European Journal of Obstetrics & Gynecology and

Reproductive Biology 130 (2007) 258–261

www.elsevier.com/locate/ejogrb

Is vaginal hysterectomy a risk factor for urinary incontinence

at long-term follow-up?
Renaud de Tayrac *, Nicolas Chevalier, Aurélia Chauveaud-Lambling,
Amélie Gervaise, Hervé Fernandez
Department of Obstetrics and Gynecology, Antoine Beclere Hospital, Clamart, France
Received 11 February 2005; received in revised form 22 November 2005; accepted 30 January 2006

Abstract

Objective: The purpose of this study was to evaluate the prevalence of urinary symptoms at long-term follow-up after vaginal hysterectomy.
Study design: One hundred and seventeen patients, who had a vaginal hysterectomy for menorrhagia, from January 1991 to December 2001,
answered to a self-report questionnaire about de novo urinary symptoms. The control group was a population of 116 patients who had a
conservative treatment for dysfunctional uterine bleeding by endometrial thermocoagulation from January 1994 to December 2001.
Results: Patient characteristics (mean age, mean parity, menopausal status, smoking status, drink habits) were similar in the two groups.
Mean follow-up was 4.6  2.2 years (range 1.5–11) after vaginal hysterectomy and 4  1.8 years (range 1.5–7) after conservative treatment.
The prevalence of urinary symptoms, included urge and stress incontinence, were statistically similar in the two groups.
Conclusion: This study reveals no risk of urge or stress urinary incontinence at long-term follow-up after vaginal hysterectomy, compared
with conservative treatment.
# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Hysterectomy; Vaginal surgery; Urinary incontinence

1. Introduction her symptoms of urge or stress incontinence before the

Hysterectomy is one of the most common operations in
women. It is an effective procedure for curing a number of
gynecologic diseases, such as uterine fibroids, dysfunctional
uterine bleeding and malignant conditions. Several pub-
lications have previously suggested that hysterectomy is
associated with the development of changes in urinary
function, especially urinary incontinence [1–3]. Recently,
van der Vaart et al. have demonstrated that women scheduled
for hysterectomy have an increased risk of developing urge
incontinence symptoms, but not stress urinary incontinence
[4]. But, in that study, information was not obtained for the
surgical route of hysterectomy (i.e. abdominal or vaginal),
and it is unclear if every woman has been questioned about
operation.
The vaginal route for hysterectomy is becoming the route
of choice in many conditions. Vaginal hysterectomy is
associated with less morbidity than abdominal hysterectomy
[5–8], therefore it might be expected that the contribution of
vaginal hysterectomy to the occurrence of urge and stress
urinary incontinence is different to abdominal hysterectomy.
We conducted a case-control study to compare the
prevalence of urinary symptoms after vaginal hysterectomy
and in a control population who had had a conservative
treatment for dysfunctional uterine bleeding.
2. Materials and methods

The study population consists of 717 patients, who had a

* Corresponding author at: Service de Gynécologie-Obstétrique, Hôpital
Carémeau, Place du Pr Robert Debré, 30029 Nimes Cedex 9, France. vaginal hysterectomy for non-malignant conditions, with no
Tel.: +33 6 03 26 32 32; fax: +33 4 66 68 34 69. urinary incontinence or genitourinary prolapse associated, in
E-mail address: renaud.detayrac@chu-nimes.fr (R. de Tayrac). our Department from January 1991 to December 2001.

0301-2115/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2006.01.032
 R. de Tayrac et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 258–261 259

During that 11-years period, we have performed hysterectomy for menorrhagia and the 116 women who had
vaginal hysterectomies according to Peham-Amreich a history of conservative treatment with uterine balloon
technique, modified by Centaro and expanded by Dargent therapy.
[9], with a suture of the uterosacral ligaments to the vaginal
angles, in order to prevent a post-hysterectomy vaginal
vault prolapse. 4. Statistical analysis
These 717 women were invited to participate in a study
on the prevalence of urogenital symptoms. All women Analysis of categorical variables was by the x-square
received a questionnaire with an accompanying letter test and Fisher’s exact test when numbers were small.
explaining the purpose of the study. Care was taken to Continuous variables with a normal distribution were
encourage women without any symptoms to participate, analysed using Student’s t-test and ordinal data by the
emphasising the importance of comparing their situation Mann–Whitney U-test. p < 0.05 was considered statistically
with women with symptoms. Four hundred and forty-nine significant. The data are summarized as the mean  S.D.
women who did not respond, received a reminding letter or the percentage according to the variables.
after 3 months. Three hundred and sixty-five questionnaires
were returned (50.9%). Fifty-one women were excluded for
the analysis, because they reported urinary symptoms before 5. Results
the operation, leaving 314 fully evaluable women. In this
sample, 197 women had a vaginal hysterectomy for pelvic Table 1 shows the characteristics of the vaginal
pain (62.7%) and 117 for menorrhagia (37.3%), including 94 hysterectomy and uterine balloon therapy groups. Mean
menorrhagia due to uterine fibroids and 23 dysfunctional age, mean parity, menopausal status, smoking status, drink
uterine bleeding. habits were similar in the two groups, and none woman had
history of urogenital symptoms before their operation.
Mean follow-up after the operation was 4.6  2.2 years
3. Measurements (range 1.5–11) for the vaginal hysterectomy group and
4  1.8 years (range 1.5–7) for the uterine balloon therapy
All women received a self-report questionnaire in 2002. group.
The questionnaire consists of 47 items about urogenital Table 2 shows the prevalence of the different types of
symptoms, defaecatory symptoms and sexual problems. For urinary symptoms, including urinary incontinence, among
the present study we used the data from the following items: women with and women without a history of vaginal
age, parity, menopausal status (yes/no), smoking status (yes/ hysterectomy. Statistical analysis for each urinary symptom
no), volume of drink per day (less/more than 2 L of water), for women with a history of vaginal hysterectomy reveals
frequency (more than eight micturitions per day), nocturia none difference for women without a history of vaginal
(more than one micturition per night), urgency (never/every hysterectomy. Since follow-up is considered to be an
month/every week/every day), urinary incontinence (yes/ important modifier of the effect of hysterectomy on urinary
no), use of pads (yes/no), urge incontinence (never/every incontinence, a separate analysis was performed for follow-
month/every week/every day), stress incontinence (never/ up <5 years and 5 years (Table 3). Again, separate analysis
every month/every week/every day) and voiding difficulties for each urinary symptom, for follow-up less and more than
(never/every month/every week/every day). Every question 5 years from the operation, reveals none difference between
on urinary symptoms was disease-specific and has been woman with and women without a history of vaginal
validated in French in the MHU (Mesure du Handicap hysterectomy.
Urinaire) scale.
In order to compare the results of these questionnaires to
a control group, we have sent the same questionnaire to 203
patients who had a history of conservative treatment for Table 1
dysfunctional uterine bleeding with the uterine balloon Characteristics of the vaginal hysterectomy (VH) and uterine balloon
therapy (control) groups
therapy (ThermachoiceTM, Gynecare, Ethicon, 1 rue
Camille Desmoulin, Issy-les-Moulineaux, France), in our VH group Control group p Value
n = 117 n = 116
Department from January 1994 to December 2001. That
procedure is incapable of compromising bladder function or Age (years) 51.4 [42–66] 50.9 [39–61] NS
Parity 2.1 [1–3] 2.2 [1–4] NS
involving any disturbance to the pelvic floor. One hundred Menopausal status 51 (43.5) 55 (47.4) NS
and sixteen questionnaires were returned (57.1%), none Smoking status 21 (17.9) 20 (17.2) NS
woman had urogenital symptoms before uterine balloon Drink >2 L/day 9 (7.7) (9.5) NS
therapy and all were fully evaluable. History of urogenital 0 0 NS
Overall, for the present study, we have chosen to compare symptoms
for urinary symptoms, the 117 women who had a history of Values are given as mean [range] or numbers (%); NS: not significant.
260 R. de Tayrac et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 258–261

Table 2 urinary incontinence 2 years after each procedure in 152

Prevalence of urinary symptoms among women with (VH) and without patients who were operated for dysfunctional uterine
(control) a history of vaginal hysterectomy
bleeding. They have also performed cystometry in 93
VH group Control group p Value
patients. Unfortunately, they did not precise the surgical
n = 117 n = 116
route for hysterectomy, and they have only included patients
Frequency (>8/day) 23 (19.7) 29 (16.4) NS
under 50 years of age. Rates of urge incontinence (21%
Nocturia (>1/night) 6 (5.1) 8 (6.9) NS
versus 19%), stress incontinence (44% versus 44%) and
Urgency 73 (62.4) 63 (54.3) 0.08 bladder dysfunction at cystometry (31% versus 35%) were
Every month 43 (36.8) 35 (30.2) NS
Every week 23 (19.7) 14 (12.1) NS
similar in the hysterectomy and endometrial ablation groups,
Every day 7 (6) 14 (12.1) NS respectively. Although that study was well designed, the
follow-up of 2 years is insufficient to conclude that
Urinary incontinence (overall) 46 (39.3) 39 (33.6) 0.43
Use of pads 18 (15.4) 15 (12.9) NS hysterectomy does not compromise bladder function.
Only few authors have studied the risk of urinary
Urge incontinence 24 (20.5) 16 (13.8) 0.26
Every month 14 (12) 9 (7.8) NS
incontinence following hysterectomy when the procedure is
Every week 5 (4.3) 6 (5.2) NS perform by the vaginal route. Because this route is
Every day 5 (4.3) 1 (0.9) NS associated with less morbidity [5–8], and a minimal
Stress incontinence 43 (36.7) 37 (31.9) 0.47 dissection it might be expected that the contribution of
Every month 22 (18.8) 19 (16.4) NS vaginal hysterectomy to the occurrence of urge and stress
Every week 15 (12.8) 10 (8.6) NS urinary incontinence is different to abdominal hysterectomy.
Every day 5 (4.3) 4 (3.5) NS Cosson et al. have compared urinary symptoms following
Voiding difficulties 31 (26.5) 29 (25) 0.64 vaginal hysterectomy versus cholecystectomy in a sample of
Every month 15 (12.8) 18 (15.5) NS 119 patients [20]. They have reported a significant
Every week 6 (5.1) 5 (4.3) NS worsening of all urinary symptoms in both groups during
Every day 10 (8.5) 6 (5.2) NS
the first 4 years after the procedure, and they concluded that
Values are given as numbers (%); NS: not significant. these symptoms could not be attributed to hysterectomy, but
more than 5-years results are missing.
In our case-control study, we have compared the
6. Comment prevalence of urinary symptoms in 233 patients who have
been operated by either vaginal hysterectomy or uterine
Several publications have previously suggested that balloon therapy with a follow-up up to 11 years. Although
abdominal hysterectomy is associated with the development our study is retrospective, every woman have been asked for
of urinary incontinence [1–3], especially urge incontinence their history before their operation, and we have only
[4]. The pathophysiology of this trouble could be pelvic included women without any past history of urogenital
nerves injury [10,11], or pelvic floor damage [12,13], symptoms. Although our study is non-randomized, we
directly in relation to the surgical procedure. Others studies believe that the use of a control group undergoing
did not find any risk of urinary incontinence following conservative treatment is valid for testing the hypothesis
abdominal hysterectomy [14–16], although the follow-up of that vaginal hysterectomy compromises bladder function.
6–12 months could be insufficient. In fact, the risk of urge The two groups of women were comparable except for the
incontinence is probably multifactorial, including the length of follow-up, because if the mean length of follow-up
procedure itself, age more than 60 years old [2,17] and was equal, the hysterectomy group has a range to 11 years,
menopausal status [18]. Furthermore, even measurement of and the control group to 7 years. Like in other series, we
sacral reflex latencies had evidence of nerve conduction have found a high prevalence of most urinary symptoms:
abnormality early after hysterectomy [10], urinary symp- urgency (62.4% versus 54.3%), urge incontinence (20.5%
toms appeared after at least 5–10 years time [2]. versus 13.8%), stress incontinence (36.7% versus 31.9%)
Bhattacharya et al. have performed a randomised and voiding difficulties (26.5% versus 25%), in the vaginal
controlled trial comparing hysterectomy with endometrial hysterectomy and uterine balloon therapy group, respec-
ablation [19]. They have studied the risk of urge and stress tively. Statistical analysis for each urinary symptom,

Table 3
Prevalence of urinary incontinence among women with (VH) and without (control) a history of vaginal hysterectomy, according to follow-up
Follow-up < 5 years Follow-up  5 years
VH group n = 62 Control group n = 81 p Value VH group n = 55 Control group n = 35 p Value
Urinary incontinence (overall) 28 (45.2) 31 (38.3) NS 16 (29.1) 11 (31.4) NS
Urge incontinence 13 (21) 12 (14.8) NS 9 (16.4) 5 (14.3) NS
Stress incontinence 26 (42) 31 (38.3) NS 16 (29.1) 9 (25.7) NS
Values are given as numbers (%); NS: not significant.
 R. de Tayrac et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 130 (2007) 258–261
including urge and stress incontinence has revealed none
difference for women with or without a history of vaginal
hysterectomy. Since follow-up is considered to be an
important modifier of the effect of hysterectomy on urinary
incontinence, a separate analysis was performed for follow-
up less and more than 5 years from the operation. Again, this
analysis has revealed none difference.
The fact that questionnaires have been send to women after
their treatment may induce recall bias, particularly for
questions regarding their pre-treatment urological status.
Furthermore, the response rate around 50% in both groups
was relative low, and the relative higher number of women
with complaints post-treatment observed could be explain by
the fact that most of women with no symptoms did not reply.
Nevertheless, these biases were equivalent in both groups.
In conclusion, this study reveals no particular risk of urge
or stress urinary incontinence at long-term follow-up after
vaginal hysterectomy, compared with conservative treat-
ment. The high number of women with urgency, urge or
stress incontinence in both groups could be explain by select
bias of patients with post-treatment urological symptoms.
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