The lower intestines complete the digestive process before food passes out of the body as waste. The bowel in its natural position and configuration temporarily stores the waste, allowing bowel movements to occur when it is convenient. Bowel problems are common after hysterectomy (the surgical removal of the uterus).
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 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 by 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 break the bladder prolapses down into the vaginal wall and may continue to move down close to the opening of the vagina. If you feel a bulge at the opening of the vagina it may be your prolapsed bladder. The bowel drifts down and takes up the space where the uterus had been. Without the support of the uterus, the bowel now sits on top of the vaginal wall. When there is stool in the bowel, that part of the bowel bulges into the vaginal wall. This is called a rectocele. When there’s 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.
Regardless of whether a hysterectomy is “total” (removal of the uterus and cervix) or “partial” (removal of the uterus from the cervix, 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 to remove the uterus, 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 is pulled through the hole that was made at the top of the vagina. The ligaments that are left hanging in the pelvis after being severed from the uterus are bundled together and the top of the vagina is usually sutured to one of the bundles of ligaments. The hole created by the incision in the top of the vagina is then sutured shut, making it a closed pocket to stop the bowel from prolapsing (falling) through the hole into the vagina and out of the introitus (the vaginal opening). When the top of vagina is sutured shut it shortens the length of the vagina. After hysterectomy doctors refer to the shortened vagina they create as the “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 and the bowel. 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.
The most common functional bowel problems after hysterectomy include slow transit constipation (which often becomes chronic), diminished or total loss of bowel motility, bowel obstruction and fecal incontinence (leakage and inability to control stool).
Without the uterus separating the bowel from the bladder, when there is gas or stool in the bowel it creates pressure on the bladder by pressing directly against it. A pocket of the bowel containing stool will then often press into the vagina, creating a rectocele, which is a ballooning of the bowel into the vagina. Unlike the often successful repair of a rectocele when the uterus is intact, repeated attempted repairs of a rectocele after hysterectomy are rarely successful.
In addition to fecal incontinence, chronic constipation after hysterectomy may lead to 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 when the nerves that attach to the uterus are severed. Some women experience what they describe as cyclical electric shocks and pulsating in the vagina as a result of damage to the pelvic nerves. Some women experience a loss of sensation in the bowel. Without receiving the signal that the bowel is full, there’s no urge to have a bowel movement, which can cause either bowel obstruction or fecal incontinence.
Bowel problems caused by hysterectomy are irreversible.