Abstract
The role of hysterectomy in the development of pelvic floor dysfunction (PFD) remains widely disputed. The controversy is fueled by two key factors. The first is conflicting association studies that make it difficult to establish whether a link truly exists. Although many retrospective studies report a correlation between hysterectomy and increased risk of stress urinary incontinence (SUI) or pelvic organ prolapse (POP), prospective studies often fail to replicate these results, leading some to conclude that no association exists. However, most prospective studies do not follow up for a sufficient length of time to account for the long latency of PFD and cannot unilaterally prove the absence of an association. The second source of controversy is the absence of a plausible mechanism to explain how hysterectomy could predispose patients to PFD. In this paper, we investigate autonomic innervation and smooth muscle in the three layers of pelvic floor support and propose a mechanism through which autonomic damage from hysterectomy could predispose patients to PFD. We then identify key research areas needed to evaluate this theory. This report aims to inspire a discussion on how to further the collective understanding of the relationship between hysterectomy and PFD. Clarifying the nature of this connection could have enormous consequences in redefining the risks and benefits of hysterectomy.
Highlights
BackgroundClinicians have long suspected a link between hysterectomy and pelvic floor dysfunction (PFD), but even after decades of research, this remains remarkably controversial [1,2,3,4]
The relationship between hysterectomy and PFD remains ambiguous due to conflicting results from association studies and the absence of a plausible mechanism for how hysterectomy might contribute to PFD
We propose the theory that autonomic nerve damage sustained during hysterectomy may cause progressive weakening of smooth muscle in the pelvic floor that promotes PFD
Summary
Clinicians have long suspected a link between hysterectomy and pelvic floor dysfunction (PFD), but even after decades of research, this remains remarkably controversial [1,2,3,4]. Some have argued that nerve injury from hysterectomy is insignificant because only nerves to the removed cervix and uterus are affected [2] This fails to consider, that autonomic nerves to the reproductive organs may contribute to smooth muscle of the endopelvic fascia and levator ani, which still have functional roles in maintaining pelvic floor integrity after hysterectomy. Some studies note that vaginal wall samples from POP patients exhibit greater smooth muscle atrophy compared to healthy controls [10], but more research is needed to establish a correlation This is challenging because there are few metrics to assess pelvic autonomic function in women, when the injury is not severe enough to cause overt symptoms. The intrafascial approach has become less popular in recent years due to high blood loss and difficult technique, but its protection of the endopelvic fascia makes it a promising candidate for reducing post-hysterectomy PFD
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