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Urinary Tract Injury following Hysterectomy
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A hysterectomy is done in women and represents the removal of the uterus with or without removal of the fallopian tube and ovaries. In hysterectomies historically, the cervix was spared and just the fundus or body of the uterus was removed. A hysterectomy can be done for a variety of reasons, including heavy vaginal bleeding, prolapsed or sagging of the uterus, urinary incontinence or frequency due to uterine myomata (benign tumors of the muscle of the uterus) or cancer of the uterus.
A hysterectomy can be done in two ways. It can be done using an open method with a vertical or horizontal incision in the abdomen. The visibility is great and there is less of a risk of urinary tract injury during the hysterectomy. The recovery time is longer, however, than a vaginal hysterectomy. A vaginal hysterectomy is done using a speculum and making an incision in the vaginal vault. The visibility isn't as good as with open hysterectomy but there is no external scar and the recovery time is faster.
Complications of a hysterectomy of any type include infection, bleeding, hematoma formation (blood clots in the pelvis), venous blood clots, pulmonary embolism and urinary tract injuries. Urinary tract injuries can occur to the bladder wall or to the ureters, the tubes that lead from the kidneys to the bladder.
In a study of 839 patients, it was found that the incidence of urinary tract injury associated with hysterectomy was about 4.3 percent. The rate of bladder injury was about 2.9 percent and the rate of ureteral injury was about 1.8 percent. A few people had simultaneous bladder and ureteral injuries. Injuries to the bladder or ureters were determined using a cystoscopy exam, a camera examination that begins by inserting the scope into the urethra. It was found that the ureters were mostly damaged at the level of the uterine artery. This was the case in 80 percent of cases. Transection of the ureter or kinking of the ureter were the most common injuries to the ureter. To the bladder, a puncture wound to the bladder wall was the most common injury.
There are several methods of detecting urinary tract injury following hysterectomy. The cystoscope is perhaps the best method as it can visualize the bladder wall and ureter wall to see what's happening and if there is any defect. Another test involves instilling dye into the bladder and ureter and watching for the presence of the dye coming from the vagina. This is perhaps the cheapest test to do for bladder injuries. A tampon can be inserted into the vagina and, after a period of time, the tampon is evaluated for the presence of dye. A reverse test is sometimes done by putting dye into the vagina and checking for dye in the urine but this is messier and less commonly done.
There are several complications of having a urinary tract injury following hysterectomy. The greatest of these is infection. Bacteria can spread through the defect between the vagina and the bladder wall and can cause a chronic urinary tract infection. This can be an obvious symptom or can simply be symptoms of lower abdominal pain, fever or fatigue. The bacteria can extend up to the kidney and can result in pyelonephritis. Kidney infections can be very painful and can lead to septicemia or sepsis.
Another complication of a urinary tract infection following hysterectomy may be leakage of urine from the vagina. If the defect is large, there can be chronic drainage of the urine from the vagina. If the defect is small, the vagina may only leak during urination.
The treatment of urinary tract injury following hysterectomy can be a surgical repair. Doctors can also have the patient use a chronic indwelling Foley catheter-sometimes for several months-until the defect heals on its own or until the area can be stable enough to be treated surgically.