European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 84–88

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Effect of simple and radical hysterectomy on quality of life – analysis of

all aspects of pelvic floor dysfunction
Selcuk Selcuk a,*, Cetin Cam a, Mehmet Resit Asoglu b, Mehmet Kucukbas a,
Arzu Arinkan a, Muzaffer Seyhan Cikman a, Ates Karateke a
a
Zeynep Kamil Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
b
The University of Texas, Department of Gynecology, Galveston, TX, USA

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The impact of simple and radical hysterectomy on all aspects of pelvic floor dysfunctions was
Received 26 August 2015 evaluated in current study.
Received in revised form 10 November 2015 Study design: This retrospective cohort study included 142 patients; 58 women (40.8%) who have
Accepted 1 January 2016
undergone simple, 41 (28.8%) radical hysterectomy, and 43 (30.2%) women without any surgical
intervention to serve as the control group. The validated versions of the Urogenital Distress Inventory
Keywords: (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Pelvic Floor and Incontinence Sexual Impact
Urinary incontinence
Questionnaire (PISQ-12), Wexner Incontinence Scale score and pelvic organ prolapse quantification
Radical hysterectomy
Anal incontinence
(POP-Q) system were used in detailed evaluation of pelvic floor dysfunction. One-way ANOVA and
Pelvic organ prolapse Pearson’s chi square tests were performed in statistical analysis.
Sexual dysfunction Results: It was found that there were significant differences in irritative and obstructive scores of UDI-6
Quality of life between Type III hysterectomy group and Type I hysterectomy group. In addition, patients of Type I
hysterectomy had significant higher irritative and obstructive scores than the control group. Type III
hysterectomy had the most significant deteriorating effect on sexual life, based on scores of PISQ-12
compared to both Type I hysterectomy group and control group.
Conclusion: Hysterectomy results in detrimental effects on the quality of life (QoL) regarding all aspects
of pelvic floor functions especially in women of radical hysterectomy. Urinary dysfunctional symptoms
like urgency, obstruction and especially sexual problems are more bothersome and difficult to overcome.
The impact of hysterectomy on QoL should be investigated as a whole and may be more profound than
previously thought.
ß 2016 Elsevier Ireland Ltd. All rights reserved.

Introduction upper vagina and the removal of uterosacral ligaments and

Hysterectomy is the most common gynecological surgical
procedure performed for both benign and malign gynecologic
conditions. The surgical approach for hysterectomy is mainly
abdominal (65%), followed by vaginal, conventional laparoscopic
and robotic routes 20%, 13% and 0.9%, respectively. Nearly 90% of
hysterectomies are done for benign symptomatic disorders;
whereas radical hysterectomy is performed to treat gynecologic
cancer, consisting of 1.2% of all hysterectomies [1]. The most
common form of radical hysterectomy is Type III radical
hysterectomy, which involves more extensive removal of the
* Corresponding author at: Zeynep Kamil Hospital, Uskudar, 34662 Istanbul,
Turkey. Tel.: +90 532 163 0488.
E-mail address: md_sel@hotmail.com (S. Selcuk).
parametrial tissue [2]. The associations of abdominal hysterectomy
with disruption of local nerve supply and distortion of anatomic
relations leading to pelvic floor disorders have been postulated
[3]. Pelvic floor dysfunction describes a range of problems associated
with one or more of the three systems in the pelvic floor, i.e., the
urinary system, anorectal system, and genital system [4].
Although the significant numbers of women are bothered
concomitantly from all pelvic floor symptoms after hysterectomy,
data on the evaluation of the whole function and dysfunction of the
pelvic floor is scarce. The impact of any bothersome pelvic floor
symptom may affect other elements of pelvic floor, leading to a
more complicated state of quality of life for women. This must be
completely understood and acknowledged for the appropriate
management of these symptoms. In addition, despite the early
transient changes in pelvic floor dysfunctions after simple and
radical hysterectomy, the long-term prevalence of symptoms and

http://dx.doi.org/10.1016/j.ejogrb.2016.01.008
0301-2115/ß 2016 Elsevier Ireland Ltd. All rights reserved.
 S. Selcuk et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 84–88
the extent of morbidity associated with the procedure have not
been well established. Therefore, the aim of this retrospective
study was to analyze the impacts of abdominal total simple and
radical hysterectomies on all aspects of pelvic floor dysfunctions,
using quality of life (QoL) questionnaires in the postoperative
follow-up period.
Materials and methods
In this retrospective cohort study, cases were identified from a
review of hospital databases. Inclusion criteria consisted of; first,
women with stage Ib–IIa cervical cancer who underwent Type III
radical hysterectomy for invasive cervical cancer; second, women
who underwent abdominal simple (Type I) hysterectomy for
benign indications. Both groups were selected randomly during
the same time period. Women applied to our outpatient clinic for
their routine gynecologic examination, and without any gyneco-
logical surgical intervention were used as control. Exclusion
criteria required a previous medical and/or surgical treatment for
prolapse and/or urinary and/or anal incontinence, adjuvant
treatment after the surgery in cancer patients. Women, who did
not answer the questionnaires adequately, were also left out of the
study. The study protocol was approved by the Local Research and
Ethics Committee of our hospital. Type I hysterectomies were
performed by completely removing the cervical fascia, resecting
cardinal ligaments medial to ureters and uterosacral ligaments at
level of cervix and leaving the vaginal vault in situ. After the
removal of the uterus, the cardinal and uterosacral ligament
stumps were sutured to the vaginal vault. In Type III hysterecto-
mies, vaginal cuff was removed up to upper one-third to one-half
and cardinal ligaments were resected at pelvic side wall and
uterosacral ligaments were resected at post-pelvic insertion. No
attempts were made to suspend the remaining vaginal vault.
Selected women were invited to the clinic and asked to answer the
previously validated (QoL) instruments to evaluate the symptoms
of urinary incontinence, anal incontinence and sexual dysfunction.
Medical professionals, who were blinded to the clinical character-
istics and history of patients, administered the questionnaires to
patients. Symptoms of urinary incontinence (UI) were evaluated by
the validated form of the Urogenital Distress Inventory (UDI-6) and
Incontinence Impact Questionnaire (IIQ-7) [5]. IIQ and UDI were
both developed and combined to assess the impact of urinary
incontinence on QoL [6]. Short versions of the IIQ and UDI
composed of 7 and 6 questions with high degree of correlation with
the longer forms were developed [7]. The short forms, IIQ-7 and
UDI-6, were developed in combination to measure the life impact
of incontinence in women. The UDI-6 can also be divided into three
subscales: the first, second and the third subscales evaluate
irritative symptoms (urgency, frequency and pain) (questions
1 and 2), stress symptoms (questions 3 and 4) and obstructive/
discomfort or voiding deficiency (questions 5 and 6), respectively.
Higher scores on both questionnaires indicated worsening of
symptoms. The presence and degree of anal incontinence was
evaluated with the validated form of the Wexner incontinence
scale. Wexner incontinence scale is a simple and effective disease-
specific questionnaire for AI, described by Jorge and Wexner
[8]. Patients, who scored 0 on the scale, were grouped as patients
with no anal incontinence and those who scored 1 as patients
were labeled with anal incontinence. Higher scores indicated
worsening of symptoms.
The impact of hysterectomy types on sexual life was evaluated
by the validated form of PISQ-12. The PISQ-12 is a condition-
specific, self-administered questionnaire that evaluates sexual
function in women with POP and/or UI. The short form provides a
single sexual function score. Higher scores indicate better
functioning [9]. Degree of the pelvic organ prolapse of patients
85
was evaluated according to pelvic organ prolapse quantification
(POP-Q) system [10]. POPQ examination was performed by a single
author who was blinded to the clinical characteristics and history
of patients. All simple and radical hysterectomies were performed
by 5 attending surgeons within the divisions of gynecology and
gynecologic oncology, using standardized surgical approaches
described elsewhere. For all definitions for pelvic floor symptoms
The International Urogynecological Association (IUGA)/Interna-
tional Continence Society (ICS) joint report on the terminology for
female pelvic floor dysfunction was used [11]. Statistical analysis
was performed using SPSS11.5 software. One-way ANOVA and
Pearson’s chi-square tests were performed where appropriate;
p = 0.05 was accepted as the degree of significance. Data were
given as mean  standard deviation or percentage.
Results
This retrospective study included 142 patients. 58 women
(40.8%) who underwent simple hysterectomy, 41 women (28.8%)
who underwent radical hysterectomy, and 43 (30.2%) women had
no surgical intervention. They served as the control group. There
were no statistically significant differences in terms of age, parity,
body mass index (BMI), postoperative interval and the ratio of
symptomatic and asymptomatic prolapse according to the POP-Q
system (Table 1). The scores of IIQ-7, irritative and obstructive
subscales of UDI-6 and PISQ-12 were statistically different. The
stress subscale and the Wexner incontinence scale were not
significant (Table 2). It is noteworthy that 84.6% of patients within
the simple hysterectomy group and 53.7% of patients within the
radical hysterectomy group answered PISQ-12 questionnaire.
Performing any type of hysterectomy resulted in difference in
irritative scores with controls. This was most significant between
Type III hysterectomy and control group (p = 0.001), and less but
also significant between Type III and Type I hysterectomy
(p = 0.035). Type I hysterectomy also showed significant differ-
ence with controls (p = 0.038). In addition, obstructive score of
Type III hysterectomy group was significantly higher than Type I
hysterectomy and control groups (p1 = 0.019, p2 = 0.011). On the
other hand, obstructive scores were higher in the Type I
hysterectomy group than in the control group, but there was
no statistically significant difference (p = 0.908). Although women
with Type III hysterectomy scored worse than any other group in
stress scores, this difference was not significant enough,
compared to each Type I hysterectomy and control groups
(p = 0.890 and p = 0.375, respectively). Similar to the irritative
scores, patients, who underwent any type of hysterectomy,
showed difference in sexual function scores. Women with Type III
hysterectomy scored significantly lower than any other group.
This was most significant between Type III hysterectomy and
control group (p = 0.001), also strongly significant between Type I
and controls (p = 0.002). There was also a statistical significance of
a lesser degree between Type I and Type III groups (p = 0.037). The
rates of symptomatic women for urinary symptoms were
statistical significantly higher in radical hysterectomy group.
The rate of women with anal incontinence symptoms showed no
statistical difference (Table 3).
Comment
In this study, the rate of pelvic floor symptoms after different
type of hysterectomies and their effect on patient’s QoL and pelvic
floor function were evaluated. According to the present data, it can
be argued that performing any type of hysterectomy may result in
more pelvic floor symptoms compared to women without any
pelvic surgery, given radical hysterectomy is more influential than
simple hysterectomy. Urinary symptoms, especially irritative and
86 S. Selcuk et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 84–88

Table 1
Demographic data of participants.

Type I hysterectomy(n: 58) Type III hysterectomy (n: 41) Control(n: 43) p

Age (years) 50.34  6.20 52.49  9.97 49.21  6.34 0.152

(mean  sd)

Parity (n) 2.95  1.05 2.82  1.27 2.57  1.68 0.331

(mean  sd)

Postoperative interval (months) 49.77  6.04 45.44  20.88 – 0.216

(mean  sd)

BMI (kg/m2) 28.18  3.47 27.07  3.24 28.01  4.94 0.378

(mean  sd)

POP-Q stage
Asymptomatic**
% 87.9 80.5 90.7 0.362
(n) (51) (33) (39)

Symptomatic***
% 12.1 19.5 9.3
(n) (7) (8) (4)

p values were demonstrated in italics.

**
POP-Q Stage II (proximal to hymenal ring).
***
POP-Q Stage II (beyond hymenal ring).

Table 2
Comparison of QoL questionnaires for urinary incontinence, fecal incontinence and sexual function.

Type I hysterectomy (n: 58) Type III hysterectomy (n: 41) Control (n: 43) p

IIQ-7 3.98  5.19 6.56  6.12 1.43  2.90 0.001*

(mean  sd)

UDI-6
(mean  sd)
Irritative 1.38  2.16 2.41  2.59 0.37  0.84 0.001*
Stress 1.07  1.85 1.24  2.07 0.71  1.67 0.388
Obstructive 1.02  1.33 1.91  2.29 0.88  0.93 0.006*

Wexner score 1.03  2.17 1.39  3.03 0.90  2.91 0.635

(mean  sd)

PISQ-12 26.56  5.21 22.63  8.68 30.85  4.99 0.001*

(mean  sd)

p values were demonstrated in italics.

*
The level of significance was accepted at p = 0.05 level.

Table 3 obstructive symptoms, were more frequent after radical interven-

Comparison of symptomatic women for urinary and fecal incontinence. tions; whereas stress urinary symptoms were found to be less
affected. A profound impact of hysterectomy on sexual function
Type I Type III Control p
hysterectomy hysterectomy (n: 43)
was observed, and this was more profound in women who have
(n: 58) (n: 41) undergone radical procedures. Despite these extensive interac-
tions with pelvic floor functions, hysterectomy of any type had no
Urinary incontinence total
% 48.3 70.7 25.6 0.002* additive effect on anal incontinence and pelvic organ prolapse.
(n) (28) (29) (11) Postoperative lower urinary tract dysfunction after pelvic surgery
Urgency
is well known and although spontaneous recovery should be
% 17.2 39.0 7.1 0.007* expected in the first postoperative six months, long-term urinary
(n) (10) (16) (3) problems are reported in over 30% of cases, and at least 16% of
Stress
women may be severely disabled by their symptoms [12]. In a
% 13.8 17.1 9.3 0.575 review which included 11 observational studies, the odds of
(n) (8) (7) (4) developing urinary incontinence after hysterectomy was sug-
Mixed
gested to be about 40% higher than for those who have not
% 10.3 14.6 4.7 0.304 undergone this procedure [13]. Despite its high occurrence, the
(n) (6) (6) (2) pathophysiologic mechanisms of pelvic floor dysfunction after
Obstructive hysterectomies are not clearly defined, but the iatrogenic injuries
% 15.5 34.1 4.7 0.002* to pelvic organ support system and to autonomous and motor
(n) (9) (14) (2) nerves during the procedures are often promoted as the causative
Anal incontinence basis [14]. In our series, being more prominent in women who have
% 22.4 39.0 23.8 0.153 undergone radical hysterectomies, irritative (urge) and obstructive
(n) (13) (16) (10) symptoms were more frequent and more bothersome than stress
p values were demonstrated in italics. symptoms. Contradictory, several studies regarding pelvic floor
*
The level of significance was accepted at p = 0.05 level. dysfunction after hysterectomies suggested that symptoms of
 S. Selcuk et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 198 (2016) 84–88
stress urinary incontinence are more common than symptoms
of urge incontinence [15,16]. Additionally, most of the studies
concern about the rate of the incontinence rather than occurrence
of urinary retention. The rate of urinary retention after radical
hysterectomies may be much higher than previously thought and
may be more bothersome in particular patients. It has been
urodynamically shown that the postoperatively bladder compli-
ance is decreased and residual volume is increased, both in short-
and long-term after radical hysterectomies [17]. Similarly, in a
questionnaire-based study, the authors stated that a proportion of
women with involuntary leakage may in fact have experienced
retention and overflow, as opposed to genuine stress incontinence
[12]. Given that stress or urge symptoms can be treated medically
or surgically, symptoms of urinary retention are more difficult to
treat, creating more problems for the QoL of women. Although the
role of hysterectomy as a cause of subsequent development of
pelvic organ prolapse is controversial, hysterectomy is identified as
a significant risk factor for pelvic organ prolapse in a case–control
study [4] and rates and degree of prolapse appear similar after
abdominal and vaginal route [18]. Most authors believe that
paying particular attention to reattaching the uterosacral liga-
ment-cardinal ligament complex to the cuff reduces the incidence
of prolapse after hysterectomy [19]. In Type I hysterectomies the
vaginal cuff is not removed and cardinal ligaments are resected
medial to ureters, and uterosacral ligaments are resected at level of
cervix [20], allowing to suture the cardinal and uterosacral
ligament stumps to the vaginal vault to suspend the vagina and
prevent its prolapse. But in radical abdominal hysterectomy,
vaginal cuff is removed up to upper one-third to one-half and
cardinal ligaments are resected at pelvic side wall whereas
uterosacral ligaments are resected at post-pelvic insertion [21]
and the remaining apical segment of the vagina is left virtually
unsuspended. Although one may expect a higher incidence of
genital prolapse after radical hysterectomy than Type I hysterec-
tomy, there were no statistical differences in the ratio of
symptomatic and asymptomatic prolapse according to the POP-
Q system in our series between the hysterectomy types. The
number of symptomatic patients for POP was higher in the radical
hysterectomy group, but this was statistically not significant. This
may be due to the relatively small number of patients and
relatively shorter follow-up period, which was practically less than
four years in average. It has been reported that the incidence of
prolapse, which required surgical correction following hysterec-
tomy, was 3.6 per 1000 person-years of risk and the cumulative
risk rises from 1% three years after a hysterectomy to 5% 15 years
after hysterectomy [18]. The mean age of our cohort may also play
a role because the frequency of uterine prolapse may increase with
age. In comparison to women aged 51 years, the odds ratio OR of
uterine prolapse was reported to be 1.3 and 1.7 respectively for
women aged 52–55 and 56 years [22]. Even we assume a
theoretical risk for POP especially after radical hysterectomies; our
data show that urinary rather than prolapse symptoms bother the
women in the first years after the interventions. Anorectal function
may be affected after both simple and radical hysterectomies.
It has been postulated that iatrogenic damage to the pelvic
autonomous plexa during surgery may result in bowel dysfunction
[15,23]. Because the bilateral plexa are located in close proximity
to the proximal vagina and distal rectum, they and their branches
are at risk of being damaged during partition of the cardinal
ligaments, blunt dissection of the bladder, and division of the
sacrouterine ligaments. Excessive mobilization of the rectum and/
or caudal and lateral dissection of the uterosacral ligaments may
result in partial denervation of the fibers of inferior hypogastric
plexus during radical hysterectomy. In addition, although there is
no direct sphincter trauma during radical hysterectomy, the
pudendal nerve supply to the EAS may be disrupted during the
87
pararectal dissection [24]. Despite these postulations, there are
controversies about the occurrence of anorectal dysfunctions after
hysterectomies of any type. A study reported no alterations of
behavior as a result of anorectal symptoms and uncommon fecal
incontinence symptoms, not differing between radical and simple
hysterectomy groups [25]. On the other hand, anal incontinence
symptoms, which were found to be associated with hysterectomy
after one year, may increase significantly even after longer follow-
up periods [4]. Wexner anal incontinence scores and the number of
symptomatic women for anal incontinence were higher in radical
hysterectomized women in our series. Although this difference
was statistically not significant, it is possible that this difference
may get significant in a longer follow-up of our cohort. Sexual
dysfunction after hysterectomy creates another area of controver-
sy. Sexual function after simple hysterectomy is reported to be
worsened, unchanged or even improved [26,27]. Improvements
may occur due the relief of symptoms associated with common
nonmalignant conditions that may also negatively affect different
aspects of sexual functions of particular women. Sexual function
can be adversely affected after radical hysterectomy and these
major sexual problems were suggested to be transient [28]. Indeed,
the long-term effects of hysterectomy on sexual function were
reported to be still unknown [29]. In contrast, there are several
reports, which suggested the persistence of dysfunctional symp-
toms after radical hysterectomy [30,31]. The possible disruption of
the pudendal nerve fibers and a shortened vagina may cause
problems in lubrication, arousal, and orgasm leading to pain and
dissatisfaction and losing interest in sex life. Our data showed a
significant impact of hysterectomy on sexual function nearly
four years after hysterectomy. Being most prominent in Type III
hysterectomized women; hysterectomy caused significant nega-
tive impact on the sexual life of women.
Conclusion
Hysterectomy, either simple or radical, is the choice of
treatment for many benign and malign gynecological conditions
but results in profound effects on the QoL of women regarding all
aspects of pelvic floor functions. Some urinary dysfunctional
symptoms like urgency, retention, obstruction and especially
sexual problems are more bothersome and difficult to overcome.
Although it can be argued that the negative impact of hysterecto-
mies – especially radical hysterectomy – is well known [32], the
advantages of this study are bundle evaluations of pelvic floor
function with several questionnaires involving bladder, rectum
and sexual functions. Unfortunately, most studies consider only
some particular parts of pelvic floor functions instead of handling
the pelvic floor function with all aspects. Our data on all pelvic
floor symptoms show that a significant number of women
concomitantly suffer from all pelvic floor symptoms. The impact
of hysterectomy on QoL should be investigated as a whole and may
be more profound than previously thought. Given the inevitable
need for hysterectomy in gynecological and oncological practice,
prospective studies with adequate number and follow-up periods,
comparing lesser invasive methods performed laparoscopically
or robotically, preferably using nerve sparing techniques, with
conventional hysterectomy techniques, are needed.
Conflict of interest
There is no conflict of interest.
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