Urinary incontinence after hysterectomy—three-year observational study

Effects of hysterectomy on pelvic floor function and sexual function-A prospective cohort study

INTRODUCTION

Hysterectomy is one of the most common major surgical procedures in women. The effects of hysterectomy on pelvic floor and sexual function are uncertain. Our objective was to investigate the effects of hysterectomy for benign indications on pelvic floor and sexual function and to compare different modes of surgery.

MATERIAL AND METHODS

We performed a prospective clinical cohort study. In all, 260 women scheduled for hysterectomy answered validated questionnaires (Pelvic Floor Impact Questionnaire, Pelvic Floor Distress Inventory and Female Sexual Function Index). Participants were followed 6 months and 1 year after surgery. Data were analyzed using nonparametric statistics and mixed effect models.

RESULTS

Women with subtotal hysterectomy, vaginal hysterectomy, laparoscopic assisted vaginal hysterectomy, and previous prolapse/incontinence surgery were excluded from further analysis, leaving the remaining cohort to 242 patients. The response rate at 6 months and 1 year follow-up was 180/242 (74.3%) and 169/242 (69.8%), respectively. There was an improvement of pelvic floor function at both follow-ups; mean score of Pelvic Floor Impact Questionnaire at baseline was 42.5 (51.7), at 6 months 19.9 (42.2) and at 1 year 23.7 (50.3) (p < 0.001). The mean score of Pelvic Floor Distress Inventory at baseline was 69.6 (51.1), at 6 months 49 (43.2) and at 1 year 49 (43.2) (p < 0.001). There was an improvement of sexual function after 6 months (mean score of Female Sexual Function Index at baseline 17.9 [SD 11.7] and at 6 months 21.0 [SD 11.7]) (p < 0.001). There was no difference in pelvic floor or sexual function when comparing surgical techniques.

CONCLUSIONS

Robotic assisted laparoscopic hysterectomy, laparoscopic hysterectomy and abdominal hysterectomy improve pelvic floor function to the same extent at 6 months and 1 year after surgery. There was an overall improvement of sexual function 6 months after hysterectomy, but this did not persist after 1 year.

[Impact of hysterectomy on urinary incontinence: A systematic review]

INTRODUCTION

The impact of a hysterectomy on urinary incontinence is a controversial subject in the literature.

OBJECTIVE

To evaluate the prevalence and incidence of urinary incontinence after a hysterectomy as well as associated risk factors such as the type of hysterectomy, the surgical approach, urodynamic criteria and uterine disease.

STUDY DESIGN

We conducted a systematic review in Pubmed database with the following keywords and MeSH term: hysterectomy, urinary incontinence.

RESULTS

A total of 1340 articles were retrieved, 42 articles were selected for the final text analysis. The results of the different studies were heterogeneous. Hysterectomy seemed to increase the rate of sphincter deficiency (VLPP<60mmH₂O for 20% of cases versus 1,7% without hysterectomy, P=0.003). The vaginal route could increase the incidence of UI with OR of 2.3 (95%CI 1.0-5.2). Subtotal hysterectomy appears to increase UI with a 0,74 RR for total hysterectomy (95%CI 0.58-0.94). A radical hysterectomy with nerve conservation would preserve urinary functions, unlike pelvic radiotherapy, which is responsible for irreversible nerve damage by demyelination and bladder fibrosis.

Risk factors and prevalence of urinary incontinence in mid-life Singaporean women: the Integrated Women's Health Program

INTRODUCTION AND HYPOTHESIS

The objective was to identify the prevalence and risk factors for urinary incontinence (UI) in healthy midlife Singaporean women.

METHODS

Healthy women, aged 45-69 years, were assessed for UI and sociodemographic characteristics, including ethnicity, menopausal status, parity, and body mass index (BMI). UI subtypes corresponding to stress (SUI) alone, urge (UUI) alone, mixed (MUI), and leakage (drops only) incontinence were classified using the Urinary Distress Inventory 6 (UDI-6). Risk factors were examined using Chi-squared tests, followed by sequential multivariate logistic regression to estimate adjusted odds ratios (aOR and 95% confidence intervals).

RESULTS

A total of 1,119 women (mean age 56.2 ± 5.2) completed the UDI-6. 52.3% reported any UI; MUI and SUI were the most common, each affecting 20% of women. Post-menopausal women had a lower risk (aOR 0.5 [0.3-0.9]) of SUI, but a higher risk (aOR 4.4 [1.0-19.9]) of UUI compared with premenopausal women. Higher education was negatively associated (aOR 0.3 [0.2-0.7]) with UUI, but positively associated with MUI (aOR 2.3 [1.3-4.0]). Parity (1-2 children) increased the risk of SUI (aOR 1.8 [1.0-3.1]), but reduced the risk of UUI (aOR 0.4 [0.2-0.9]). Obesity was associated with increased risk for MUI (aOR 2.2 [1.4-3.4]) and leakage (aOR 2.0 [1.0-4.1]). Malays and Indians had a higher risk of MUI, having (aOR 2.1 (1.2-3.7) and 1.7 (1.1-2.7) respectively compared with Chinese, a difference mediated by higher BMI.

CONCLUSION

Urinary incontinence is a major morbidity prevalent in healthy midlife Asian women. Post-menopausal status, education level, parity, BMI (and its link with ethnicity) are independent risk factors in this population, and should be incorporated into counseling and targeted interventions.

Relationship between hysterectomy and severity of female stress urinary incontinence

Background

Stress Urinary Incontinence (SUI) is one of the most reported health dilemmas of women suffering from lower urinary tract symptoms.

Aim

To determine the relation between hysterectomy and severity of female SUI using Valsalva Leak Point Pressure (VLPP).

Methods

This case-control study was conducted at a public urology clinic in Tehran in 2015. The study population was all female with SUI complaints who visited the clinic during 2015. We compared Valsalva leak point pressure in two groups of female SUI patients with and without hysterectomy history. The inclusion criteria were: not taking any alpha-blocker or anti-cholinergic medicines two weeks prior to the urodynamic test as well as no history of pelvic surgery or cesarean delivery in their lifetime. All qualified patients were invited to participate in the study randomly, and among them, 120 qualified patients agreed to participate by filling out the informed consent form. Data was gathered through direct interview, and double checked by patients’ medical records. All the study variables including age, BMI, delivery number, hysterectomy and UTI history were entered and analyzed by estimating ordered logistic regression and by using Stata14.1 software.

Results

The mean of VLPP was 70.17 cmH₂O in the group with hysterectomy history, and 94.55 cmH₂O in those without hysterectomy history. The difference of VLPP pressure between the two studied groups were significant (p<0.05), even after control of confounding variables. Also, the odds of severe SUI among hysterectomy group patients was 6.3 times more than no hysterectomy (OR=6.32, p<0.001).

Conclusions

Our study confirms significant relation between hysterectomy and SUI severity measured by Valsalva leak point pressure. Hysterectomy patients are more likely to suffer from more severe grades of SUI.

Effects of Hysterectomy on Pelvic Floor Disorders: A Longitudinal Study

BACKGROUND

Hysterectomy might adversely affect pelvic floor functions and result in many different symptoms, such as urinary and anal incontinence, obstructed defecation, and constipation.

OBJECTIVE

The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders.

DESIGN

This was a prospective and longitudinal study.

SETTINGS

The study was conducted at the Ankara University Department of Surgery and the Dr Zekai Tahir Burak Women's Health Research and Education Hospital between September 2008 and March 2011.

PATIENTS

The study was performed on patients who underwent hysterectomy for benign pathologies.

MAIN OUTCOME MEASURES

A questionnaire about urinary incontinence (International Continence Society scoring), anal incontinence, constipation, and obstructed defecation (Rome criteria and constipation severity score), along with an extensive obstetric history, was administered preoperatively and postoperatively annually for 4 years.

RESULTS

Patients (N = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. Compared with the preoperative observations, the occurrence of each symptom was significantly increased at each of the follow-up years (p < 0.001). Over the 4 postoperative years, the frequencies for constipation (n = 245) were 7.8%, 8.2%, 8.6%, and 5.3%; those for obstructed defecation (n = 269) were 4.5%, 5.2%, 4.1%, and 3.0%; those for anal incontinence (n = 252) were 4.8%, 6.3%, 6.0%, and 5.2%, and those for urinary incontinence (n = 99) were 12.1%, 12.1%, 11.1%, and 13.1%. In addition, patients who had no preoperative symptom (n = 70) from any of the selected symptoms showed a postoperative occurrence of at least 1 of these symptoms of 15.8%, 14.3%, 11.4%, and 8.6% for the postoperative years 1, 2, 3, and 4.

LIMITATIONS

Although the study had several limitations, no comparison with a control population was the most important one.

CONCLUSIONS

Hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms.

Patient-reported lower urinary tract symptoms after hysterectomy or hysteroscopy: a study from the Swedish Quality Register for Gynecological Surgery

Introduction and hypothesis

Hysterectomy is sometimes considered the cause of lower urinary tract symptoms (LUTS). We hypothesized that hysterectomy for abnormal uterine bleeding and/or symptoms of fibroids is more likely to cause LUTS than a hysteroscopic procedure for the same indications.

Methods

Two groups of women were compared: one group comprised 3,618 women who had had a hysterectomy due to abnormal uterine bleeding or symptoms of fibroids and the other group comprised 238 women who had had hysteroscopic treatment for the same indications. The main outcome measures were occurrence of LUTS before and 1 year after the surgical intervention. The frequencies of LUTS before and after surgery were compared between the groups. Binary logistic regression was used to model the odds of having postoperative urinary leakage and urgency while controlling for uterine size, surgical procedure and preoperative LUTS.

Results

There were no statistically significant differences between women after hysterectomy and after hysteroscopy in the frequencies of LUTS before or after surgery, when uterine size was comparable. However, there was a difference in the rates of de novo urinary incontinence between women with hysterectomy and women with hysteroscopy (7.6%, 95% CI 6.3–9.0, and 3.2%, 95% CI 1.6–6.5, respectively). Of the women with a large uterus, 58.6% (95% CI 51.5–65.5) reported relief of urinary incontinence and 85.5% (95% CI 82.3–88.4) reported relief of urinary urgency postoperatively.

Conclusions

Our results suggest that it is important to individualize preoperative information in women prior to hysterectomy since the outcome concerning LUTS depends on preoperative symptoms and uterine size.

Objective comparison of subtotal vs. total abdominal hysterectomy regarding pelvic organ prolapse and urinary incontinence: a randomized controlled trial with 14-year follow-up

OBJECTIVE

To compare subtotal and total abdominal hysterectomy regarding objective assessment of pelvic organ prolapse, urinary incontinence and voiding function 14 years after hysterectomy for benign diseases.

STUDY DESIGN

Long-term follow-up of a randomized clinical trial of subtotal vs. total abdominal hysterectomy with objective outcomes. All randomized women still alive and living in Denmark (n=304) were invited to answer a questionnaire and come for clinical examination consisting of 20-min pad weighing test, urinary flow, measurement of residual urine, POP-Q measurement for pelvic organ prolapse, 3 day voiding diary and also filled out the pelvic floor distress inventory (PFDI-20) questionnaire.

RESULTS

We included 100/304 (32.9%) women (subtotal hysterectomy: 53, total hysterectomy: 47) in the clinical examinations. The study questionnaire was answered by 197 (64.8%) (subtotal: 97, total: 100), the PFDI-20 questionnaire was answered by 140 (46.1%) (subtotal: 68, total: 72). We found no difference between subtotal and total abdominal hysterectomy in the PFDI-20 scores or regarding objectively assessed urinary incontinence or pelvic organ prolapse. In the subtotal hysterectomy group, 31 (59.6%) women had objective stage 2 pelvic organ prolapse compared with 33 (70.2%) in the total hysterectomy group (P=0.27); however, only 6/31 and 9/33 had symptoms (P=0.45). There were more anterior pelvic organ prolapses in the total hysterectomy group (N=10) than in the subtotal hysterectomy group (N=4) (P=0.048). We found a higher mean maximum flow rate (Qmax) in the subtotal hysterectomy group (34.78ml/s) than in the total hysterectomy group (27.08ml/s) (P=0.042) as well as a higher mean functional capacity in the subtotal hysterectomy group (526ml) than in the total hysterectomy group (443ml) (P=0.0147) according to the voiding diary.

CONCLUSION

Subtotal and total abdominal hysterectomy are comparable regarding long-term objective pelvic organ prolapse and urinary incontinence. The subtotal hysterectomy group had a higher Qmax and voided volume.

Prevalence and risk factors of urinary incontinence among Estonian postmenopausal women

Aims

To estimate the prevalence of urinary incontinence (UI) and to assess its risk factors among postmenopausal Estonian women.

Methods

In 2004, 1363 women participating in the Estonian Postmenopausal Hormone Therapy Trial were asked at the closure visit to the trial physician about symptoms of UI. The type of incontinence was assessed with the help of a questionnaire, based on recommendations from the working group set up by the Finnish Gynaecological Association. Frequency characteristics were analysed by descriptive statistics. Risk factors were examined using logistic regression.

Results

Mean age of study women was 53.3 years (min = 48, max = 67; SD 4.0). The prevalence of UI was 18.12% (95% CI: 16.07 - 20.17). Stress incontinence was diagnosed in 78.83% (95% CI: 73.32 - 84.33) and urge or mixed incontinence in 21.17% (95% CI: 15.67 - 26.68) of women who reported incontinence. Prevalence of UI slightly increased with age. Women who used hormone therapy (HT) (OR 1.67; 95% CI: 1.17 - 2.39), had had hysterectomy (1.73, 95% CI: 1.06 - 2.83), and those with secondary education (OR 1.87, 95% CI: 1.23 - 2.82) or basic education (OR 3.29, 95% CI: 1.80 - 6.02) had a higher risk for UI. Parity, having a BMI over 30 kg/m², being a smoker or a former smoker, having diabetes and being physically or sexually active, tended to increase the risk of UI.

Conclusions

About one in five postmenopausal women in Estonia reported to have UI. Risk factors linked with UI, its prevalence in other age groups and the impact of UI on quality of life deserve more research.

Trial registration

Number: ISRCTN35338757

Surgical treatment of mixed and urge urinary incontinence in women

BACKGROUND/AIMS

The etiology of urge urinary incontinence is unknown. Pharmacological treatments are disappointing, since they are only slightly more effective than a placebo. In this study, we analyzed whether the surgical replacement of the uterosacral ligaments by an alloplastic tape can cure patients with mixed and urge urinary incontinence.

METHODS

This study was a nonrandomized clinical trial. The study was performed in the Department of Gynecology of a general hospital and a university clinic. 135 women with urge or mixed urinary incontinence were operated on. The utero-sacral ligaments as well as the pubo-urethral ligaments - if necessary - were replaced by alloplastic tapes. Clinical outcome was evaluated immediately after surgery, 3 months later and 1 year later. Outcome was classified as cure, improvement or failure and recurrences.

RESULTS

102 patients (77%) were cured and a further 24 patients (18%) showed improvement after surgery. 19 patients developed a recurrence between 5 and 33 months after surgery.

CONCLUSION

We therefore conclude that most patients with urge and mixed urinary incontinence can be cured by surgery.

Reoperation for urinary incontinence

OBJECTIVE(S)

The objective of the study was to describe the rate and associated factors of reoperation for urinary incontinence.

STUDY DESIGN

A cohort study using Washington state hospitalization records from 1987 to 2005 of inpatient urinary incontinence surgeries. The cumulative reoperation rate was estimated for the entire cohort and by procedure. Cox regression was used to estimate the hazard of reoperation.

RESULTS

A total of 41,705 women underwent either a sling or retropubic colposuspension (Burch); 1895 underwent reoperation for urinary incontinence (8.6%; 95% confidence interval, 7.8-9.5%), a rate of 5.5 per 1000 woman-years. Women undergoing Burch had a lower reoperation rate than those undergoing slings (4.2 vs 6.7 per 1000 woman-years; P < .001). Concomitant hysterectomy was associated with a lower reoperation rate for Burch and sling repairs (5.4-2.9 and 7.7-4.2 per 1000 woman-years).

CONCLUSION(S)

Reoperation for urinary incontinence occurs commonly in the general population. The variable reoperation rate observed should be further investigated, given current trends toward increased Sling use.

Chapitre G - Les conséquences neuro-urologiques de la chirurgie gynécologique (endométriose, hystérectomie simple, colpo-hystérectomie élargie), de la chirurgie colo-rectale et de la radiothérapie pelvienne

Apart from damage to bladder innervation, a number of local diseases and treatments such as radiotherapy can induce lower urinary tract functional disorders. Some of these disorders can be treated according to the principles used in the management of neurogenic bladder The purpose of this review is to report the functional consequences of pelvic endometriosis, radiotherapy, colorectal surgery and urinary incontinence surgery with particular emphasis on situations in which a neurogenic mechanism is suspected.