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Hysterectomy is the commonest major gynecological
operation, and the most of them done for benign uterine
lesion. The uterus from the anatomical view has close
relationship with bowel, bladder, and vagina. So the
hysterectomy may alter the function of these organs and
not necessary the alteration is deleterious. The
operation may be total or subtotal, when only the body
of the uterus is removed, retaining the cervix.
This
paper aims to present the available evidence on the
effects of various types of hysterectomy for benign
conditions on pelvic organs and sexual function.
In
U.K in 1994-1995, 1.5% of hysterectomies were only
subtotal. In Finland, S.T.A.H in 1981-1985 were 53%,
believing that is essential to keep sexuality intact.
But by 1991 the rate of S.T.A.H had dropped to 13%.This
might have been due to increased incidence of prolepses
in S.T.A.H (1, 2).
Anatomical
consideration.
The
bladder, uterus, and rectum are all attached to pelvic
side wall by the endopelvic fascia, which in some sites
forms sort of ligaments known as cardinal and
uterosacral ligaments.
The
autonomic nervous plexus (sympathetic and
parasympathetic) which supply the pelvic organs such as
bladder, bowel, uterus and vagina, is disrupted during
hysterectomy procedure.
This
plexus has paramount importance inco-ordination of
smooth muscle of these organs. The disruption, of course
is more extensive in T.A.H and deleterious action in
bowel and bladder from theoretic view is more.
Hysterectomy may include the removal of structures that
are the source of symptoms such as endometriomas, pelvic
adhesions, and adenomyosis.
Bladder
function following hysterectomy.
Hanley (3) reported (1969) increased late gynecological
complication after hysterectomy such as urinary
frequency, dysuria and incontinence. Since then, there
were many conflicting reports regarding this subject,
but these reports, most of them, are retrospective
studies. In prospective study done by Langer etal1989(4)
had found no difference in symptoms or urodynamic
results after T.A.H.Virtanen etal 1993(5) reported
significant decrease in urinary frequency, nocturia and
stress incontinence. Maine women's health study in 1999
showed that T.A.H and vaginal hysterectomy effectively
reduced symptoms of urinary frequency and urgency.
In
Mary land women's health study, the largest prospective
study to date-2002(6), they found that most women with
sever and moderate urinary incontinence before
hysterectomy improved one year after surgery, with
further improvement at two years. However, some women
with mild or no incontinence before hysterectomy had new
onset incontinence16.7%.
Women who are going for hysterectomy, should be made
aware of a 10% risk of new onset or worsening of urinary
incontinence in the first two years. However other
comparative studies do not show an increased risk
(7,8).In three randomized studies (9,10), in T.A.H and
S.T.A.H there were no significant difference between
both, fewer women in both groups reported urinary
incontinence, urgency, frequency, nocturia, and
incomplete emptying. Similarly, a randomized study from
U.S.A. did not find any difference between T.A.H and
S.T.A.H and found an improvement in urinary incontinence
and voiding dysfunction after hysterectomy. Other
workers with urodynamic studies showed no operative
induced changes in urethral relaxation and functional
length, closure pressure or resistance to stress
associated with either operation.
Does
the bowel function is affected after hysterectomy?
Prospective studies (11) had failed to demonstrate
adverse bowel function after hysterectomy. One
retrospective study (12) showed infrequent defecation
and firmer stool consistency.
Thakar etal (9) in a randomized trial comparing total
with S.T.A.H, found no change in any of the parameters
of bowel function after T.A.H and S.T.A.H.
A
prospective study designed to determine the incidence of
symptoms of irritable bowel syndrome arising after
hysterectomies and the effect of surgery on pre-existing
gastrointestinal symptoms, found less marked change, and
concluded that hysterectomy had little if any effect on
de novo development of irritable bowel syndrome (13).
Hysterectomy
and female sexuality.
Disturbance of innervations of the cervix and upper
vagina after hysterectomy, specially after T.A.H could
interfere with lubrication and internal orgasm. Women
who achieve orgasm through clitoral stimulation might
not be affected. But who had experienced both types of
orgasm, a decrease in sexual response following
hysterectomy might be noted from theoretic aspect. A
reduction in cervical mucous and vaginal dryness and
vaginal shortening may play a role in sexual arousal.
Poor knowledge of reproductive anatomy, pre hysterectomy
negative expectation of sexual recovery following
surgery, preoperative psychiatric morbidity, depression,
poor preoperative sexual relations and poor preoperative
counseling have all been associated with poor outcome
(14,15).
Also
preoperative hysterectomy positive factors including
frequency of coitus, frequency of desire, orgasm
response and freedom of sever life stress and absence of
financial worry and low income play a role in outcome.
Most
retrospective studies (16) showed no change or an
enhancement of sexuality after hysterectomy. The removal
of the uterus might increase sexual pleasure because it
remove the fear of pregnancy, and uterine disease and
relieves dysmenorrheal and dyspareunia.
Alexander etal (17) and Wierrani etal (18) in
prospective randomized trial comparing hysterectomy with
endometrial ablation found no difference in
postoperative sexuality after 12 months. Type of
hysterectomy made no difference to these parameters at
12 months follow up.
In
Maryland women's health prospective study (6), it is
found a significant increase in frequency of sexual
activity, improvement of dysparunia, orgasm, libido and
vaginal dryness.
Kilkka etal (19,20)compared coital frequency, dysparunia,
libido and frequency of orgasm before surgery and 6
weeks, 6 months and one year in 105 women with T.A.H and
107 with S.T.A.H. Frequency of orgasm was significantly
reduced in T.A.H group but not in subtotal group because
of presence of cervical orgasm. Thakar etal (9) study
did not show this difference and this might suggest that
cervix per se does not play a significant role in
sexuality.
Discussion
Hysterectomy will continue to be a final treatment for
some disease, whether S.T.A.H or T.A.H. Subtotal
hysterectomy is undoubtedly the safer operation, what
ever the skill of surgeon. There is less bleeding and
less disruption of autonomic nervous system. All over
the morbidity after S.T.A.H is less. S.T.A.H often
reflects surgical inexperience of surgeon.
Butler, Manuel etal (21) suggest that the nerve content
of uterosacral and cardinal ligaments has a
significantly greater nerve content in the middle to
lateral thirds toward their origin at pelvic sidewall.
So in simple hysterectomy, whether is S.T.A.H or T.A.H,
the innervations of bladder, bowel and vagina is
slightly disrupted.
In conclusion, the recent studies suggest
that significant pelvic organ dysfunction is not common
after simple hysterectomy. And the patient should be
reassured that hysterectomy might even improve pelvic
organ function, specially the sexuality among women who
are still young.
No
doubt that the uterus is very important organ in the
women and during productive life in some culture; she
will try to keep it by any means specially who has no
children. But sometimes, some diseases necessitate to
remove it and here a good preoperative counseling should
be carried out and the patient should be informed that
the operation might be beneficial.
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