Urinary symptoms following hysterectomy

Hysterectomy: a study in coping with recovery

This article reports on part of a descriptive study of recovery from hysterectomy which was set within a cognitive-phenomenological theory of coping. Women's pessimistic beliefs in old wives' tales and the possible effects of hysterectomy were modified as they experienced operation and recovery. The majority made a good recovery in health and activity terms, and according to their own assessments. However information provided by staff and social support from partners, families and friends were low in quality and quantity, and the data includes some evidence that lack of support may have interfered with progress after hysterectomy. Implications of the study for nursing practice and research are discussed in conclusion.

Influence of nonradical hysterectomy on the function of the lower urinary tract

Hysterectomy will sometimes be identified by the patient as the starting point of lower urinary tract (LUT) symptoms. However, it is questionable whether there is a causal relationship. A number of epidemiological studies have found an increase in the relative risk of LUT symptoms of up to 2.2 in patients after simple hysterectomy. However, in numerous prospective, controlled studies including studies using urodynamic testing before and after the operation, such an effect can not be established. The discrepancy between the two types of studies is striking. A number of possible explanations are presented. It is concluded that there is little or no effect of nonradical hysterectomy on the lower urinary tract function.

Hysterectomy and urinary incontinence: a systematic review

BACKGROUND

Serious complications after hysterectomy are estimated to occur in around six women per 10,000 hysterectomies in the USA. We did a systematic review of evidence that hysterectomy is associated with urinary incontinence.

METHODS

We identified English-language and non-English-language articles registered on MEDLINE from January, 1966, to December, 1997, did manual review of references, and consulted specialists. We identified 45 articles reporting on the association of urinary incontinence and hysterectomy. We selected reports that presented original data on development of incontinence in women who underwent hysterectomy compared with those who did not. Results were abstracted by two independent reviewers and summarised with a random-effects model.

FINDINGS

12 papers met our selection criteria--eight cross-sectional studies, two prospective cohort studies, one case-control study, and one randomised controlled trial. The summary estimate was consistent with increased odds for incontinence in women with hysterectomy. Because incontinence might not develop for many years after hysterectomy, we stratified the findings by age at assessment of incontinence. Among women who were 60 years or older, the summary odds ratio for urinary incontinence was increased by 60% (1.6 [95% CI 1.4-1.8]) but odds were not increased for women younger than 60 years.

INTERPRETATION

When women are counselled about sequelae of hysterectomy, practitioners should discuss the possibility of an increased likelihood of incontinence in later life.

Abdominal hysterectomy practice patterns in the United States

OBJECTIVE

To describe nationwide practice trends for two principal techniques of abdominal hysterectomy in the United States, numbers and rates of total (TAH) and supracervical (SCH) hysterectomy were reviewed with charges for each operation.

METHODS

Practice patterns for all inpatient TAH and SCH discharges in the US from 1991 to 1994 were studied using HCUP-3 NIS, a nationwide hospital discharge database. Hysterectomies performed for malignant disease, vaginally or with laparoscopic assistance were not sampled. For each year studied, the number and rate of TAH and SCH, average length of stay (LOS), and mean institutional charge were evaluated.

RESULTS

From 1991 to 1994, the US TAH rate (cases/10000 females) decreased significantly from 25.7 to 20.5 (P = 0.02). During the same interval the SCH rate increased significantly from 0.16 to 0.41 (P = 0.04). Nevertheless, TAH accounted for > 99% of all abdominal hysterectomies for each of the 4 years evaluated. The mean institutional charges for the two operations generally depicted SCH to be more costly than TAH.

CONCLUSION

The national rates of TAH and SCH rates changed significantly in the United States from 1991 to 1994, with TAH declining and SCH increasing. This mix of cases continues to reflect a strong preference for TAH. Although hospital charges for both procedures increased during this study, these data show that SCH is more expensive than TAH. The much lower utilization of SCH renders nominal its impact on national healthcare expenditures, however. Further studies are needed to assess specific causative factors for these changes in US hysterectomy technique.

Supracervical and total abdominal hysterectomy trends in New York State: 1990-1996

To describe practice trends for total abdominal hysterectomy (TAH) and supracervical abdominal hysterectomy (SCH) in New York State and to identify fiscal features associated with these two operations, all inpatient discharges for TAH and SCH performed for benign indications from 1990 to 1996 were reviewed using the Statewide Planning and Resource Cooperative System, a centralized data reporting system. For each year examined, the number of TAHs and SCHs performed, the procedure rates adjusted for the total New York State female population, and the per diem charge (calculated from mean institutional charge as a function of average length of stay) were evaluated. While the TAH rate declined in New York State, from 34.0 in 1990 to 28.4 in 1996 (P = .01), the SCH rate increased nearly five-fold during the same period, from 0.62 to 3.07 (P = .0003). Patients tended to be discharged later following SCH than for TAH, although by 1996, the LOS for both operations was equivalent. The per diem institutional charge for SCH was consistently higher than for TAH in each year studied. The changes in charge and relative frequency of TAH and SCH in New York State invite further study to describe these trends more fully.

A study of female urinary incontinence in general practice. Demography, medical history, and clinical findings

The aim of this study was to provide valid data on the demography, medical history and clinical findings among adult women presenting with urinary incontinence to general practitioners. In a rural community in Norway, all women > 20 years who consulted their general practitioner for urinary incontinence during a 3 year period were included in a prospective study. A thorough medical history and both a general and focused clinical examination were undertaken. Gynecological examination, stress provocation test, and 48 h frequency/volume chart and pad weighing test were also performed. 105 women were included (4.4% of women > 20 years in the total population). Mean age was 57 years, 64% were postmenopausal. A lot of comorbidity was reported. Duration of incontinence was > 5 years in 49%. By a severity index, 64% were classified as severe, 28% as moderate and 8% as having slight incontinence. 59% were using protective pads or garments. Mean leakage per 24 h was 31 g. 38% had significant genital prolapse. Contractility of the pelvic floor muscles was weak in 28%. Diagnostic classification revealed 50% stress incontinence, 10% urge and 40% mixed incontinence. 42% of the patients were a great deal or much bothered by their incontinence. Patients with stress incontinence were less bothered than others. Women presenting with urinary incontinence at a primary care level are prevalent, and often have significant incontinence. It is a challenge for the general practitioners to investigate and treat these patients optimally.

Effects of abdominal hysterectomy on urinary and sexual symptoms

A prospective study of 102 women undergoing abdominal hysterectomy for benign conditions was performed in order to evaluate pre- and post-operative urinary and sexual symptoms. The mean age of the patients was 44.9 years (range 30-65). Urinary disorders such as urgency, dysuria, frequency, nocturia, slow bladder emptying, sensation of residual urine as well as stress and urge incontinence were observed pre-operatively and 2, 6 and 12 months post-operatively. Dyspareunia, libido and the number of orgasms were evaluated as disorders affecting sexual life. At follow-up 12 months post-operatively a statistically significant decrease in stress incontinence, frequency and nocturia was observed. Dyspareunia was also significantly less frequent and increased libido was experienced. It was concluded that abdominal hysterectomy does not provoke adverse urinary or sexual symptoms and that it can have beneficial effects.

Adverse urinary symptoms after total abdominal hysterectomy--fact or fiction?

Urinary symptoms before and after total abdominal hysterectomy in a study group of 80 pre-menopausal women were compared with those in a control group of 78 pre-menopausal women who had dilatation and curettage alone. No urinary symptom was found more commonly after hysterectomy than after curettage, whilst stress incontinence was less common in the study group. Transient symptoms occurred more frequently after hysterectomy.

Urodynamic evaluation of lower urinary tract function in relation to total hysterectomy

Although many women relate the onset of urinary symptoms to the operation of simple hysterectomy, many also have symptoms prior to surgery. Prospective study is therefore the most valid method of objective analysis of the effects of this operation upon micturition. To determine whether total hysterectomy is associated with increased postoperative vesicourethral abnormality, the incidences of urinary symptoms and urodynamic abnormality were assessed pre and postoperatively in 36 women undergoing hysterectomy. Preoperative symptoms were present in 58.3%, although urodynamically proven dysfunction was found in only 38.9%. After hysterectomy, 75% of women were symptomatic with a further 30.6% developing a urodynamic abnormality. The operation of total (simple) hysterectomy is associated with a significant increase in the subjective and objective incidence of vesicourethral dysfunction.

The effects of simple hysterectomy on vesicourethral function

Many women who present with symptoms of bladder dysfunction relate the onset to the operation of simple hysterectomy. A group of 42 women undergoing simple hysterectomy was studied prospectively. Urinary symptoms, urodynamic findings and sacral reflex latencies (SRLs) were assessed pre- and post-operatively. After hysterectomy the incidence of urinary symptoms increased from 58.3 to 75.0%. Vesicourethral dysfunction was altered in 30.6% of patients, 72.7% of whom had evidence of pelvic neuropathy as detected by SRLs. The results show that simple hysterectomy is associated with a significant incidence of post-operative vesicourethral dysfunction and that there is an identifiable neurological abnormality incurred at operation which is pertinent to the subsequent disordered voiding.

Does simple hysterectomy affect lower urinary tract function--a urodynamic investigation

Twenty-five patients who had a simple hysterectomy procedure underwent urodynamic assessment to assess the effect of surgery on lower urinary tract function. This one year survey suggests that neither vaginal or abdominal hysterectomy causes significant ongoing disruption of such function.

Supra-vaginal uterine amputation vs. abdominal hysterectomy: the effects on urinary symptoms with special reference to pollakisuria, nocturia and dysuria

Post-operative symptoms of hysterectomy have received relatively little attention in the literature. In the present study the first author has personally interviewed and examined 105 abdominal hysterectomy patients and 107 patients with supravaginal uterine amputation pre-operatively and thrice post-operatively. At one year the follow-up percentage was 99.5 (211/212). In the statistical analysis McNemar's test of symmetry and Fisher's exact test were used. Loglinear models were developed where applicable. A number of patients had urinary symptoms pre-operatively: 27.6% of the abdominal hysterectomy and 48.6% of the supra-vaginal amputation patients suffered from pollakisuria; preoperative nocturia and dysuria were present in about 10% of patients in each group. These urinary symptoms disappeared more frequently in patients who underwent supra-vaginal amputation; with regard to pollakisuria the difference is statistically significant. Twelve months post-operatively pollakisuria was present in 10.3% of supra-vaginal amputation and 13.5% of hysterectomy patients. The advantage of supra-vaginal amputation over abdominal hysterectomy with regard to these symptoms may result from the considerably less extensive manipulation of the bladder during supra-vaginal amputation. Possibly the support provided by the remaining stump and the round ligaments fixed to it also help to reduce urinary symptoms in these patients. However, further urodynamic studies are needed.

Vaginal morphology following hysterectomy

This study was designed to gain more information about morphology of the vagina after hysterectomy. The prospective clinical observations of patients subjected to abdominal or vaginal extrafascial or intrafascial hysterectomy with or without correction of anatomical urinary stress incontinence were included. The length, configuration and axis of the vagina were determined using a vaginal cast technic. Vaginal casts were prepared prior to and 6 months to 4 years after surgery. The gross appearance of the vagina after hysterectomy is affected by understanding normal pelvic anatomy an physiology, careful preoperative evaluation of pelvic defects, proper planning and competent performance of surgery. Proper handling of the endopelvic fascia and its condensations, the cardinal and sacrouterine ligaments, corrects preexisting weakness, provides vaginal suspension and prevents future vaginal disfigurement. Inadequate surgical technics result in magnifying preexisting weakness of pelvic supports. Successful surgery involves correcting the levator complex by reducing and shifting the levator hiatus ventrally. Reconstruction of the perineal body is essential. This study suggests a relationship between successful surgical treatment of urinary stress incontinence and reconstruction of pelvic supportive structures, with restoration of the physiological vaginal axis.

Urinary Symptoms and total hysterectomy

A prospective study of urinary symptoms before and after total hysterectomy for a variety of gynaecological disorders has been made in 104 women. 62% were symptomatic preoperatively. Of this group 11% of the preoperatively symptomatic and 25% of the preoperatively asymptomatic either had their symptoms worsened or had symptoms appear 6 months after the operation. However, the total number of symptomatic women was reduced to 50% 6 months postoperatively. The case against total hysterectomy in the production of urinary symptoms remains to be proven.