1. Midurethral Sling Surgery and Weight Loss in Women Does effective treatment of urinary incontinence improve soldier readiness? Alan P. Gehrich MD COL, MC Assistant Chief, Dept. OB/GYN Chief, FPMRS Tripler Army Medical Center

2. Disclaimer The views expressed in this presentation are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

3. US Marines Female Engagement Team in Afghanistan

4. Female F-15 Pilots at Elmendorf AFB

5. First Female Army Ranger AUG 2015

6. Defense Policy Change All combat positions should be opened to female soldiers. Defense Secretary Ashton Carter said “Women should have the chance to meet the standards of combat jobs currently closed to them.”

7. The Way Forward To determine the prerequisites for success in these positions To determine how best to select and prepare female soldiers for combat roles

8. Pelvic Floor Disorders Incontinence Prolapse Pelvic pain Recurrent UTI FSD

9. Background 15 % of AD personnel are women – 16% Officers – 14% Enlisted Urinary Incontinence is the most common pelvic floor complaint among women Risk Factors – Age – Parity – Body Mass Index – Socioeconomic background – Race – Diet – Hysterectomy – Comorbid diseases

10. Prevalence of Urinary Incontinence by Age in Civilian Cohort AgeNo. of WomenPrevalence of UIConfidence Interval Overall714217.1%(15.8-18.4) Age 20-291,1283.5%(2.6-4.9) Age 30-391,1179.2%(7.5-11.2) Age 40-491,31815.0%(12.7-17.6) Age 50-501,08522.4%(19.1-26.1) Wu, J et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women OB GYN 2014;123:141-8

11. Non-Modifiable Risk Factors VariableOR ( 95% CI)P value Age (decade)1.2 (1.2-1.3)<.001 Race (Non- Hispanic white compared with all other racial groups) 1.3(1.1-1.5).009 Comorbid Diseases 01.0.001 11.3(1.3-1.5)<.001 21.6(1.4-2.0)<.001 3 or greater2.1(1.6-2.6)<.001 Wu, J et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women OB GYN 2014;123:141-8

12. Modifiable Risk Factors VariableOR ( 95% CI)P value BMI (kg/m 2 ) Less than 251.0 25-29.91.3(1.1-1.6).004 30.0 and greater1.6(1.2-2.0)<.001 Parity O1.0 11.6(1.2-2.1).004 21.5(1.1-2.0).009 31.8(1.3-2.5)<.001 4 or greater2.0(1.5-2.6)<.001 Hysterectomy1.5(1.3-1.7)<.001 Mode of delivery (CS vs VD) NO SIGNIFICANT DIFFERNCE

13. Pelvic Floor Complaints among AD Women AD are exposed to: – Increased physical stressors – Pregnancy Rates comparable to civilian counterparts Pelvic Floor complaints may have greater impact on AD than civilian women – 31% of women modify physical training and field training to prevent urinary incontinence (Davis et al. 1999) Is there also a potential of aggravating pelvic floor disorders with increasing physical demands on women?

14. Percentage of Soldiers Reporting Urinary Incontinence by Age AGE % Davis G et al. Urinary Incontinence Among Female Soldiers Mil Med 164 3:182 1999

15. Activities during which Urinary Incontinence becomes a Social or Hygienic Factor Davis G et al. Urinary Incontinence Among Female Soldiers Mil Med 164 3:182 1999

16. Weight Issues for AD Women Over the past 15 years 3x increase in number of soldiers that do not make height/weight standards Increasing number of Medical Board procedures based on the overweight status

17. Weight Issues for AD female troops Increase in overweight and obese AD females – From 1999 to 2006 Pre-pregnancy BMI increased 24.3-25.4 Demonstrated among all ethnicities – Obesity in pregnancy was associated with adverse obstetric outcomes Hill, CC et al. Military maternal weight trends and perinatal outcomes Mil Med 2013 AUG 178 :880-6

18. Effects of Pregnancy on the Army Physical Fitness Test 52 healthy AD women who participated in pregnancy and post partum physical fitness regimens Weight gain during pregnancy - 15-80lbs Mean 40 point decrease in Army Physical Fitness Test scores (11 months post partum) For every 10lb weight gain during pregnancy, decrease of 6.8 points Weina S et al. Effects of Pregnancy on the Army Physical Fitness Test MilMed 171 :534-537 (2006)

19. Thesis Physical training (PT) clearly precipitates Urinary Incontinence (UI) in AD women UI inhibits full participation of women in PT UI also leads to unhealthy behavior such as dehydration prior to PT EFFECTIVE TREATMENT OF SUI SHOULD IMPROVE LEVEL OF FITNESS AND THEREBY EFFECT A DECREASE IN WEIGHT/ BMI

20. Treatment Options for SUI Weight loss – very effective in obese women but questionably so in overweight women (BMI 25-30) – Suback LL et al. Weight Loss to treat Urinary Incontinence in Overweight and Obese women NEJM 360:481-490 (2009) Pelvic Floor Physical Therapy- 40-60% @ 3 months but markedly deteriorates at 12 months – Richter et al. Conservative Therapy for Stress Incontinence Obstet Gynecol (2010) 115: 609-617 – Doumolin C et al. Pelvic floor muscle training versus no treatment or inactive control treatment for urinary incontinence in women. Cochrane Database Syst Rev 2010 Pessary – 40 % effective @ 1 year – Richter et al. Conservative Therapy for Stress Incontinence Obstet Gynecol (2010) 115: 609-617 Mid urethral sling surgery- 80-90% effective – Appropriate First Line Therapy for SUI – Longevity 5-10 years (70%) – Surgery vs. Physiotherapy for SUI NEJM 2013: 369:1124-33

21. Midurethral Sling and Weight Loss (MUSAWL) study Primary objective - to determine if MUS surgery is associated with a change in postoperative weight and/or BMI Retrospective cohort study –AD females –Civilian beneficiaries WEIGHT/BMI from 3 distinct time periods: –1year prior to operation –At time of surgery –1 year after surgery

22. Methods Any patient who underwent MUS procedures performed between 2006-2013 @ Tripler Army Medical Center were eligible Utilized EMR System to obtain data Paired t-tests - assess change in Weight/BMI between time points P<0.05 = Significant

23. Results 130 Patients with adequate data 22 AD females Age (mean) – AD - 42.1 years – CIV - 47.0 years Parity – 2.4 30 % menopausal (1 AD) Race Caucasian (62%) African American (4%) Asian (14%) Other (20%)

24. Perioperative BMI Change with MUS surgery

25. BMI CHANGE FOLLOWING Midurethral Sling Surgery

26. MUSAWL Conclusion MUS surgery for treatment of SUI does not appear to lead to weight loss AD women seeking surgical treatment for symptomatic SUI are more likely to be: – Overweight – Significantly older than the average soldier

27. Weaknesses Inadequate Numbers – initiating multicenter research Retrospective – Future research needs to be prospective Weight/BMI is only one marker of soldier readiness

28. Future Research Big Data – APFTs Scores now recorded on central database – Corroborate physical fitness with SUI treatment Intervention – Pregnancy/Postpartum Physical Fitness Regimens – Allowing more time for post partum recovery Measure success of interventions for UI by APFT scores, retention, and promotion

29. Conclusion The assessment and maintenance of pelvic floor physical health in addition to musculoskeletal and psychological health will be keys to further integrate women in to active combat roles in the US Army.