Hysterectomy Is Associated with Stress Incontinence

Original Article Gynecol Obstet Invest 2007;63:121–125 DOI: 10.1159/000096433

Received: June 9, 2006 Accepted after revision: August 19, 2006 Published online: October 19, 2006

Hysterectomy Is Associated with Stress Incontinence in Women Who Previously Had a Transcervical Endometrial Resection Rubab Agha Krogh Gudrun Astrid Neumann Finn Friis Lauszus Eigil Guttorm Kjeld Leisgaard Rasmussen Department of Gynecology and Obstetrics, Herning/Holstebro Hospital, Ringkoebing County, Herning, Denmark

Key Words Hysterectomy ? Transcervical endometrial resection ? Urinary incontinence ? Stress incontinence

Abstract Objectives: To compare the prevalence of urological symptoms in a population of women, who had a transcervical endometrial resection (TCER) only, and a population of women, who had a TCER and a subsequent hysterectomy. The superior goal was to evaluate the possible association between hysterectomy and urinary incontinence. Design: All women, who had a TCER at our department during the period of 1990–1996 received a questionnaire with focus on urological symptoms. The answers from women, who later had a hysterectomy were compared to the answers from women, who were sufficiently treated with TCER only. Results: Of 356 women, who were alive, 16 were lost to follow-up, leaving 340 women to receive the questionnaire, which was returned by 310 women (85%). Ninety-three (31%) had a subsequent hysterectomy mainly indicated by metrorrhagia or dysmenorrhea. Of the hysterectomized women 24% reported bothersome stress incontinence against 14% in the group of women, who had TCER only (p = 0.03). No significant difference was seen with respect to urge incontinence, urgency, pollakisuria or nocturia. Significantly more women with

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a normal sized uterus reported bothersome stress incontinence after the hysterectomy compared to women with a slightly enlarged uterus. Conclusion: Hysterectomy is significantly associated with stress urinary incontinence in women, who previously had a TCER. Copyright © 2007 S. Karger AG, Basel

Brief Summary

Hysterectomy is significantly associated with stress urinary incontinence in women, who previously had a transcervical endometrial resection (TCER). Hysterectomy is related to urinary incontinence in several studies [1–4]. However, newer reports fail to show any association [5–9], and some authors report data that are directly conflicting with a theory of simple surgical lesion to the bladder or bladder neural structures as the cause of urinary incontinence. Gimbel et al. [10] showed in a randomized study that women with previous supracervical hysterectomy had a significantly higher prevalence of urinary incontinence than women with previous total hysterectomy. In a non-randomized study, Neumann et al. [11] showed a similar correlation between supracervical hysterectomy and late postoperative urological symptoms. K. Rasmussen Glensovej 10 Skovsborg DK–8620 Kjellerup (Denmark) Tel. +45 868 790 09, Fax +45 992 723 46, E-Mail [email protected]

A possible explanation of the conflicting data may be that hysterectomy is not necessarily the cause of urinary incontinence, but that conditions leading to hysterectomy share some common factors with conditions leading to urinary incontinence. The present study was designed to investigate the possible association between hysterectomy and urinary incontinence after TCER indicated by meno-metrorrhagia.

Materials and Methods During a 7-year period from 1990 to 1996 420 TCER were performed in 366 women at the Department of Gynecology and Obstetrics, Holstebro Hospital, Ringkoebing County, Denmark. In all cases TCER was indicated by meno-metrorrhagia and performed only on normal sized (n = 237) or slightly enlarged uteri (n = 64). Uterine size was evaluated by clinical examination and measurement of uterine cavity depth in all patients and supplied by vaginal ultrasound from approximately 1992. A uterine cavity measurement of more than 10 cm was regarded as a contraindication to TCER. In January 2005, a questionnaire including items on urological matters (appendix) was sent to all traceable women. The questionnaire has previously been presented [11]. Data were stratified as the women had or had not a subsequent hysterectomy. Bladder release from the cervix was at abdominal hysterectomy done by sharp dissection in the midline followed by gentle blunt pushing down of eventually residual tissue more laterally. At vaginal hysterectomy the cervical mucosa and connective tissue was cut down to the point where fascial tissue was divided. The bladder was then bluntly pushed upwards, until the peritoneum between the uterus and the bladder could be opened sharply. No special technique was used when removing the slightly enlarged uteri. Statistical analysis of difference between two means was performed with Student’s t test, if Gaussian distribution could be assured. Otherwise, Mann-Whitney’s test was used. Chi-square test was performed with Yates correction for discontinuity or, when appropriate, Fisher exact test. Linear regression analysis was performed with incontinence scoring as dependent variable and BMI, age, vaginal deliveries, number of cesarean sections, parity, and sterilization and hysterectomy status as independent variables. Multivariate analysis was performed to test the conclusion on incontinence status for confounding of the results by the above variables. Values are given as mean 8 SD, unless otherwise stated. A two-sided p value ! 0.05 was the level of significance. The statistical software was SOLO (BMPD, Los Angeles, Calif., USA).

Results

Of the 366 included women, 10 had died since the TCER. Sixteen (2%) were lost to follow-up leaving 340 women to receive the questionaire, of whom 310 (85%) responded. Nine women returned the questionnaire, but did not want to participate in the study. The statistical 122

Gynecol Obstet Invest 2007;63:121–125

Table 1. Basic information on total population investigated in re-

lation to hysterectomy status

Number Age at TCER, years Age at questionnaire, years BMI, kg/m2 Height, cm Weight, kg Nullipara, % Parity Ever had a cesarean section, % Hysterectomy type Abdominal total, n (%) Vaginal, n (%) Supracervical, n (%) LAVH, n (%)

No hysterectomy

Hysterectomy

208 4586 5686 24.784.4 16786 68.7813.1 3 2.4 14

93 4387 5587 25.585.4 16685 70.5814.6 8 2.4 16 61 (66) 11 (12) 9 (10) 12 (13)

Table 2. Urological symptoms in relation to hysterectomy status

No hyster- Hysterectomy ectomy Number Significant stress incontinencea Bothersome stress incontinence* Significant urge incontinencea Bothersome urge incontinence* Urgency Voiding > ! 10/24 h Nocturia > ! 2/night Use of devices Hygienic problem Reduced social ability

208 29 (14) 26 (13) 11 (5) 11 (5) 56 (27) 20 (10) 9 (4) 53 (25) 43 (21) 12 (6)

93 24 (26) 22 (24) 9 (10) 9 (10) 27 (29) 10 (11) 4 (4) 29 (31) 26 (28) 17 (18)

p

0.02b 0.03c 0.21 0.21 0.68 0.89 1.00 0.33 0.19 0.002d

Percentages in parentheses. * Significant incontinence plus either use of device, having a hygienic problem or having reduced social ability. a Incontinence weekly or more. b OR = 2.2 (1.2–4.0); c OR = 2.1 (1.1–4.0); d OR = 3.7 (1.7–8.1).

analysis is therefore based on 301 questionaires. We had data on BMI in 289 women (96%) and their delivery data and parity in 262 women (87%). Basic informations on the patients are shown in table 1. Ninety-three of the respondent women (31%) had a subsequent hysterectomy. Indications for hysterectomy were mainly persisting meno-metrorrhagia (75%) or dysmenorrhea (18%). None Krogh/Neumann/Lauszus/Guttorm/ Rasmussen

Table 3. Significant urinary stress incontinence in relation to the

size of uterus in women having a hysterectomy. + Stress – Stress Number incontinence incontinence

Normal size uterus Slightly enlarged uterus

20 (33) 4 (12) 24 (26)

40 (67) 29 (88) 69 (74)

40 (100) 33 (100) 93 (100)

Percentages in parentheses. Normal size vs. slightly enlarged uterus: p = 0.028.

had a malignant disease. Data on present urological status are shown in table 2. There was a significant association between significant or bothersome stress incontinence and hysterectomy, while this was not shown for urge incontinence or urgency. At simple regression analysis BMI, vaginal deliveries, and hysterectomy were found associated with stress incontinence score (r = 0.22, r = 0.16, and r = 0.12, p ! 0.001, p ! 0.01, and p ! 0.04, respectively), while age at TCER was only marginally significant (r = 0.11, p ! 0.06). By stepwise manual regression, previous hysterectomy turned out to have the strongest association with stress incontinence adjusting for BMI, vaginal delivery, and age at TCER (r = 0.20, p ! 0001). When stratifying data after the size of the uterus, only women with a normal sized uterus at the time of hysterectomy reported significantly increased prevalence of stress incontinence (table 3).

Discussion

Hysterectomy was originally thought to cause urinary incontinence by the minutious dissection to release the bladder from the cervix, which may damage the nerve supply to the bladder and the sphincter. Furthermore, removal of the uterus including the cervix may interfere with the supporting structures responsible for maintenance of continence. In accordance with this, Brown et al. [1] published a systematic review on hysterectomy and urinary incontinence showing a 60% increase in odds for having urinary incontinence if hysterectomized previously. In another review from 2001 Vierhout [5] on the contrary found no effect of hysterectomy on lower urinary tract symptoms. He pointed out a pronounced discrepancy between some cross-sectional studies showing an adverse effect of hysterectomy on continence status, Hysterectomy in Women Who Had TCER

and some prospective, controlled studies that did not show such negative effect. As mentioned by Vierhout [5] and supported by Kjerulff et al. [9], many prospective, controlled studies in fact show a positive effect of hysterectomy on continence. The increased risk of urinary incontinence in subtotal hysterectomized women compared to total hysterectomized women shown by some investigators [10, 11] is difficult to explain either from a theory based on nerve damage caused by dissection or on loss of support from adjacent pelvic connective tissue. As vaginal hysterectomy is becoming increasingly popular, it may be interesting to compare this operation to total abdominal hysterectomy with respect to later development of urinary symptoms. Our study was not designed to compare different modes of hysterectomy, as randomization was not performed in the past. No previous study suggests, however, that one method is superior to the other [6, 7, 11]. In contrast to van der Vaart et al. [2] and Kaya et al. [3], we did not find any increased risk of urge incontinence after hysterectomy. A major problem in all studies on hysterectomy and urinary incontinence is the control of confounding factors. A heavy uterus compressing the bladder may cause as well meno-metrorrhagia as urinary incontinence, which either are cured or improved by a hysterectomy. This may consequently overshadow a possible negative effect on urinary continence of the hysterectomy per se. Our finding of a significantly increased prevalence of stress incontinence after hysterectomy in women with a normal sized uterus, but not in women with a slightly enlarged uterus, suggests that this bimodal effect is very likely. Overweight is another common risk factor for as well meno-metrorrhagia as urinary incontinence. In our study, all women, whatever they ended with a hysterectomy or not, shared the common factor of meno-metrorrhagia as the index symptom, and had a TCER performed on a normal sized or only slightly enlarged uterus. None had a heavily enlarged uterus, which was regarded as a contraindication to TCER. Hysterectomized and nonhysterectomized women did not differ in body weight or age. After controlling these confounders, we found a significantly higher prevalence of bothersome stress incontinence in hysterectomized women compared to women, who had their meno-metrorrhagia sufficiently treated with TCER alone. Our investigation thereby supports the point of view that hysterectomy is associated with and possibly an independent risk factor for urinary stress incontinence. Gynecol Obstet Invest 2007;63:121–125

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Our study was controlled and based on a long-time follow-up, but was not randomized. We may have included the well-known biases of such design; confounding events happened during the observational period without our knowledge as the most likely. However, we have controlled for the indication of the hysterectomy, the size of the uterus, and for the weight and age of the patient, why we consider our data as valid.

Conclusion

In conclusion, our study shows a possible relationship between hysterectomy and urinary stress incontinence in women previously treated with TCER for meno-metrorrhagia. The risk of urge incontinence was not increased in the hysterectomy group. Only women with a normal sized uterus at the time of hysterectomy reported an increased prevalence of stress incontinence.

Appendix Urological Items used in the Questionnaire (Author’s Translation from Danish) 1 Do you experience involuntary urination when coughing, sneezing or lifting a heavy weight without having felt an urge to urinate? – No, never – Yes, less than once a week – Yes, approximately once a week – Yes, several times a week – Yes, daily

4 How often do you urinate during 24 h? – 6 times max – 6–10 times – More than 10 times

2 Do you experience involuntary urination when having felt an urge to urinate, but without being able to control it until you reach the toilet? – No, never – Yes, less than once a week – Yes, approximately once a week – Yes, several times a week – Yes, daily

6 Do you use any devices due to involuntary urination? – No – Yes, panty shields (No. each 24 h: _______) – Yes, diapers (No. each 24 h: ____________) – Yes, other devices (Which? _____________)

3 Do you ever feel a strong urge to urinate, but being able to control it until reaching the toilet? – No, never – Yes, less than once a week – Yes, approximately once a week – Yes, several times a week – Yes, daily Significant stress incontinence: (1); once a week or more. Bothersome stress incontinence: (1); once a week or more PLUS Yes in (6) and/or (7) and/or (8). Significant urge incontinence: (2);

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5 Do you get up to urinate during the night? – No – Yes, once or twice – Yes, three times or more

7 If you are experiencing involuntary urination, do you consider it to be a hygienic problem for you? – No – Yes, but a minor problem – Yes, a major problem 8 If you are experiencing involuntary urination, does it prevent you from engaging in activities you would otherwise take part in (i.e. exercising, traveling by bus)? – Yes – No once a week or more. Bothersome urge incontinence: (2); once a week or more PLUS Yes in (6) and/or (7) and/or (8). Urgency: (3); once a week or more.

Krogh/Neumann/Lauszus/Guttorm/ Rasmussen

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Hysterectomy in Women Who Had TCER

5 Vierhout ME: Influence of nonradical hysterectomy on the function of the lower urinary tract. Obstet Gynecol Surv 2001; 56: 381–386. 6 Altman D, López A, Falconer C, Zetterström J: The impact of hysterectomy on lower urinary tract symptoms. Int Urogynecol J 2003; 14:418–423. 7 El-Toukhy TA, Hefni MA, Davies AE, Mahadevan S: The effect of different types of hysterectomy on the urinary and sexual functions: a prospective study. J Obstet Gynaecol 2004;24:420–425. 8 Demirci F, Ozden S, Alpay Z, Demirci ET: The effects of abdominal hysterectomy on bladder neck and urinary incontinence. Aust N Z J Obstet Gynaecol 1999;39:329–342.

9 Kjerulff KH, Langenberg PW, Greenaway L, Uman J, Harvey LA: Urinary incontinence and hysterectomy in a large prospective cohort study in American women. J Urol 2002; 167:2088–2092. 10 Gimbel H, Zobbe V, Andersen BM, Filtenborg T, Gluud C, Tabor A; and the Danish Hysterectomy Group: Randomized controlled trial of total compared with subtotal hysterectomy with one-year follow up results. Br J Obstet Gynaecol 2003; 110: 1088– 1098. 11 Neumann G, Olesen PG, Hansen V, Lauszus FF, Ljungstrøm B, Rasmussen KL: The shortterm prevalence of de novo urinary symptoms after different modes of hysterectomy. Int Urogynecol J 2004;15:14–19.


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