Understanding Hysterectomy and Your Pelvic Floor: What Every Woman Should Know
Hysterectomy is one of the most commonly performed surgical procedures worldwide. For many women, it can be a life-changing solution for conditions such as heavy menstrual bleeding, fibroids, endometriosis, or chronic pelvic pain.
However, it is also very common for women to ask an important and valid question: “How will a hysterectomy affect my pelvic floor and long-term body function?”
Some women worry about making the wrong decision, particularly when they hear mixed information about bladder, bowel, or prolapse issues after surgery. This article aims to educate, reassure, and empower women by explaining how hysterectomy can influence pelvic floor function and what to expect during recovery.
As a urogynaecologist, my goal is to ensure patients understand that the uterus doesn't live in isolation. It plays a crucial role in the vaginal apex support and typically lives in harmony with the bladder and bowel if the support is undisrupted. This does not mean hysterectomy is unsafe or inappropriate, but it does mean that the surgery can influence how the pelvic organs behave over time.
If hysterectomy is considered as part of the prolapse management, I strongly encourage women to question their specialist the rationale of the treatment if the uterus is deemed healthy or absent of risk factors of possible future pathology. This is a seperate discussion topic as there are multiple factors to consider.
Here is a breakdown of the impact of hysterectomy on your pelvic floor function and what you can expect during recovery
Vaginal Vault Prolapse: The Support Challenge
The uterus is held in place by a network of ligaments (uterosacral and cardinal ligament) and connective tissues (the endopelvic fascia). When the uterus is removed, these supports are reconfigured. In some cases, the vaginal vault (top of the vagina) can begin to descend because the primary anchors are no longer there. The incidence of post hysterectomy vagina vault prolapse is around 1.8% for benign gynaecology disease.
The risk vaginal vault prolapse is typically higher in women with:
Pre-existing vaginal prolapse
Previous vaginal births
Menopause
Poor connective tissue strength and quality (genetic disorder)
Maintaining strong pelvic floor muscles through regular exercise offers you the best long-term protection.
The need for concurrent vaginal vault suspension at the time of hysterectomy should always be carefully assessed before surgery.
In theory, it may seem sensible to offer a prolapse prevention procedure during hysterectomy to reduce the risk of future vaginal prolapse. However, in women without prolapse symptoms, this is not recommended practice. Performing additional surgery in the absence of symptoms exposes patients to unnecessary surgical risks including longer operating time, increased pain, and potential complications, without clear evidence of benefit.
On the other hand, if a woman already has pre-existing vaginal prolapse symptoms or clinical signs of pelvic organ prolapse, a different approach is required. In these cases, a detailed pelvic floor assessment by an experienced urogynaecologist is important. This allows careful consideration of whether a concurrent vaginal vault suspension should be performed at the time of hysterectomy to restore support and reduce the risk of prolapse progression.
Bladder Function: Finding a New Normal
The bladder sits directly in front of the uterus. Because they share a close anatomical space, surgery can temporarily or permanently alter bladder habits.
Urinary frequency and urgency: Some women experience overactive bladder symptoms shortly after surgery as the bladder adjusts to its new space. Conversely, if a large fibroid uterus was previously pressing on the bladder, a hysterectomy often provides significant relief from constant pressure.
Stress urinary incontinence: If there was pre-existing weakness in the pelvic floor, removing the uterus can sometimes unmask or worsen leakage when coughing or sneezing.
Incomplete bladder emptying: This can occur if there was pre-existing vaginal prolapse that was not addressed. The prolapse can sometimes cause intermittent urethral obstruction depending on the severity of the condition
Bowel Function: Managing the Change
The rectum sits behind the uterus, and the nerves governing bowel movements pass through the pelvic region.
Constipation is the most common post-operative complaint, often due to a combination of pain medications and reduced mobility.
Changes in the pelvic support structure can sometimes lead to a feeling of incomplete bowel emptying. Conversely, if a large fibroid uterus was previously pressing on the bowel, a hysterectomy often provides significant relief from constant pressure.
Maintaining a high-fiber diet and correct "toileting posture" is vital during recovery.
Sexual Function: Intimacy After Surgery
One of the biggest concerns for patients is how a hysterectomy affects their sex life, which is usually unspoken.
Physical changes: If the cervix is removed (complete hysterectomy), the vaginal canal may be slightly shortened, but for most women, this does not impact pleasure.
Libido and Lubrication: If the ovaries are removed (oophorectomy) alongside the uterus, the sudden change in estrogen can lead to vaginal dryness. This is easily managed with localized estrogen therapy or lubricants.
Most studies show that women who had painful intercourse (dyspareunia) before surgery report a significant improvement in their sex lives once the underlying uterine pathology is gone.
How soon can women return to sexual activity after surgery?
Most specialists recommend a period of 6 to 8 weeks of pelvic rest. This allows the vaginal cuff (the surgical site where the uterus was removed) to heal completely. It is important to have a follow-up assessment with your specialist to confirm that healing is sufficient before resuming intercourse
The Importance of Pelvic Floor Physiotherapy
Regardless of the surgical technique used (laparoscopic, robotic, or vaginal), your pelvic floor muscles remain the foundation of your core. I am a strong believer in rehabilitation and recommend that all patients see a specialised women’s health physiotherapist both before and after surgery. Maintaining these muscles strengths and function is the best defense against future prolapse and incontinence.
A hysterectomy is not just the end of a medical issue, it is the beginning of a new phase of pelvic health. With the right surgical technique and post-operative care, most women return to their daily activities feeling better than they have in years.