Relationship between hysterectomy and urinary incontinence

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.

Dr. Ling reports no financial relationship to this field of study.

Synopsis: Previous hysterectomy does not appear to be a factor in the development or remission of incontinence.

Source: Neumann GA, et al. Incidence and remission of urinary incontinence after hysterectomy—a 3-year follow-up study. Int Urogynecol J. 2007;18:379-382.

In this Danish study, 415 women who had undergone hysterectomy between 1998 and 2000 responded to the same questionnaire related to incontinence both in September 2001 and also in January 2005. A group of 97 women who had laparoscopic cholecystectomy in 1999 or 2000 served as the control group as they were asked to respond to the same questionnaire at the same time intervals. Stress incontinence was found in 30% of the hysterectomy group in 2005, compared to 28% in 2001. Urge incontinence was reported in 15% and 13%. Interestingly, stress incontinence was found more often at both times in patients who had subtotal hysterectomy.

Within the similar prevalences of incontinence in 2001 and 2005 are the findings that 16% of women who had previously undergone hysterectomy changed from continent in 2001 to stress incontinent in 2005 while 32% changed from stress incontinent to continent. In patients with urge incontinence, these changes were 8% and 35%.

Commentary

This study adds another facet to the complicated relationship between the bladder and the uterus. In fact, the natural history of urinary incontinence is not well-understood. Long ago, ie, when I was a resident, it was felt that once a patient was incontinent, the natural course would be that the woman would remain incontinent. Studies since then have demonstrated that it is not uncommon for patients to go back and forth between continence and incontinence. That would increase the importance for those of us who do hysterectomies to ask the questions about continence before we embark upon the surgery, if, for nothing else, to serve as a baseline determination. This is similar to the importance of us asking about depression and sexual functioning prior to hysterectomy. "Way back when," it was suggested that there is more depression and more sexual dysfunction after hysterectomy. More careful research has determined that this is not the case. Apparently, incontinence falls into that same category.

The finding that subtotal hysterectomy was more associated with subsequent incontinence than total hysterectomy calls into question whether the dissecting of the bladder flap off the cervix truly adversely affects innervation of the bladder as has been suggested by some.

By no means is this the final answer on this topic. My bet is that each of the readers has been queried by surgical candidates about hysterectomy and subsequent incontinence. I know I have. I've also been asked about the risks and benefits of subtotal hysterectomy. I'm sure you have. I admit, though, that I've not suggested to the patients that subtotal hysterectomy is associated with more incontinence. I won't start saying that because I feel that more data are needed, but it certainly appears to me that subtotal hysterectomy benefits do not include prevention of incontinence. Let's all wait and see.