Hysterectomy Patients May Face Incontinence Later

Aug. 15, 2000 -- Even after having suffered through bleeding or pain, then agonizing over the decision whether to have a hysterectomy, and then going through and recovering from the surgery, women may still have to face a possible side effect from the surgery later in life: incontinence.

Women 60 years old and older who have previously undergone hysterectomies have a 60% higher risk of urinary incontinence later in life than women who have not had the procedure. The incontinence can develop years after the procedure. So, anyone considering having a hysterectomy needs to take that risk into account, according to an article in the Aug. 12 issue of the Lancet.

A hysterectomy involves the surgical removal of the uterus. Hysterectomies are often done to resolve uterine bleeding, pain, collapsing of the pelvic organs, including the uterus, or when a uterine tumor is present. Approximately 600,000 hysterectomies are performed in the U.S. each year.

"One thing we haven't considered about hysterectomies is, are there long-term [consequences]?" article author Jeanette S. Brown, MD, tells WebMD. "Ninety percent of women deciding about hysterectomies are having one for a benign [noncancerous] condition. They need to weigh, 'How bad are my symptoms today compared to the risk of incontinence later in life?'"

Brown, a professor of obstetrics, gynecology, and reproductive sciences at the University of California in San Francisco, says some hysterectomies may well be worth that risk. She tells the story of two patients who were considering hysterectomies

"One was a patient of mine who had fibroids, and when she went to Europe she had to take an extra backpack full of sanitary pads because she bled so much. She said, 'My life is miserable. I can't travel, and sex is uncomfortable.' That patient's benefit was huge compared to the potential risk of incontinence later in life."

On the other hand, Brown had another patient who came to her for a second opinion after her doctor had recommended a hysterectomy as part of another surgical procedure.

"This patient had no symptoms, but her doctor had said, 'We're going to do a hysterectomy because we'll be in there anyway and you're done with childbearing.' She decided she preferred not to have her uterus removed, because she had no [immediate] benefit. That's the type of decision we're talking about," Brown tells WebMD.

In the article, Brown and colleagues looked at 12 different studies examining the potential link between hysterectomies and later incontinence. In the five studies that looked at women 60 years and older, researchers found an average 60% higher likelihood of incontinence in the women that had undergone hysterectomies, compared with those who had not. The researchers analyzed findings based on age because they assumed that "incontinence might not develop for many years after hysterectomy."

It's not clear why women who have their uteruses removed develop incontinence more often, but it may be that the procedure simply results in chronic, progressive damage to the pelvic area that takes years to show up, Brown and colleagues theorize. "It's like if you have a knee injury when you're 20; you don't start wearing a knee brace until you're 40, and all the other [aging] factors kick in," says Brown.

On the whole, hysterectomies are probably done too often in the U.S., she says. "In Scandinavia, the rate of hysterectomy among women is 11%; in the United Kingdom, it's about 20%, and in the U.S., it's 40%. That's a huge [percentage]."

Women considering hysterectomies should talk the matter over with their physicians and weigh all the risks and benefits, Brown tells WebMD. "You need to decide as an individual, 'How bad are my symptoms?' If you are miserable, I'd take the roll of the dice and go for the hysterectomy."

But, Shari Thomas, MD, MPH, assistant professor of obstetrics and gynecology at UCLA, does not agree. "You have to follow the basic indications for hysterectomy and not scare the patient and say, 'Wait until you?re miserable, because you might get incontinent later.'"

Also, Thomas is not convinced incontinence is a long-term outcome of hysterectomy.

She tells WebMD anywhere from 25 to 50% of these patients are having hysterectomies for conditions that "already have an underlying increased risk of urinary incontinence. So you have to take out the people who have had surgery for pelvic organ prolapse, and [Brown]hasn?t done that. She has built her own bias into the meta-analysis," says Thomas.

"Menopause is also a risk factor for incontinence; we know that," says Thomas. "We have a decreased amount of collagen in our tissue with menopause, and that means decreased blood flow and a decrease in elasticity, which helps support our pelvic organs."

Lawrence Gratkins, MD, a gynecologist at Christie Clinic in Champaign, Ill., tells WebMD that there are also more options now than in the past for women. He suggests that women and their physicians use all conservative or medical approaches to treament before proceeding with a hysterectomy.

For instance, there is surgery a woman can undergo just for the bleeding that can save her uterus. Even if she needs a hysterectomy, Gratkins says, there are newer procedures that are getting less invasive all the time.

And Gratkins emphasizes that women should discuss all conservative treatment options with their doctors before resorting to hysterectomy, and, if they need surgery, they should discuss the possibility of simultaneous repairs.