218 (7.8) | 0.0732 |
| Prior Stress Urinary Incontinence Surgery, n/N (%) | 3/87 (3.4) | 10/218 (4.6) | 0.6571 |
| Randomized Vault Suspension Group: ULS, n/N (%) | 42/87 (48.3) | 114/218 (52.3) | 0.5269 |
| Randomized PMT Group: PMT, n/N (%) | 46/87 (52.9) | 102/218 (46.8) | 0.3378 |
| Stress Urinary Incontinence Symptoms, n/N (%) | 81/87 (93.1) | 199/218 (91.3) | 0.6016 |
| Hunskaar Score, N | 84 | 206 | |
| Median (P25, P75) | 4 (3, 8) | 4 (3, 8) | 0.2371 |
| UDI Score, N | 84 | 206 | |
| Median (P25, P75) | 115 (74, 152) | 120 (91, 161) | 0.1093 |
Active is defined as strenuous exercise at least 90 minutes per week at the point of interest. Less active is defined as strenuous exercise less than 90 minutes per week at the point of interest.
P-values were obtained using Wilcoxon rank-sum test for continuous measures, and Chi-square tests for categorical measures. All tests were conducted at a significance level of 0.05.
Estrogen use is defined as the use of oral, vaginal cream, tablets or cream, or skin patch.
Table 2:
Symptomatic SUI Rates by Activity Level
| Symptomatic SUI 1 | More Active 2 at Baseline N=72 | Less Active 2 at Baseline N=266 | P-value 3 |
|---|---|---|---|
| 6 months | 8/69 (11.6) | 42/243 (17.3) | 0.2563 |
| 12 months | 11/64 (17.2) | 41/233 (17.6) | 0.9393 |
| 24 months | 5/56 (8.9) | 63/222 (28.4) | 0.0025 |
| More Active 2 at 6 months N=97 | Less Active 2 at 6 months N=237 | ||
| 6 months | 14/95 (14.7) | 36/217 (16.6) | 0.6819 |
| 12 months | 12/87 (13.8) | 39/209 (18.7) | 0.3132 |
| 24 months | 15/83 (18.1) | 51/193 (26.4) | 0.1365 |
| More Active 2 at 1 year N=82 | Less Active 2 at 1 year N=237 | ||
| 6 months | 8/76 (10.5) | 38/216 (17.6) | 0.1465 |
| 12 months | 12/74 (16.2) | 38/218 (17.4) | 0.8109 |
| 24 months | 13/68 (19.1) | 48/200 (24.0) | 0.4077 |
| More Active 2 at 2 years N=87 | Less Active 2 at 2 years N=218 | ||
| 6 months | 8/86 (9.3) | 36/196 (18.4) | 0.0539 |
| 12 months | 9/81 (11.1) | 36/194 (18.6) | 0.1289 |
| 24 months | 10/78 (12.8) | 53/199 (26.6) | 0.0138 |
Among women without voiding dysfunction 4, symptomatic SUI is defined as the reoperation or retreatment for SUI (i.e. surgery for UI, pessary for incontinence, supervised pelvic muscle exercises (PME) for UI from 2 weeks to the point of interest) or any positive response to PFDI question 20 (Do you usually experience urine leakage related to coughing, sneezing, or laughing?), 21 (Do you usually experience urine leakage related to physical exercise such as walking, running, aerobics, or tennis?), or 22 (Do you usually experience urine leakage related to lifting or bending over?) at the point of interest.
More active is defined as strenuous exercise at least 90 minutes per week at the point of interest. Less active is defined as strenuous exercise less than 90 minutes per week at the point of interest.
P-values were obtained using Chi-square tests for categorical measures. All tests were conducted at a significance level of 0.05.
Voiding dysfunction was manually classified by the authors based on the specified surgery and medications: if women were on bethanechol, flomax, or rapaflo between 6 and 24 months they were considered to have voiding dysfunction
Figure 1. Distribution of Minutes of Strenuous Exercise Per Week by Visit and SUI Persistence at 2 Years.
* Minutes of strenuous exercise per week for all women who exercised ≤ 110 minutes/week are plotted and the maximum is displayed. The medians (represented by filled symbols), 25th, and 75th percentiles (represented by the whiskers) at each visit by SUI status at 2 years are overlaid.
Only 12 women (3.4%) were extremely active (exercising 300 minutes or more per week) at baseline, 14 (4.2%) were extremely active at 6 months, and 12 were extremely active at 12 and 24 months (3.8 and 3.9% respectively). A total of 38 unique women make up these extremely active groups over the various time points. There were no statistically significant differences in SUI between extremely active women and those who exercised less at any time point. Of the 14 extremely active women at 6 months, 15.4% had symptomatic SUI versus 16.1% of the less active women at that visit. At 12 months, SUI symptoms occurred in 16.7% of extremely active women versus 17.1% of less active. At 24 months, of 12 extremely active women, two had symptomatic SUI (16.7%) versus 23% of the less active women.
Multivariable analysis revealed higher baseline UDI score, white race and increasing time from surgery were predictors of SUI symptoms (Table 3). There were no statistically significant associations between symptomatic SUI and either the surgical or the pelvic muscle training randomization groups.
Table 3:
Model to Predict SUI Symptoms at 6 Months, 1 and 2 Years 1
| Covariate | Odds Ratio (95% Confidence Interval) | P-value 2 |
|---|---|---|
| Active 1 at Visit: Yes vs. No | 0.9 (0.6, 1.5) | 0.7032 |
| Active 1 at Baseline: Yes vs. No | 0.7 (0.3, 1.4) | 0.3123 |
| Age at Randomization: increase of 1 year | 1.0 (1.0, 1.0) | 0.5684 |
| Parity: increase of 1 delivery | 1.0 (0.9, 1.2) | 0.7242 |
| UDI Score at Baseline: increase of 14 units | 1.1 (1.0, 1.1) | 0.0305 |
| Visit: 12 vs. 6 months 2 | 0.9 (0.6, 1.4) | 0.7332 |
| Visit: 24 vs. 6 months 2 | 1.6 (1.1, 2.3) | 0.0157 |
| Visit: 24 vs. 12 months 2 | 1.7 (1.2, 2.5) | 0.0071 |
| Education: Less than 4 years of college vs. 4 years or more of college | 1.7 (0.9, 3.1) | 0.1042 |
| Public Insurance: Yes vs. No | 1.2 (0.6, 2.3) | 0.6477 |
| Race: White vs. Other | 2.6 (1.1, 5.9) | 0.0254 |
| Hispanic: Yes vs. No | 1.4 (0.7, 2.7) | 0.2996 |
| Surgical Group: ULS vs. SSLF | 0.9 (0.5, 1.4) | 0.5552 |
| PMT Group: PMT vs. Usual Care | 0.9 (0.6, 1.5) | 0.6969 |
More active is defined as strenuous exercise at least 90 minutes per week at the time of the visit (6 months, 1 or 2 years). Less active is defined as strenuous exercise less than 90 minutes per week at the time of the visit (6 months, 1 or 2 years).
These variables reflect increasing time since surgery
Discussion
These data failed to support our assumption that increased physical exercise after reconstructive pelvic surgery to correct prolapse and incontinence increases risk of symptomatic SUI. Rather, we found that 2 years after surgery, participants who engaged in a greater amount of strenuous exercise were less likely to report SUI symptoms than less active women. This disparity between more and less active women was also observed 6 and 12 months postoperatively, although the differences in rates of symptomatic leakage were not statistically significant. Similarly, at 2 years, women who performed less strenuous exercise had higher UDI scores indicating a greater degree of urinary distress and bother. Interestingly, supervised pelvic floor muscle therapy was not protective against symptomatic SUI. In multivariable analysis, factors associated with increased odds of symptomatic SUI were higher UDI scores, time since surgery and white race. This is consistent with prior data that slings fail over time 14 and that higher UDI scores predict failure 15. To our knowledge, white race has not previously been shown to predict failure after MUS.
Our findings are consistent with the Nurses Health Study which found that increasing levels of total physical activity were significantly associated with a reduced risk of urinary incontinence, specifically SUI 16. However, the primary activity in that study was walking which most would not consider strenuous exercise. While prospective cohort data also support that greater physical activity is associated with a lower odds of progression to severe incontinence in women with new onset incontinence 17, there is a paucity of evidence for direction of patients on either short or long-term levels of physical exercise after gynecologic surgery 18. Indeed, after an extensive review of the literature Nygaard et al failed to identify a single randomized trial or prospective cohort study that examined the association between postoperative activity and surgical success 18. Similarly, the Society of Gynecologic Surgeons’ Systematic Review Group found that evidence was insufficient to support guidelines for greater or lesser periods of convalesce postoperatively 19. Analogous to the growing body of evidence in orthopedics supporting early resumption of activity to promote restoration of function after soft tissue reconstruction, there are increasing data to support early return to activity after reconstructive procedures for prolapse and incontinence. Mueller et al found fewer pelvic floor symptoms and no differences in anatomic outcomes in women randomized to “liberal” postoperative restrictions compared to restricted activity recommendations, although women in both groups reported similar amounts of strenuous activity despite recommendations 20. With respect to activity levels remote from surgery, until now, data has been absent connecting degree of physical exercise with risk of stress leakage after MUS. The current analysis suggests that increased strenuous exercise is associated with lower rates of symptomatic leakage and, at minimum does not appear to be detrimental postoperatively. It is also possible that MUS work better with high-impact leakage than leakage occurring at low pressures, however, this requires further study.
The Centers for Disease Control provides recommendations for the minimum levels of physical activity for adults. Specifically, to enjoy “substantial health benefits”, adults should engage in at least 150 minutes a week of moderate intensity activity (e.g., brisk walking) or 75 minutes of vigorous-intensity aerobic activity. Further, muscle strengthening activities of moderate or high intensity involving all major muscle groups should be done 2 or more days a week 21. Conversely, increased sedentary behaviors may be detrimental, increasing cardiovascular risk independent of levels of moderate to vigorous physical activity 22. In our study, the “more active” group was defined by the upper quartile of participants’ activity levels, which corresponded to at least 90 minutes of strenuous exercise per week, falling well short of the 150 minutes of moderate intensity activity suggested by the CDC guidelines. Regardless, the more active participants in this study experienced less SUI. In our sub-analysis of “extremely” active participants (described as those with more than 300 minutes of strenuous exercise per week) compared to all others, while we observed less symptomatic SUI in these active participants 2 years after surgery, the differences were not statistically significant. It is not clear from our study whether increased exercise might at some threshold be associated with increased rates of symptomatic incontinence due to our relatively low number of women at the upper extremity of strenuous exercise.
There are several strengths to this study. All patients underwent a standard retropubic midurethral sling procedure at the time of their transvaginal native tissue prolapse repair. Validated instruments were used to assess activity as well as urinary incontinence. A limitation of the study is that our activity measure only looked at minutes of strenuous exercise and not actual force that the exercise might place on the pelvic floor and our assumption that more active women are experiencing more force may not be accurate. Also, activity assessment was subjective and there was no objective measure of exercise, which creates recall bias. Subjects were also asked about strenuous exercise over the prior month, but data was collected at greater than monthly intervals and might not reflect exercise over a yearlong period. As mentioned previously, exercise is a fluctuating variable to which many factors may contribute. For example, while a subject may have been exercising in the fall, once winter hits they may dramatically decrease their exercise and it may have nothing at all to do with their SUI. This is a limitation of using the activities assessment questionnaire to assess exercise. Additionally, correlation of increased strenuous exercise and reduced SUI does not prove causation. Thus, it is possible that symptomatic leakage played a role in reducing strenuous exercise or that reduced exercise is a surrogate for overall worse incontinence or worse health. We were unable to assess whether change in activity level affected SUI symptoms, as in our population, only nine participants changed activity levels from one time point to another, becoming less or more physically active with respect to the 90 minute cut off. This was deemed too few women for a subanalysis to determine if changing activity levels (e.g., increasing exercise) was associated with symptomatic leakage. Less active women were older and more likely to have diabetes. We did not have baseline information on other chronic medical conditions to be able to analyze those differences. Finally, only 305 of the 338 women who had baseline data were available for analysis at 24 months which creates possible bias.
Moderate and vigorous physical activity confers many benefits to overall health and possibly to the maintenance of pelvic floor function in healthy women who have had surgery to correct prolapse and SUI. In this study, more strenuous exercise at the time of and in the years subsequent to MUS was associated with lower rates of symptomatic SUI. This association may support the benefits of ongoing, regular exercise in our patients. Future studies randomizing women to specific physical activity regimens after surgery should provide more insight into the benefits vs. risks of postoperative exercise.
Acknowledgements
We would like to acknowledge those who contributed to the OPTIMAL study:
From Cleveland Clinic: Matthew D Barber, Anna Frick, John Eric Jelovsek, Betsy O’Dougherty, Marie FR Paraiso, Ly Pung, Beri M Ridgeway, Cheryl Williams
From Duke University: Cindy L Amundsen, Ingrid Harm-Ernandes, Mary Raynor, Nazema Y Siddiqui, Anthony G Visco, Alison C Weidner, Jennifer M Wu
From Kaiser Permanente – Downey: John Nguyen
From Kaiser Permanente – Bellflower: Sharon Jakus-Waldman
From Kaiser Permanente – San Diego: Gouri Diwadkar, Keisha Y Dyer, Lynn M Hall, Linda M Mackinnon, Shawn A Menefee, Jasmine Tan-Kim, Gisselle Zazueta-Damian
From Loyola University Chicago: Linda Brubaker, Elizabeth Mueller, Mary Tulke
From University of Pittsburgh, Magee-Womens Research Institute: Diane Borello-France
From RTI International: Marie Gantz, Lauren Klein Warren, Daryl Matthews, Amanda Shaffer, Tamara T Terry, Jutta Thornberry, Dennis Wallace, Ryan E Whitworth, Kevin A Wilson
From Vanderbilt University: Katherine Hartmann
From University of Alabama at Birmingham: Alicia Ballard, Julie Burge, Kathryn L Burgio, Kathy Carter, Patricia S Goode, Alayne D Markland, Lisa S Pair, Candace Parker-Autry, Holly E Richter, R Edward Varner, Tracey S Wilson
From University of California at San Diego: Michael E Albo, Cara Grimes, Emily S Lukacz, Charles W Nager
From University of Michigan: Yang Wang Casher, Yeh-Hsin Chen, Donna DiFranco, Bev Marchant, Cathie Spino, John T Wei
From University of Utah Medical Center: Jan Baker, Yvonne Hsu, Maria Masters, Amy Orr
From University of Texas-Southwestern: Shanna Atnip, Elva Kelly Moore, David Rahn, Joseph Schaffer, Clifford Wai
From Northwest Texas Physician Group, Amarillo, TX: Susan F Meikle
Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development
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