Urine Leakage After Hysterectomy: What to Expect & Strategies for Relief

Urine leakage after hysterectomy varies: sometimes a hysterectomy can relieve the conditions that led to incontinence, but sometimes the impact of surgery on the pelvic floor can cause incontinence. There are concrete strategies you can implement after your surgery to minimize the likelihood of urinary incontinence.

Why does urine leakage occur after hysterectomy?

Approximately 500,000 hysterectomies are performed per year in the United States. While for most patients, this surgery provides much-needed relief of symptoms, for some, a hysterectomy is followed by an increase in urine leakage. Let’s begin with a definition of terms: when I say urine leakage, I mean urinary incontinence, both stress incontinence (sneeze pee) and urge incontinence (difficulty holding urine in when the urge strikes). Both types of incontinence have several different causes, and hysterectomy can sometimes be one of them. 

There are several possible complications that can result from a hysterectomy, both as a major surgery and as an operation that can affect the structure of the pelvic floor. As with all major surgeries, there is an increased risk of respiratory and circulatory issues, primarily blood clots and lung infections. Because the uterus, ovaries, and the ligaments that hold them in place take up significant amounts of space in the abdomen and pelvic bowl, removing them can have a major impact on pelvic floor function, including an increased risk of pelvic organ prolapse, overactive pelvic floor muscles, and incontinence.

Who is at risk for post-hysterectomy urine leakage?

There is an overall increased risk for urine leakage post-hysterectomy, but that risk depends on several factors and is not universal: a 2002 survey of just over 1000 American women found that “The majority of women who undergo hysterectomy for nonmalignant indications experienced improved urinary incontinence during the first 2 years after surgery.” And a Finnish study found that the primary drivers of whether women would seek help for stress incontinence in the 10 years after their hysterectomies were the type of surgery they’d had, and whether they already had a history of pelvic organ prolapse. 

While there are many causes for urinary incontinence, age is a major factor–in menopause, the drop in estrogen decreases the tone of the pelvic floor muscles, which can also contribute to leakage. Similarly, if your ovaries are removed during your hysterectomy, you will enter menopause immediately and may experience menopause symptoms like incontinence, vaginal dryness, and mood shifts.

Thankfully, there are a number of methods to manage and find relief from urine leakage after a hysterectomy–you should get in touch with your physician first, but you can also use targeted exercises to help your pelvic floor muscles function well.

The Surgical Impact on Your Pelvic Floor Muscles and Urinary Tract

For the purposes of this article, let’s assume that you’re experiencing incontinence symptoms fairly regularly–every day to a few times per week. And you don’t have any illnesses or stressors that could be playing a role, other than having had a hysterectomy at some point. Hysterectomy-related leaking can happen many years after your surgery.

There are three primary surgical routes for hysterectomy: vaginal, laparoscopic (sometimes assisted by robots), and abdominal. Within those routes, you may have a partial, total, or radical hysterectomy. No matter which route your surgeon decides to take, several ligaments will need to be cut in order to remove the uterus, and thus will reduce the amount of what’s called “apical support”–how far the vaginal apex descends or does not descend toward the vaginal opening. Less apical support means an increased risk of other pelvic organs prolapsing, and higher chance of developing incontinence: 

“Unless specific procedures are performed at time of hysterectomy to reattach the vaginal cuff to the USCL complex, level I support is lost in women without prolapse and is not re-established in women with prolapse. This loss of vaginal support likely leads to increased intra-abdominal forces on the remaining vaginal support, which may already be damaged in parous women, predisposing women to prolapse or recurrence of prolapse.” (source)

The USCL complex mentioned above is the uterosacral ligament, one of the major ligaments in the pelvic floor, connecting the cervix to the sacrum. And “parous women” are women who have given birth. Ideally, your surgeon will reattach the vaginal cuff to the uterosacral ligament, since doing so is one of the best ways to prevent urinary incontinence and pelvic organ prolapse post-hysterectomy. Since the article cited above was published in 2017, this has become more of a standard practice. 

However, there are other aspects of hysterectomy surgery which may still affect whether you develop urine leakage after a hysterectomy: 

• Incisions can cause temporary or permanent nerve damage 
• There is a risk that an incision will nick or change the tension in structures like the urethral neck
• Surgical trauma to the pelvic floor can cause excessive pelvic floor tension
• Hormonal changes due to ovary removal
• Potential early menopause onset, even if you keep your ovaries

What to Expect After Your Hysterectomy

In the immediate post-operative phase (first 2-4 weeks), you will likely have considerable amounts of discomfort at the surgical site. You’ll be prescribed pain medicine and should be able to use the bathroom regularly soon after your surgery. Getting out of bed and moving around is essential to preventing post-surgical complications such as blood clots and shortness of breath.

Your focus during this phase will likely be on the basics: nutrition, hydration, rest, and very gentle movement (anyone who has had abdominal surgery can tell you that getting out of bed and into your kitchen to make a cup of tea requires quite a lot of effort). You may need to manually brace your incisions as you do things like cough or sneeze until your sutures are healed. 

Some leakage is a normal part of the healing process, as your body relearns how to function, and your pelvic floor muscles and nerves begin to reintegrate. Ongoing leakage however could indicate that there is a physiological change related to the surgery. 

Once your sutures are healed, you should be able to begin connecting with your core & pelvic floor muscles, for long-term pelvic health, it’s important to maintain solid core & pelvic floor strategies. While it’s somewhat common to leak when your pelvic floor is under extraordinary pressure (for example, during an illness that has involved a lot of coughing), the leaking should resolve as you return to your normal activities. If it does not, you will want to reach out to a pelvic health specialist.

Comprehensive strategies for urine leakage after hysterectomy relief

Concrete strategies you can take to relieve incontinence after hysterectomy are holistic in nature–there isn’t one simple tool to fix it all, unfortunately. 

Lifestyle modifications such as integrating more mindfulness into your day, making sure you’re eating, drinking, and sleeping well, and paying attention to your mental and emotional health can play a big part in pelvic floor function. You may need to cut back on bladder irritants. You might also need to use absorbent pads or underwear to catch leaks as you work on improving your pelvic floor function. If you’re experiencing painful intercourse or vaginal dryness, finding resources to help is essential–a healthy sex life is good for your pelvic floor, too.

Physical therapy and targeted exercises for pelvic floor health can be a game changer. Of course, I need to mention my 12-week, whole-body program Restore Your Core®, but finding a PT or OT near you who specializes in pelvic floor dysfunction is also great. If you’re an athlete and experiencing urine leakage during your sport, modifying your exercise routines to better reflect your pelvic floor’s actual capacity to manage loads may be necessary for a period of time.

Medical interventions include additional surgeries or pessaries–both of these options aim to better support the pelvic organs.