Understanding Urinary Incontinence Risks Post-Surgery

In this episode, I address the common questions I'm asked about the risk of urinary incontinence following surgery, specifically focusing on hysterectomy, prolapse repairs, and hip replacement. I discuss several key studies, including a 2000meta-analysis by Jeanette Brown and a 2023 paper in the American Journal of Obstetrics and Gynecology, which highlights the significant risks associated with these surgeries. I also provide tips on pelvic floor strengthening and the benefits of different surgical approaches to help minimize incontinence. I discuss how hip replacement surgery can have varying impacts on bladder function and the importance of a holistic view of the body's interconnectedness.

https://pubmed.ncbi.nlm.nih.gov/10950229/

https://www.nejm.org/doi/full/10.1056/NEJMoa054208

https://pubmed.ncbi.nlm.nih.gov/24408744/

https://pubmed.ncbi.nlm.nih.gov/36300551/

Timeline:

00:30 Introduction to Urinary Incontinence Risks
00:59 Hysterectomy and Urinary Incontinence
04:17 Prolapse Repairs and Bladder Leaking
06:15 Hip Replacement and Bladder Function
08:59 Conclusion and Key Takeaways

Transcript

 Hi there. I am continuing my series of podcasts on questions that I commonly get asked. And so today I wanted to talk to you about the risk of urinary incontinence after surgery, and I'm gonna talk to you specifically about three different surgeries. So the first is hysterectomy.

The second is. Prolapse repairs. And then the third is hip replacement. So these are pretty common questions that I get asked. Um, you know, if you're having a surgery like a hysterectomy, I think it's important for you to know the different risks. Um, and there is some data. To guide us guide. So way back in 2000, um, there was a meta-analysis that was done by Jeanette Brown and it was published in The Lancet, and she reviewed 12 different papers.

And when she compiled all of this data. She found that women were more likely to have urinary incontinence after a hysterectomy, and in this initial work, she found that it wasn't necessarily urinary incontinence immediately, that it happened in 60-year-old women or greater. So patients had their hysterectomies, and then when they were 60, they were much more likely to.

Um, have leaking. Um, so there was an increased risk of bladder leaking later in life. And the risk of urinary incontinence in these women was, um, there was an increase of about 60%. So a pretty substantial, um, increase in the chance that you would have leaking in your sixties. There's been some additional work over time, um, and it has really validated this work.

Some of the studies show that the incontinence can start right away and that there's an increased chance of leaking over time. There was a paper in the American Journal of Obstetrics and Gynecology in 2023 that found that the risk of having. A surgery for stress incontinence doubled after a hysterectomy, right?

And usually women who seek surgery, that's just kind of the, the tip of the iceberg, right? There are lots of other women who have problems but don't want a surgical intervention or maybe have a little bit more mild incontinence. Um, but there's definitely a risk. The thought is that this is because the urethra isn't as well supported anymore, that doing a hysterectomy impacts the support, but we don't exactly know why that happens.

If you have some leaking at the time of your hysterectomy, you can absolutely have an incontinence procedure at the time. If that's something appeals to you. You have your hysterectomy and then you wanna do a lot of pelvic floor strengthening to help minimize that risk. Um, but that association is definitely there and it's regardless of type of hysterectomy, right?

So if you have a big incision, if you have the uterus removed through the vagina, if you haven't removed laparoscopically or robotically, there's still that increased risk of leaking. So the second thing that I wanted to talk about is the risk of leaking after a prolapse surgery. Frequently when we do prolapse surgeries, it is the bladder that is prolapsing or isn't well supported.

And with a prolapse it can make it harder to empty your bladder. Um, your tubing is just kind of kinked off, and because of that, it actually protects you against leaking. But then after. Surgery for prolapse. When you're un kinking things, you can unmask some of this leaking. Um, and so you can have your prolapse fixed and develop stress incontinence.

And in general, I would tell you that does not make women very happy. So there was a study done by Brew Baker in the new. In the New England Journal of Medicine, and what they found was that women who had prolapse and had no symptoms of stress incontinence, if they underwent a prolapse repair and nothing else was done, the risk of bladder leaking afterwards was just under 60%.

So it's really, um, pretty common because of this. Um, before we do a prolapse repair, we'll discuss this with the patient sometimes. Do testing to see if it looks like you're going to leak more when the prolapse is supported. Um, sometimes we'll put in a sling. Sometimes we'll just wait and see if symptoms developed.

Um, but this is an important thing to discuss before a prolapse procedure because the risk of bladder leaking and someone who has no bladder leaking ahead of time is close to 60%. The next thing I wanted to talk about is hip replacement and the impact of hip replacement on bladder function. And this may be surprising to you, but there's actually, um, been quite a few studies done.

On this very topic, um, you know, the, the muscles around the hip are connected to your pelvic floor muscles, and so when those muscles are bothered, it can impact your pelvic floor muscles and the whole continence mechanism. And so there are different ways to do. Um, a hip replacement. So there's an anterior approach where the incision is in the front.

There's a posterior approach where the incision is in the back. The posterior approach goes through more muscles, and the research shows pretty clearly that. If you have an anterior approach, it improves urinary incontinence, but a posterior approach worsens urinary incontinence. Um, and that's also thought to be because of, um, the muscle dissection that has to be done, um, to perform the surgery.

If you have an anterior approach, how much of an improvement? Um, is there in urinary incontinence, a bed and all looked at this in 2023 and what they found was that about 54% of patients had stress incontinence before their hip replacement. And this went down to 16% three months after the surgery. Urinary incontinence, and this went down to about 8% at three months.

Um, so there was a pretty dramatic improvement just with, um, the hip replacement. I think these relationships between the pelvic floor and other parts of the body sometimes surprise people, but it's important to know that, you know, these things can impact your continence mechanism. I've definitely seen an increase in bladder symptoms in the short term after a hip replacement, but then it generally improves by that three month mark.

There are also some studies out there looking at low back pain and pelvic girdle pain. Um, and those studies all show that back pain and pelvic girdle pain also correlate with urinary incontinence. So when we're thinking about incontinence, it's important to look at the rest of your body too, just because that impacts how those sphincters work and how your muscle function.

Works. So this episode may surprise you a little bit. The risk of incontinence increases with a hysterectomy. It increases with a prolapse repair if only the prolapse is repaired and if there's no thought to how the bladder and the urethra are going to function. But bladder symptoms can get better with, um.

Hip replacement, um, and with treating back pain as well. So it's important to look at the whole body and not just the one system when we're thinking about fixing, uh, incontinence