Comment on “Associations Between Hysterectomy and Pelvic Floor Disorders: A Systematic Review and Meta-analysis”

More than 600,000 hysterectomies are performed every year in the United States, making it one of the most common surgeries undergone by female patients. It is performed for various gynecologic conditions when other treatments are unsuccessful, and these indications can include abnormal uterine bleeding, uterine fibroids, endometriosis, and pelvic organ prolapse (POP). Current evidence is lacking, however, surrounding the impact of hysterectomy on pelvic floor disorders (PFDs) such as overactive bladder (OAB), stress urinary incontinence (SUI), POP, voiding dysfunction (VD), and fecal incontinence (FI). This study was a systematic review designed to assess current evidence surrounding associations between hysterectomy for benign indications and the onset of PFDs. Literature searches were conducted using Medline (PubMed) and Embase (Ovid) through October 11, 2024. Inclusion criteria for studies were peer-reviewed comparative studies with randomized controlled (RCT), cohort, or case-control design. Exclusion criteria were studies without outcomes of interest or studying individuals undergoing concomitant surgery for PFDs. The primary outcomes of interest were POP, SUI, OAB, urinary incontinence (nonspecific), mixed urinary incontinence, VD, FI, and defecatory dysfunction. Subjective outcomes were also assessed using validated questionnaires or self-reporting. Risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs and the Newcastle Ottawa Scale for cohort and case-control studies. Strength of evidence was evaluated using the US Agency for Healthcare Research and Quality framework. Final analysis included 60 articles, with a total of 3,567,848 patients, published between 1994 and 2024, with 8 RCTs, 20 cohort studies, and 32 case-control studies. A total of 11 prospective studies (8 RCTs and 3 cohort studies) assessed baseline symptoms or excluded patients with prior symptoms. Outcome distribution included 11 studies reporting POP, 19 reporting SUI, 16 reporting OAB, 3 reporting mixed urinary incontinence, 25 reporting nonspecific urinary incontinence, 3 reporting VD, 1 reporting FI, and 1 reporting defecatory dyssynergia. A total of 58 studies reported outcomes within 10 years of hysterectomy, and 11 studies reported them more than 10 years after hysterectomy. Meta-analysis of 5 studies that reported POP outcomes within10 years of hysterectomy showed that there was no significant increase in the likelihood of POP in patients who had a hysterectomy compared to those who did not. After removing the 2 studies that used an outcome of surgery for POP, a significantly reduced likelihood of POP after hysterectomy was noted. Analysis of SUI within 10 years of hysterectomy showed a significant association between hysterectomy and an increased likelihood of SUI. Hysterectomy was additionally associated with a higher likelihood of OAB within 10 years, but not after 10 years. Studies reporting on mixed urinary incontinence within 10 years of hysterectomy showed an association with a higher likelihood of mixed urinary incontinence, and there were no studies that reported on this outcome beyond 10 years. Similarly, hysterectomy was shown to be associated with a higher likelihood of nonspecific urinary incontinence within 10 years of the procedure, and no studies reported on this outcome after 10 years. Analysis of studies on patients 10 or more years after hysterectomy showed slightly different findings. Six studies reporting POP showed that an increased risk of POP in patients who had a hysterectomy compared to people who did not. Analysis of studies reporting SUI beyond 10 years showed a higher likelihood of SUI after hysterectomy. These results indicate that hysterectomy is associated with a significant increase in risk for urinary incontinence, SUI, OAB, and mixed urinary incontinence within 10 years and POP and SUI after 10 years. No significant association was shown between VD or defecatory dysfunction and hysterectomy, although one study reported an increased risk of fecal incontinence associated with hysterectomy. This is consistent with previous literature showing hysterectomy to be associated with an increased risk of various PFDs. Although there is evidence supporting this, patient counseling often centers only on the short-term impacts of the surgery. This study provides evidence that patient counseling should also include long-term health and risks. Future research should focus on pursuing evidence surrounding the surgical approach for hysterectomy as well as evidence surrounding associations with age, parity, and standardizing reporting of PFD outcomes to improve generalizability and comparability of future studies. (Summarized from Chang OH, Saldanha IJ, Encalada-Soto D, et al. Associations between hysterectomy and pelvic floor disorders: a systematic review and meta-analysis. Am J Obstet Gynecol. 2025;233(3):141-151.e6. doi: https://doi.org/10.1016/j.ajog.2025.03.018.)