The Pelvic Floor After a Hysterectomy
A total hysterectomy is the irreversible removal of the uterus (womb) and cervix through surgery. It is carried out to treat a variety of female reproductive issues, such as:
- Unbearable pelvic pain
- Otherwise untreatable heavy periods (menorrhagia)
- Fibroids - benign (non-cancerous) tumours
- Gynecologic cancer - of the female reproductive organs including the ovaries, uterus and cervix
- Endometriosis - a painful condition where the tissue that lines the uterus begins to grow on the other reproductive organs
- A complete uterine prolapse - when non-surgical treatments have been unsuccessful
It is a major pelvic operation, performed through the vagina or abdomen (open or minimally invasive robot-assisted/laparoscopic). It is one of the most common gynecological surgeries, and has many similarities to other pelvic operations in terms of its effect on the pelvic floor.
What Happens to Your Pelvic Floor During a Hysterectomy?
During a hysterectomy, all effort will be taken by the surgical team to preserve the abdominal and pelvic floor muscles. However, it is not uncommon for tissue and nerve damage to occur as the muscles are separated and moved out the way of the procedure.
Often a hysterectomy is required as a result of the pelvic floor already being weak or damaged, therefore the surgery may also include a procedure to increase the support of the pelvic floor. However, it is important to note that no surgery can improve the strength of the pelvic floor. Only pelvic floor / Kegel exercises are able to do this.
To reduce the risk of a pelvic organ prolapse occurring, you may also undergo a sacrospinous fixation surgery (sacrocolpopexy). Where the top of the vagina is stitched to the sacrospinous ligament, near the tail bone, for support. A synthetic mesh may be used to provide additional support, however this is currently only recommended within the context of research whilst further studies are completed into the risk of mesh erosion.
What Happens to Your Pelvic Floor After a Hysterectomy?
When the uterus and cervix are removed, a void is left which the other pelvic organs can droop and prolapse into. If your pelvic floor is damaged or weak as well, then it will be unable to sufficiently support the other pelvic organs and you will likely experience one or more of the pelvic floor disorders listed below. Sadly, these disorders are so common that the improved quality of life expected from the hysterectomy is often not initially realised.
If you undergo a oophorectomy at the same time as your hysterectomy, where your ovaries are also removed, you will also experience a change in hormones and the onset of the menopause (if you haven't already experienced it). The reduction of oestrogen will result in a natural weakening of your pelvic floor muscles, further increasing your risk of developing one of the following pelvic floor disorders:
- A vaginal/pelvic organ prolapse - There is a 40% chance of developing a vaginal vault prolapse as the uterus is no longer present to support the other pelvic organs.
- Urinary incontinence - As a result of damage to the bladder or urinary tract during surgery, or the prolapse of the bladder as the uterus is no longer there to support it. There is a higher risk if your surgery was performed vaginally.
- Frequent urinary tract infections - As a result of damage to the urethra.
- Faecal incontinence - As a result of damage to the bowel or rectum.
- Damage to pelvic organs and tissue - As with any pelvic surgery, your surgeon will enter your pelvis through the vagina or abdomen. This allows for a risk of accidental damage to the other pelvic organs and tissue by the instruments.
Can I Reduce My Risk or Reverse the Damage to My Pelvic Floor?
To reduce the risk of experiencing a pelvic floor disorder as a result of undergoing a hysterectomy, you will need to look after your pelvic floor both before and following the procedure. To make your exercises even more efficient you can use an electronic pelvic toner, which has specific programmes to help concentrate on the different issues you may face:
- Exercise your pelvic floor daily - Do your Kegels! Like any muscle you need to keep exercising your pelvic floor to keep it in tip top shape. You may be able to begin your exercises as early as six weeks after your surgery, speak to your doctor if you have any questions.
- Stop smoking and treat chronic coughs - This will reduce the pressure put on your pelvic floor.
- Maintain a healthy weight - The National Institute for Heath and Care Excellence (NICE) recommend keeping your BMI under 30 to avoid putting excess weight on your pelvic floor.
- Avoid high impact exercise - Once you have recovered from the surgery, swap out running for swimming and cross fit for cycling. High impact exercises are those where you land heavily on your feet, shooting pressure up your legs and to your pelvis. Yoga and Pilates are also very good at helping you break a sweat whilst reducing the pressure on your pelvic floor. They can also be modified to balance your weight more evenly.
- Avoid carrying large weights - When it cannot be avoided, learn how to lift large weights safely from the National Health Service (NHS); hold the load close to your waist and avoid bending your back.
- Avoid constipation and straining - Its widely known that eating a high fibre diet keeps you regular. But did you know that the best position for going to the toilet is to have your knees high in a squat? You can use a toilet stool to get it just right.
Watch the video below where renowned Australian Physiotherapist, Michelle Kenway, explains the best pelvic floor exercise routine to do following a hysterectomy:
Alkatout, I. Holthaus, B. Jonat, W. Mettler, L. Noé, G. Peters, G. Schollmeyer, T. (2014). Journal of the Society of Laparoendoscopic Surgeons. Laparoscopic Hysterectomy and Prolapse: A Multiprocedural Concept. [online] 18(1), p 89-101. [viewed 05/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939350/
altman, D. Cnattingius, S. Forsgren, C. Granath, F. (2008). American Journal of Obstetrics & Gynecology. Pelvic organ prolapse surgery following hysterectomy on benign indications. [online] 198(5), p 572. [viewed 05/04/2018]. Available from: http://www.ajog.org/article/S0002-9378(08)00027-6/pdf
altman, D. Forsgren, C. (2013). Aging Health. Long-term Effects of Hysterectomy. [online] 9(2), p 179-187. [viewed 04/04/2018]. Available from: https://www.medscape.com/viewarticle/805517
Bharucha, A. E. Blandon, R. E. Gebhart, J. B. Melton, L. J. Schleck, C. D. Zinsmeister, A. R. (2009). Obstetrics & Gynecology. Risk Factors for Pelvic Floor Repair After Hysterectomy. [online] 113(3), p 601-608. [viewed 04/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720564/
Buckinghamshire Healthcare NHS Trust (2016). Vaginal Hysterectomy and Pelvic Floor Repair. [online] National Health Service, 2016 [viewed 03/04/2018]. Available from: http://www.buckshealthcare.nhs.uk/Downloads/Patient-leaflets-Obstetrics-and-Gynaecology/Vaginal%20hysterectomy%20pelvic%20floor%20repair.pdf
Burgio, K. L. Goode, P. S. Markland, A. D. Redden, D. T. Richter, H. E. Vaughan, C. P. Wu, J. M. (2014). Obstetrics & Gynecology. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women. [online] 123(1), p 141-148. [viewed 03/04/2018]. Available from: https://insights.ovid.com/pubmed?pmid=24463674
Cichowski, S. Gattoc, L. Jeppson, P. C. Rahimi, S. Raker, C. Sung, V. Weber LeBrun, E. Westermann, L. (2016). Female Pelvic Medicine & Reconstructive Surgery. Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions. [online] 22(5), p 364-368. [viewed 05/04/2018]. Available from: https://journals.lww.com/jpelvicsurgery/Citation/2016/09000/Comparison_of_Perioperative_Complications_by_Route.16.aspx
Clarke-Pearson, D. L. Geller, E. J. (2013). Obstetrics & Gynecology. Complications of hysterectomy. [online] 121(3), p 654-73. [viewed 04/04/2018]. Available from: https://insights.ovid.com/pubmed?pmid=23635631
Fang, K. A. Uzoma, A. (2009). Obstetrics & Gynecology International. Vaginal Vault Prolapse. [online] 275621, p 1-9. [viewed 03/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778877/
Giarenis, I. Robinson, D. (2014). F1000 Prime Reports. Prevention and management of pelvic organ prolapse. [online] 6(1) p 77. [viewed 03/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4166938/
Kjerulff, K. H. Legro, R. S. Leppert, P. C. (2007). Journal of Psychosomatic Research. Hysterectomy and loss of fertility: Implications for women' mental health. [online] 63(3), p 269-274. [viewed 05/04/2018]. Available from: http://www.jpsychores.com/article/S0022-3999(07)00142-0/fulltext
Lakeman, M. M. E. Roovers, J. P. W. R. (2009). Facts, Views & Vision in ObGyn. Effects of genital prolapse surgery and hysterectomy on pelvic floor function. [online] 1(3), p 194-207. [viewed 04/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4255511/
NHS. (2015). Endometriosis [online] National Health Service, 2016 [viewed 03/04/2018]. Available from: https://www.nhs.uk/conditions/endometriosis/
NHS. (2015). Laparoscopy (keyhole surgery) [online] National Health Service, 2016 [viewed 04/04/2018]. Available from: https://www.nhs.uk/conditions/laparoscopy/
NHS. (2016). Hysterectomy [online] National Health Service, 2016 [viewed 03/04/2018]. Available from: https://www.nhs.uk/conditions/hysterectomy/
NHS. (2016) Safe lifting tips [online] National Health Service, 2016 [viewed 20/03/2018]. Available from: https://www.nhs.uk/livewell/workplacehealth/pages/safe-lifting-tips.aspxNHS. (2018) Pelvic organ prolapse [online] National Health Service, 2018 [viewed 14/03/2018]. Available from: https://www.nhs.uk/conditions/pelvic-organ-prolapse/
NICE. (2015). Urinary incontinence in women: management, 1 Recommendations [online] National Institute for Health and Care Excellence, 2015 [viewed 14/03/2018]. Available from: https://www.nice.org.uk/guidance/cg171/chapter/1-Recommendations#physical-therapies
NICE. (2017). Endometriosis: diagnosis and management [online] National Institute for Health and Care Excellence, 2017 [viewed 05/04/2018]. Available from: https://www.nice.org.uk/guidance/ng73
NICE. (2017). Sacrocolpopexy with hysterectomy using mesh to repair uterine prolapse [online] National Institute for Health and Care Excellence, 2017 [viewed 05/04/2018]. Available from: https://www.nice.org.uk/guidance/ipg577
NICE. (2017). Uterine suspension using mesh (including sacrohysteropexy) to repair uterine prolapse, 3 The Procedure [online] National Institute for Health and Care Excellence, 2017 [viewed 04/04/2018]. Available from: https://www.nice.org.uk/guidance/ipg584/chapter/3-The-procedure
NICE. (2018). Heavy menstrual bleeding: assessment and management. [online] National Institute for Health and Care Excellence, 2018 [viewed 05/04/2018]. Available from: https://www.nice.org.uk/guidance/ng88