The impact of hysterectomy on pelvic floor functions, sexual functions, body perception and quality of life

Introduction and Objective: Hysterectomy is one of the most commonly performed major gynecological surgeries worldwide. The impact of hysterectomy on pelvic floor functions and its effects on sexual functions related to pelvic floor functions have been a long-standing and controversial topic in the literature over the short, medium, and long term. While the impact of hysterectomy on pelvic floor functions, quality of life and sexual functions related to pelvic floor functions, as well as body perception and women's genital self-image, have been discussed separately numerous times, there is currently no comprehensive longitudinal clinical study that evaluates all these aspects together. Our objective is to delineate the changes in pelvic floor functions, quality of life, sexual functions, body perception, women's genital self-image, and post-hysterectomy patient satisfaction over a one-year follow-up period in women planning abdominal hysterectomy for reasons other than cancer and prolapse. Materials and Methods: Our study was designed as a prospective longitudinal investigation. Between March 2022 and October 2022, a total of 150 patients aged 18 and above, in the premenopausal and postmenopausal periods, who were admitted to the Department of Obstetrics and Gynecology at Ankara University Faculty of Medicine Cebeci Hospital and Lösante Children's and Adult Hospital for total abdominal (open-laparoscopic) hysterectomy due to reasons other than cancer and prolapse were included in the study. After selecting those who met the exclusion criteria among women planning to undergo total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH), the study was completed with a total of 130 patients. Patients admitted to the hospital for hysterectomy underwent assessments four times during the one-year follow-up: immediately pre-operation, and postoperatively at the 3rd, 6th, and 12th months. The evaluations included pelvic floor functions, quality of life and sexual health related to the pelvic floor, body perception and genital self-image. Validated questionnaires in the Turkish language were utilized for these assessments. For this purpose, Pelvic Floor Distress Inventory-Short Form (PFDI-20) was used to assess pelvic floor functions. To evaluate the impact of pelvic floor functions on the quality of life associated with these functions, the Pelvic Floor Impact Questionnaire (PFIQ-7) was employed. The PFIQ-7 assesses the effect of pelvic floor functions on quality of life in three subdomains: urinary incontinence, colorectal functions, and pelvic organ prolapse. For the assessment of sexual functions associated with pelvic floor functions, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was utilized. To evaluate changes in body perception and genital self-image, the Female Genital Self-Image Scale (FGSIS) and Body Cathexis Scale (BCS) were employed. Additionally, the patient's overall satisfaction was assessed three times post-hysterectomy at the 3rd, 6th, and 12th months using the Patient Global Impression of Improvement (PGI-I) scale. Repeated Measures Analysis of Variance was employed to examine changes in measurements across our follow-up time points. When investigating whether there was a difference in the change of questionnaire scores for identified demographic and clinical characteristics, the Mann-Whitney U test and Kruskal-Wallis H test were utilized. Spearman's Correlation Coefficient was used to explore the relationship between quantitative demographic data and clinical characteristics. Results: A total of 130 patients who underwent TAH or TLH were followed up by administering the specified questionnaires and scales three times: pre-hysterectomy, immediately post-hysterectomy and at the 3rd, 6th, and 12th months post-hysterectomy. A statistically significant difference was found in the analysis of variance for the total PFDI-20 scale score between preoperative and postoperative assessments at 3, 6, and 12 months (p<0.001). When examining differences between paired time points, statistically significant differences were observed for preoperative to 3-month scores (77.52±52.56; 37.09±29.95, p0-3<0.001), preoperative to 6-month scores (77.52±52.56; 37.16±32.34, p0-6<0.001), and preoperative to 12-month scores (77.52±52.56; 35.46±27.59, p0-12<0.001). For the POPDI-6 sub-scale, a statistically significant difference was found between preoperative and postoperative assessments at 3, 6, and 12 months based on the analysis of variance (p<0.001). When examining differences between paired time points, statistically significant differences were observed for preoperative to 3-month scores (31.06±19.61; 10.58±9.30, p0-3<0.001), preoperative to 6-month scores (31.06±19.61; 8.91±11.23, p0-6<0.001), and preoperative to 12-month scores (31.06±19.61; 8.65±11.48, p0-12<0.001). For the CRADI-8 sub-scale, a significant difference was found between preoperative and postoperative assessments at 3, 6, and 12 months based on the analysis of variance (p<0.001). When examining differences between paired time points, statistically significant differences were observed for preoperative to 3-month scores (16.66±16.94; 10.46±10.61, p0-3<0.001), preoperative to 6-month scores (16.66±16.94; 11.51±11.90, p0-6=0.004), and preoperative to 12-month scores (16.66±16.94; 11.11±9.12, p0-12=0.001). For the UDI-6 sub-scale, a significant difference was found between preoperative and postoperative assessments at 3, 6, and 12 months based on the analysis of variance (p<0.001). When examining differences between paired time points, statistically significant differences were observed for preoperative to 3-month scores (29.81±25.88; 16.06±15.87, p0-3<0.001), preoperative to 6-month scores (29.81±25.88; 37.16±32.34, p0-6<0.001), and preoperative to 12-month scores (29.81±25.88; 15.71±13.49, p0-12<0.001). The improvement observed in the total assessment of pelvic floor functions and each sub-scale continued from the 3rd month to the 12th month. The only parameter influencing the change in the PFDI-20 scale score was the POPDI-6 scale and uterine volume (r=0.186 and p=0.034). When evaluating the quality of life related to pelvic floor functions using the PFIQ-7 total questionnaire score, no significant change was observed between pre-hysterectomy and the 1st year post-hysterectomy (37.88±46.98; 38.46±37.00, p>0.05). Improvement in PISQ-12 questionnaire scores began from the 3rd month post-hysterectomy (preop-3 months: 31.36±5.55; 34.02±3.76, p0-3<0.001) and continued until the 6th month (31.36±5.55; 33.48±3.85, p0-6<0.001). However, in the 1st year, similar average scores were obtained compared to pre-hysterectomy (31.36±5.55; 31.23±7.26, p0-12>0.05). In the analysis of changes in sexual functions, significant differences were found for menopause (p=0.003), systemic medication use (p=0.036), employment status (p=0.015) and intraoperative salpingectomy and/or salpingo-oophorectomy (p=0.026) among demographic data and clinical parameters. A statistically significant negative relationship of low magnitude was found between PISQ-12 and BMI measurement in the 1st year post-hysterectomy (r=-0.202 and p=0.021). Moderate-sized negative relationships with statistical significance were found between PISQ-12 and age (r=-0.308 and p<0.001), postmenopausal duration (r=-0.423 and p=0.014) and parity (r=-0.304 and p<0.001). There was no significant difference observed in body perception between the 3rd, 6th, and 12th months (p=0.075). The type of surgery performed (TAH-TLH) was the only factor associated with changes in body perception. Regarding women's genital self-image, a non-significant negative impact was detected up to the 3rd month, while a statistically significant score increase was observed from the 3rd month to the 12th month (3-12 months: 18.15±2.85; 19.18±2.82, p<0.001). At the completion of the one-year follow-up, similar scale scores were obtained compared to pre-hysterectomy. When examining the average scores of PGI-I, it was observed that the satisfaction level post-hysterectomy was high from the 3rd month onwards, and this satisfaction increased towards the 12th month. Conclusion: Following abdominal hysterectomy performed for indications other than cancer and prolapse, improvement in pelvic floor functions was observed during the one-year follow-up compared to pre-hysterectomy. However, there was no significant change in the quality of life associated with pelvic floor functions at the end of one year. Over the course of one year post-hysterectomy, there was no adverse impact on sexual functions, body perception, and women's genital self-image. The type of surgery may play a role in changes in body perception. Overall, satisfaction is high after hysterectomy surgery.