Long-term Effects of Hysterectomy

A Focus on the Aging Patient

Catharina Forsgren; Daniel Altman


Aging Health. 2013;9(2):179-187. 

In This Article

Fistula Disease

Pelvic organ fistula disease is a distressing illness that is complicated to treat and often requires repeat surgical interventions.[58,90] Due to advances in modern obstetrical care, fistula disease as a complication of childbirth is rare in industrialized countries, but remains a major problem in developing countries.[91] Instead, pelvic surgery, and hysterectomy in particular, are widely considered major causes of genital fistula disease.[90] The main types of fistulas are: urogenital fistula, intestinogenital fistula, urointestinal fistula, anorectal fistula and nonspecified pelvic organ fistula. The incidence of fistulas after hysterectomy on benign indication has been estimated to be less than 1%.[92]

In a nationwide cohort study from Sweden using prospectively collected data in national health registers of all hysterectomies performed on benign indications between 1973 and 2003,[34] the rate of fistula surgery was four-times higher among women having had a hysterectomy compared with women with an intact uterus. The highest overall fistula rates were observed among older women, which can be attributed to peri- and postmenopausal estrogen deficiency resulting in degenerative changes of the vaginal tissues, which in turn may affect tissue susceptibility to infectious and/or inflammatory processes. Older women may also have a higher incidence of comorbidity associated with poor tissue healing and susceptibility to infections.

In a US hospital-based case series by Hjern et al., 80% of women treated for diverticular fistula disease to the female genital tract were found to be hysterectomized.[93] The notion that hysterectomy increases the risk of pelvic organ fistula disease in women with diverticular disease, and diverticulitis in particular, has also been confirmed in a population-based cohort study from Sweden.[94] The rate of fistula disease was 51.7 compared with 22.0 per 100,000 person-years in hysterectomized women with and without diverticulitis, respectively. A prior hysterectomy may precipitate the formation of enterovaginal fistulas in women with diverticulitis, as the inflammation will be close to the vagina without a protecting uterus in place. These findings are particularly important in elderly women since diverticular disease becomes more common with age. Although it seems biologically plausible that the same holds true for inflammatory bowel disease, the association has not been explored.