The urological complications of Wertheim's hysterectomy

Aetiology and Management of Acute Female Urinary Retention

Aims:

Interest in female urinary retention has increased recently because of improved understanding in the pathophysiology as well as the availability of specialised treatments such as sacral neuromodulation. There is little in the literature regarding the incidence and aetiology of urinary retention in females. We therefore undertook a review of all female retention patients presenting to our urology unit over an 11 year period.

Methods:

300 females presented with retention in 11 years January 1996 to January 2007 (7% of the male incidence). 81 presented more than once. Median age was 67. Aetiology included urethral stenosis ( n = 51), urinary tract infection ( n = 33), constipation ( n = 23), neurological causes ( n = 14), gynaecological causes ( n = 16), non urological post-operative patients ( n = 21), medications ( n = 7) and clot retention secondary to bladder cancer ( n = 12). Results: Ultrasound ( n = 240) was carried out in the majority, cystoscopy ( n = 140), and urodynamics in a minority ( n = 38). Urethral pressure profilometry ( n = 38) revealed significantly higher closure pressures as compared to a control group—median 90 vs. 57mmH20 ( p = 0.02). 245 had successful trials without catheter. Prior to this, treatments included cystoscopy and urethral dilatation ( n = 73), laxatives ( n = 25) or antibiotics ( n = 29). Initially 54 patients were taught intermittent self-catheterisation; 38 patients were unable to perform this, and left with a long-term catheter.

Conclusions:

The number of female retentions encountered in our practice is fairly high, with very few of these fitting the criteria for sacral nerve stimulation. In a third no aetiology was found. Approximately half of those who successfully voided did so with no treatment.

Voiding dysfunction

Voiding dysfunction in women is common, but is frequently undiagnosed until the patient presents with symptoms. The aetiology of voiding dysfunction includes the following, any of which may lead to acute or chronic disorders: obstructive causes; postsurgical conditions; neurological disorders; overdistension; inflammatory, pharmacological, psychogenic causes and learned voiding dysfunction; detrusor myopathy and urethral sphincter hypertrophy. Clinical assessment should include history, and general, neurological and pelvic examinations. Investigations may include uroflowmetry, ultrasound for residual urine and upper urinary tract dilatation, urodynamic assessment and electromyography. New surgical techniques to identify vesical branches of the pelvic nerves intraoperatively during radical hysterectomy have been shown to help prevent voiding dysfunction postoperatively. If acute retention occurs, then bladder drainage is the most important measure. Suprapubic catheters are superior to transurethral catheters if long-term voiding difficulties are expected. Whenever possible, patients with chronic retention should be taught clean intermittent self-catheterization. Depending on the cause, other possible treatment options include urethral dilatation, insertion of an intraurethral device, and neuromodulation. Voiding dysfunction in women is still poorly understood. Prompt management of acute retention is essential, and clean intermittent self-catheterization remains the most effective therapy for chronic retention.

Behavioural treatment (biofeedback) for constipation following hysterectomy

BACKGROUND

Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment.

METHODS

Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance.

RESULTS

Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups.

CONCLUSION

The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.

Changes in bowel function after hysterectomy

PURPOSE

It has been suggested that hysterectomy has a disturbing influence on bowel function. To assess the incidence and nature of these changes, we performed a retrospective study.

METHODS

A retrospective study was performed in all 593 women who had undergone hysterectomy between 1989 and 1993. A control group consisted of 100 women who had undergone laparoscopic cholecystectomy.

RESULTS

The response rate was 90 percent (n = 531; median age, 45 (range, 18-84) years). Of the responding women, 315 patients (59 percent) indicated a normal defecation pattern before hysterectomy. Of these women, severe deterioration in bowel function was reported by 98 patients (31 percent), whereas 36 women (11 percent) mentioned a moderate change after hysterectomy. Most frequent symptoms were severe straining (90 patients), incomplete and/or digital evacuation (83 and 50 patients, respectively). According to most patients, the changes in bowel function were reported to have started within one month after hysterectomy. With advancing age, fewer complaints were recorded (P = 0.008). No significant difference was found in the incidence of disturbed bowel function between the different types of operation (abdominal, vaginal, supravaginal, or radical hysterectomy). In the control group, the response rate was 96 percent. Median age of these women was 46 (range, 25-78) years. Fifty-eight patients (60 percent) reported normal bowel function before laparoscopic cholecystectomy. In this group of patients, disturbed bowel function after surgery was reported by five women (9 percent), which figure is significantly (P < 0.001) lower compared with that in the corresponding hysterectomy group.

CONCLUSION

Hysterectomy seems to play an important role in the pathogenesis of disturbed defecation.

Lower urinary tract dysfunction as persistent complication of radical hysterectomy

BACKGROUND

This study was performed to evaluate late effects on the lower urinary tract after radical hysterectomy.

METHODS

We studied 9 women treated with radical hysterectomy for cervical cancer. All patients underwent surgery more than 10 years age (range, 14 to 36 years). Six patients had urologic complications associated with lower urinary tract dysfunction. The remaining 3 were referred for urinary tract abnormalities detected by radiologic examinations. Lower urinary tract function was evaluated with thorough history taking, laboratory examinations, intravenous urography, and conventional urodynamic studies.

RESULTS

Obstructive voiding symptoms and/or urinary incontinence were observed in 7 patients. Uroflowmetry, which was assessable in 7 patients, revealed intermittent flow and a significant amount of residual urine in all patients. Cystometry revealed impaired bladder sensation, detrusor areflexia, straining on voiding, and probable impaired relaxation of the sphincter in all assessable patients. In addition, decreased bladder compliance was observed in 5 patients.

CONCLUSION

All of the examined patients had severe and complicated urinary tract dysfunctions, even at more than 10 years after surgery. Careful follow-up may be mandatory for patients after radical hysterectomy, because compensating factors tend to mask their urologic symptoms.

Effects of abdominal hysterectomy on urinary and sexual symptoms

A prospective study of 102 women undergoing abdominal hysterectomy for benign conditions was performed in order to evaluate pre- and post-operative urinary and sexual symptoms. The mean age of the patients was 44.9 years (range 30-65). Urinary disorders such as urgency, dysuria, frequency, nocturia, slow bladder emptying, sensation of residual urine as well as stress and urge incontinence were observed pre-operatively and 2, 6 and 12 months post-operatively. Dyspareunia, libido and the number of orgasms were evaluated as disorders affecting sexual life. At follow-up 12 months post-operatively a statistically significant decrease in stress incontinence, frequency and nocturia was observed. Dyspareunia was also significantly less frequent and increased libido was experienced. It was concluded that abdominal hysterectomy does not provoke adverse urinary or sexual symptoms and that it can have beneficial effects.

Autonomic influences on colorectal motility and pelvic surgery

The nervous control of the motility of the human distal bowel was investigated by two physiological studies of electrical stimulation of sacral parasympathetic outflow in patients with high spinal injuries and in patients with intractable constipation following pelvic surgery. Identical and reproducible motility responses of the left colon, rectum, and anal sphincters were obtained by sequential electrical stimulation of anterior sacral roots S2, S3, and S4 in patients with spinal injury. S2 stimulation provoked isolated low-pressure colorectal contractions. S3 stimulation initiated frequency-dependent high-pressure colorectal motor activity which appeared peristaltic and was enhanced with repetitive stimuli. S4 stimulation increased colonic and rectal tone. Quantitative responses were maximal at the splenic flexure and rectum. Pelvic floor activity was stimulated in increasing magnitude from S2 to S4. These results of distal bowel motility were achieved by an implanted Brindley stimulator. A newer generation of externally active stimulators are envisaged for the control of lower bowel in fecal incontinence. Women with intractable constipation following hysterectomy had significantly increased rectal volume and compliance together with deficits of rectal sensory function. Following stimulation with Prostigmine (neostigmine) a colorectal motility gradient was paradoxically reversed in the patients following hysterectomy, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in 2 patients tested with carbachol provocation. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients following hysterectomy.

Disordered colorectal motility in intractable constipation following hysterectomy

Colorectal and anal sphincter motility and electrophysiology were investigated in 14 women with profound constipation following hysterectomy and compared with an asymptomatic group of control subjects. Twelve patients complained of significant urinary symptoms. No differences in the motor function of the anal sphincters were detectable. The latency of the pudendoanal reflex was unchanged after hysterectomy. Proctometrograms demonstrated significantly increased rectal volumes and compliance in the hysterectomy group together with deficits of rectal sensory function. In the basal state a significant proximal-to-distal sigmoid colon motility gradient existed only in the control group. Following stimulation with Prostigmin, this gradient was enhanced in the control group but paradoxically reversed in the hysterectomized patients, thus constituting a functional obstruction. Denervation supersensitivity was demonstrable in two patients tested with carbachol provocation but not in control subjects. These findings suggest dysfunction in the autonomic innervation of the hindgut in some patients who had undergone hysterectomy, resulting in severe constipation.

Urodynamic evaluation of lower urinary tract function in relation to total hysterectomy

Although many women relate the onset of urinary symptoms to the operation of simple hysterectomy, many also have symptoms prior to surgery. Prospective study is therefore the most valid method of objective analysis of the effects of this operation upon micturition. To determine whether total hysterectomy is associated with increased postoperative vesicourethral abnormality, the incidences of urinary symptoms and urodynamic abnormality were assessed pre and postoperatively in 36 women undergoing hysterectomy. Preoperative symptoms were present in 58.3%, although urodynamically proven dysfunction was found in only 38.9%. After hysterectomy, 75% of women were symptomatic with a further 30.6% developing a urodynamic abnormality. The operation of total (simple) hysterectomy is associated with a significant increase in the subjective and objective incidence of vesicourethral dysfunction.

The radiology of urinary tract abnormalities associated with hysterectomy

A review of urinary tract complications following hysterectomy shows that these are more likely to occur after radical hysterectomy than after hysterectomy for benign conditions. The role of associated radiotherapy has also been considered and the use of preoperative and postoperative radiological investigations of the urinary tract discussed. Ureteric complications include transient hydroureter and hydronephrosis, ureteric stricture, ureteric fistulae and ureteric severance. The bladder complications which may occur are vesicovaginal fistula, impingement from postoperative haematoma and abscess, the development of bladder calculi, urinary retention and prolaspe of the bladder base. Ureteric complications are often serious especially when there has been fistula or stricture formation, but other abnormalities may be transient. Serious bladder complications such as fistula formation are rare, but urinary retention and prolapse of the bladder base are not uncommon. The purpose and means of radiological investigation have been discussed, as well as some diagnostic pitfalls.

Psychological complications of hysterectomy

This paper reports on the preliminary findings of a study which was carried out at the Royal Brisbane Hospital between September 1970 and December 1971 on 100 women who had been admitted for hysterectomy.

Pre-operative prediction was made as to the likelihood of a well-adjusted or mal-adjusted outcome on the basis of a semi-structured psychiatric interview.

Follow-up assessments were made six months post-operatively and correlated significantly with the predicted outcome.

Reference is made to factors which related positively to a mal-adjusted outcome and the implications of the study are discussed.