Urinary incontinence affects nearly 40% of women. Hysterectomy is also common, and studies of the procedure’s effect on urinary tract function have yielded conflicting results. Now, Swedish investigators have used nationwide registries of surgical procedures and inpatient discharge diagnoses during a 30-year observation period to examine the rates of stress–urinary-incontinence surgery in women who had (165,000) or had not (480,000) undergone hysterectomy.

The rate of surgery for urinary incontinence was 2.4-fold higher in women who underwent hysterectomy than among those who did not (regardless of age or hysterectomy technique). The risk for stress–urinary-incontinence surgery was especially high during the initial 5 years after hysterectomy (hazard ratio, 2.7) but persisted at elevated levels for more than 10 years (HR, 2.1). The combined effect of hysterectomy and multiple vaginal deliveries was pronounced; for example, risk increased 16-fold in women who had four vaginal deliveries and a hysterectomy. When adjusted for other elective surgical interventions not involving the pelvic floor (a measure of tendency to opt for surgical interventions), HRs were largely unchanged.

Comment: This well-designed study adds to the debate about the possible deleterious effects of hysterectomy on lower urinary tract function. Strengths of the study include its population-based approach and the adjustment for confounders such as propensity for other elective surgical procedures. Interestingly, an editorialist notes that the same authors previously published contradictory conclusions based on a small observational study. Results of the current, larger (albeit also observational) study sway the bulk of the data toward a positive association. For women who are contemplating hysterectomy for a benign indication, counsel about the increased risk for urinary incontinence associated with the procedure may be appropriate.

— Anna Wald, MD, MPH

Published in Journal Watch Women’s Health November 1, 2007
Citation(s):

Altman D et al. Hysterectomy and risk of stress-urinary-incontinence surgery: Nationwide cohort study. Lancet 2007 Oct 27; 370:1494.