Elsevier

The Lancet

Volume 356, Issue 9229, 12 August 2000, Pages 535-539
The Lancet

Articles
Hysterectomy and urinary incontinence: a systematic review

https://doi.org/10.1016/S0140-6736(00)02577-0Get rights and content

Summary

Background

Serious complications after hysterectomy are estimated to occur in around six women per 10000 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% Cl 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.

Introduction

In the USA, more than 600 000 women have hysterectomies each year, making this the second most common major surgical procedure done, after caesarean section.1 By age 60 years, about 40% of women in the USA have had a hysterectomy.2 Nearly 90% of hysterectomies are done for benign symptomatic disorders (uterine fibroids, vaginal bleeding, pelvic pain, and pelvic-organ prolapse), and most are elective. Fever is the most common perioperative complication of hysterectomy, arising in about 25%.3 Serious complications, including haemorrhage requiring transfusion, repair of adjacent organ injury, or life-threatening events, are seen in about 10% of cases,3 and the mortality rate has been reported as six women per 10 000 hysterectomies.4 On the basis of these data, hysterectomy is judged a safe surgical procedure. Possible long-term sequelae after hysterectomy are generally not taken into account or discussed with patients.

Hysterectomy may lead to damage to the pelvic nerves5, 6, 7 or pelvic supportive structures8, 9 that increases risk of urinary incontinence. Several studies have reported no rise in incontinence within 6–12 months of hysterectomy.10, 11, 12 Parity is a risk factor for urinary incontinence but incontinence does not increase substantially until several years after childbirth.13, 14, 15, 16 If the mechanism of incontinence after hysterectomy is similar to that for multiple births, incontinence may not develop for many years.

To find out whether urinary incontinence is a long-term sequela of hysterectomy, we reviewed and summarised data on urinary incontinence after hysterectomy.

Section snippets

Data sources

We searched English-language and non-English-language medical reports published from January, 1966, to December, 1997, on MEDLINE. We used key words including: hysterectomy (total, supracervical, supravaginal, and subtotal), genital surgery, and urinary incontinence. In addition, we searched the reference lists from identified articles and consulted with respected specialists.

Study selection

We included studies that presented primary data and compared incontinence in women who underwent hysterectomy with women

Results

45 articles reported urinary incontinence in women who underwent hysterectomy. Of these, 24 had no control group that did not undergo hysterectomy;6, 7, 9, 10, 11, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 seven did not provide odds estimates;26, 50, 51, 52, 53, 54, 55 and two had outcomes other than incontinence.5, 56 Therefore, we included 12 studies— eight cross-sectional14, 15, 17, 19, 20, 22, 23, 24 and two prospective cohort studies,12, 21 and one

Discussion

Results of the 11 observational studies that met our inclusion criteria suggest the odds of developing urinary incontinence after hysterectomy is about 40% higher than for women who have not undergone hysterectomy. Our results were, however, significantly heterogeneous. Because urinary incontinence might not develop for many years after hysterectomy, we stratified our analyses by age; the odds were increased 60% for women older than 60 years at first assessment. This finding corresponds with an

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