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Examining the Evidence


Hysterectomy and incontinence

July 2002 · Vol. 14, No. 7

THE QUESTION:
Does hysterectomy contribute to the occurrence of urinary incontinence?

Past studies

These have shown that hysterectomy is associated with the development of changes in urinary function, particularly urinary incontinence.

This study

The study population consisted of a random sample of 2,322 women between the ages of 35 and 70 selected from a suburban area in the central part of the Netherlands. These women were invited to fill out a questionnaire from the Urogenital Distress Inventory regarding their sociodemographic variables and medical history.

Of the approximately 1,626 respondents, 1,417 had no history of hysterectomy. The remaining 209 women had undergone hysterectomy for nonmalignant conditions; information on the surgical route of the procedure was not obtained.

The adjusted odds ratio of urinary incontinence for women with a history of hysterectomy was 1.4 (95% confidence interval [CI], 1.0-1.9) compared with women without such a history. Further, the adjusted odds of urge (relative risk [RR], 1.9; 95% CI, 1.4-2.6) and bothersome urge (RR, 2.6; 95% CI, 1.4-4.4) urinary incontinence were increased in women who had a hysterectomy.

The authors’ findings suggest that hysterectomy is associated with a 30% increased risk of urge and bothersome urge incontinence. These symptoms were present in women younger and older than 60 years.

Find this study

Van der Vaart et al, February 2002 issue of the British Journal of Obstetrics and Gynaecology; abstract online at www.bjogelsevier.com.

Who may be affected by these findings?

Women who had or will have a hysterectomy.

Expert commentary

This study explores the possibility that iatrogenic overactive bladder is an unavoidable complication of a common procedure. Why hysterectomy is a risk factor for urge incontinence is not clear, although overactivity has been linked to innervation problems of the detrusor muscle. Here, I will outline the surgical techniques of hysterectomy and the pelvic anatomy that may contribute to the problem.

Whether the surgeon utilizes “push with a sponge stick” or “sharp dissection” techniques, detaching the bladder from its underlying anterior vaginal wall may disrupt the pelvic plexus of nerves, which contains both autonomic (sympathetic and parasympathetic) and somatic pathways. The sympathetic nerves originate at spinal cord levels T5 to L2 and wind their way from the presacral fascia to the lateral pelvic sidewall, close to the ureter. Here, they join with parasympathetic nerves to form the pelvic plexus, which innervates the upper vagina, bladder and proximal urethra.1 Clearly, dissecting the bladder flap can disrupt the plexus. From a neurophysiologic standpoint, this disruption may explain the occurrence of de novo overactive bladder.

The pelvic surgery literature suggests that dissection of the anterior vaginal wall, especially under the bladder neck, may result in bladder dysfunction.2 This investigation supports previous studies that have implicated hysterectomy as a causative factor of an overactive bladder.3-5 One weakness: Van der Vaart and associates use no clinical tools to assess bladder dysfunction, and self-reporting may be difficult to validate. At the same time, the authors point to the poor reliability of urodynamic testing as the “gold standard” in evaluating the overactive bladder.

The bottom line

There is good reason to believe that innervation to the bladder is disrupted during a routine hysterectomy. Although we lack conclusive data, a supracervical hysterectomy may completely obviate this problem.

Until more information becomes available, we should ask our patients about frequency and urgency prior to surgery and alert them of these potential sequelae. It may only be a matter of time before we approach the hysterectomy similar to the “nerve sparing” prostatectomy.

REFERENCES

1. Benson JT. Pelvic floor neuropathy in female pelvic floor disorders. In: Benson JT, ed. Female Pelvic Floor Disorders:Investigation and Management. New York: WW Norton & Co; Norton Medical Books; 1992;142-152.

2. Zivkovic F, Tamussino K, Ralph G, et al. Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. Obstet Gynecol. 1996;87:257-260.

3. Virtanen H, Makinen J, Tenho T, et al. Effects of abdominal hysterectomy on urinary and sexual symptoms. Br J Urol. 1993;72:868-872.

4. Parys BT, Woolfenden KA, Parsons KF. Bladder dysfunction after simple hysterectomy: urodynamic and neurological evaluation. Eur Urol. 1990;17:129-133.

5. Parys BT, Haylen BT, Hutton JL, et al. The effects of simple hysterectomy on vesicourethral function. Br J Urol. 1989;64:594-599.

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