Associations between hysterectomy and pelvic floor disorders: a systematic review and meta-analysis

Hysterectomy is the second most common surgery performed among women in the United States. The associations between hysterectomy and the risk of pelvic floor disorders remain unclear. The objective of this study is to systematically review the associations between hysterectomy and the likelihood of pelvic floor disorders.

A systematic search of Medline and Embase from inception to October 11, 2024, was performed without language restrictions. The systematic review was registered in The International Prospective Register of Systematic Reviews (CRD42023443210).

Studies included randomized controlled studies and nonrandomized comparative studies (that reported adjusted analyses) of adult female individuals aged ≥18 years old who underwent a hysterectomy through any route for benign indications. At least 1 year of follow-up after hysterectomy was required. Studies of individuals undergoing concomitant surgery for pelvic floor disorders were excluded.

Twelve investigators independently screened each abstract and potentially eligible full-text article in duplicate. Data extraction, risk of bias assessment, and strength of evidence grading were conducted using standard instruments. Meta-analyses were performed using random-effects models. Outcomes included pelvic organ prolapse, urinary incontinence (nonspecific, mixed, and stress), overactive bladder, voiding dysfunction, fecal incontinence, and defecatory dysfunction. Results were stratified by time since hysterectomy (≤10 years vs >10 years).

We included 60 studies (8 randomized controlled trials, 20 cohort studies, and 32 case-control studies) with 3,567,848 participants. In the first 10 years, hysterectomy was associated with higher likelihood of (nonspecific) urinary incontinence (effect size 1.29, 95% confidence interval 1.11-1.47; 25 studies), stress urinary incontinence (effect size, 1.31; 95% confidence interval, 1.06-1.56; 14 studies), overactive bladder (effect size, 1.41; 95% confidence interval, 1.25-1.58; 16 studies), and mixed urinary incontinence (effect size, 1.62; 95% confidence interval, 1.40-1.85; 3 studies). Beyond 10 years, hysterectomy was associated with higher likelihood of pelvic organ prolapse (effect size, 1.56; 95% confidence interval, 1.35-1.78; 6 studies) and stress urinary incontinence (effect size, 2.40; 95% confidence interval, 2.17-2.63; 5 studies).

Hysterectomy is associated with a statistically significant higher likelihood of urinary incontinence of all types within 10 years, as well as pelvic organ prolapse and stress urinary incontinence beyond 10 years after hysterectomy. It is important to discuss these risks at the time of counseling for hysterectomy with consideration of medical or nonhysterectomy treatment options if clinically acceptable.