Urine is the fluid created by the kidneys that contains waste products. Urine travels down the ureters from the kidneys to the urinary bladder. The bladder temporarily stores urine until you empty it when you urinate. After hysterectomy bladder and urinary changes, such as a thin urinary stream, spraying (rather than the normal stream), urinary frequency and urgency are common.
The uterus is a powerful, muscular sex organ that is attached to broad bands of ligaments, bundles of nerves and networks of arteries and veins. In addition to many other important lifelong functions, the uterus provides structural support to the bladder and the bowel. The bowel is posterior to the uterus; it sits behind the uterus. The bladder is anterior to the uterus; it sits in front of the uterus. The uterus sits in the pelvis above the vagina, between the bladder and the bowel and it supports the bowel in its natural location and configuration.
The uterus is continuous with the cervix, which is continuous with the vagina, much in the same way that your head is continuous with your neck, which is continuous with your shoulders. The cervix, which is the opening from the vagina to the uterus, is usually removed with the uterus.
The opening of the vagina is the introitus. Inside the introitus is the vaginal wall, which is composed of muscle and covered with mucus tissue. The vaginal wall contains layers of tissue with numerous elastic fibers. Pleats of tissue allow the vagina to expand during sex and birthing. After the uterus is removed and no longer supports the bladder and the bowel, if the stitches used to hold the bladder in place stretch or breakthe bladder prolapses down into the top of the vaginal vault.
Regardless of whether a hysterectomy is “total” (removal of the uterus and cervix) or “partial” (removalof the uterus leaving the stump of the cervix), and regardless of whether the hysterectomy is laparoscopic, robotic, vaginal or abdominal, everything attached to the uterus must be severed for the uterus to be removed, including the ligaments, blood supply and nerve supply.
Whether a total hysterectomy is abdominal, vaginal, laparoscopic or robotic, an incision is made in the top of the vagina and continued in a circle around the circumference of the cervix. In an abdominal hysterectomy the uterus is either pulled out of the pelvis through an abdominal incision or it is pulled through the hole that was made in the top of the vagina. The ligaments that are left hanging in the pelvis after being severed from the uterus are tied and bundled together and left hanging in the pelvis. The hole created by the incision is then sutured shut to stop the bowel from prolapsing (falling) through the hole into the vagina and out of the introitus (the vaginal opening). The top of the vagina is then usually sutured to one of the bundles of ligaments. When the top of vagina is sutured shut it shortens the length of the vagina. Doctors refer to the shortened vagina they sutured shut at the top during the hysterectomy as a “vaginal vault.”
The round ligaments, cardinal ligaments, broad ligaments, and uterosacral ligaments that attach to the uterus provide structural integrity and support to the bladder, the bowel and the pelvis. When the ligaments are severed and the uterus is amputated and removed, the structure and natural configuration of the remaining pelvic organs is compromised. It is like removing the supports for a bridge. If the supports are removed the bridge will collapse.
Without the uterus separating the bowel from the bladder, when there is gas or stool in the bowel it presses against the bladder, putting pressure on the bladder. When there is stool in the bowel it presses against the bladder, often causing painful bladder spasms. This pain is usually relieved by drinking any carbonated liquid, such as seltzer or soda. Urinary incontinence (the inability to control urination) may be caused by the weakening of the pelvic floor as a result of severing the ligaments and a loss of feeling from the severing of pelvic nerves.
In addition to urinary incontinence, hysterectomy may cause perineal descent and pudendal or obturatornerve damage. Perineal descent is the sagging of the perineum (the area between the anus and the opening of the vagina) as a result of structural loss caused by the removal of the uterus and the severing of the ligaments. The pudendal nerve, which travels from the lower back to the vagina and rectum, is often damaged during the surgery.
Many women experience a permanent searing pain of the nerve pathways that radiate down from the waist through the buttocks to the back of the knee and sometimes down the legs to the toes, making it painful to sit or walk. Pudendal and obturator nerve damage can also cause vaginal, labial and clitoral pain, often described by hysterectomized women as the feeling of a hot poker on the nerve.
Sensation in the vagina, clitoris, labia and nipples is diminished or lost entirely. Some women experience what they describe as cyclical electric shocks in the vagina as a result of damage to the pelvic nerves, and some women experience a loss of sensation in the bladder and urethra. With no sensation, the signal to empty the bladder and urinate is no longer received, which causes urinary incontinence.