Urodynamic Evaluation of Lower Urinary Tract Function in Relation to Total Hysterectomy

EDITORIAL COMMENTS: The lower urinary and genital tracts are closely associated both anatomically and functionally. It is not surprising therefore that many gynaecological conditions, such as pregnancy, pelvic tumours (ovarian cysts, uterine fibroids) and genital prolapse may cause urinary symptoms. Pelvic surgery can also predispose to urinary tract dysfunction by anatomical distortion of the lower urinary tract, disruption of its nerve or vascular supply, or by less obvious means such as alteration of the woman's hormonal status or mental well‐being. It is my clinical impression that simple hysterectomy without vaginal repair or ovarian ablation is an uncommon cause of urinary incontinence or voiding dysfunction. Clinical impressions are notoriously unreliable so the truth will only be established by carefully controlled prospective trials. This study does show that urinary symptoms are common both before and after hysterectomy and emphasizes the importance of taking a careful urological history in all women with gynaecological symptoms and giving appropriate counselling prior to any pelvic surgery. Hysterectomy is such a common operation that any causal relationship with bladder disorder is an important consideration. I find it difficult to believe that a total abdominal hysterectomy could cause significant permanent stress incontinence of urine. The paper reported here will interest readers but is not the last word on the subject and is not, by itself, sufficient to incriminate abdominal hysterectomy as a cause of urinary problems. After accepting this paper for publication we were relieved to read another prospective study: The Effect of Total Abdominal Hysterectomy on Bladder Function in Asymptomatic Women. Longer R, Neuman M, Ron‐El R et al, Obstet Gynecol 1989; 74: 205–207. This paper studied 16 patients, all who lacked urinary symptoms preoperatively, who had cystometry and uroflometry performed preoperatively, at 4 weeks and again 4 months postoperatively. This study reported ‘no clinical symptoms of frequency, nocturia, urgency, or urge or stress incontinence postoperatively. There were no significant differences from the preoperative values for cystometry, uroflometry and urethral pressure profiles.’ However this is not the end of the story since Taylor et al have recently found a ‘highly significant association between persistently reduced bowel frequency and persistently increased urinary frequency after hysterectomy’ (Effect of hysterectomy on bowel function. Br Med J 1989; 299: 300–301). Summary: 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.