Hysterectomy has been the mainstay treatment for various gynecologic disorders, with a very low postoperative morbidity. However, the removal of the uterus and the surgical dissection within the pelvis disrupts the anatomy and may affect the physiological function of other pelvic organs, in part because of an adverse effect on pelvic floor functions. Pelvic floor disorders compose a variety of interrelated clinical entities that include constipation, obstructed defecation, and urinary and/or anal incontinence. In addition, pelvic pain and sexual difficulties are bothersome adverse effects of hysterectomy. These disorders may result in serious implications for daily function, social interactions, sexuality, and psychological well-being.1 Nevertheless, the effects of hysterectomy on pelvic floor function have been debated. Various studies have reached controversial results. Although some studies have reported an increased incidence of urinary incontinence and bowel dysfunction symptoms after hysterectomy,2,3 other studies failed to show any relation between the operation and pelvic floor dysfunction,4,5 and some studies went on to show beneficial effects.6,7 The aim of this prospective study was to evaluate the influence of hysterectomy on pelvic floor disorders in a longitudinal study.
PATIENTS AND METHODS
This prospective, longitudinal study consisted of consecutive adult women patients (n = 378) who underwent elective hysterectomy for benign pathologies at the Dr Zekai Tahir Burak Women’s Health Research and Education Hospital Department of Obstetrics and Gynecology between September 2008 and March 2011. The study was approved by the ethical committee of the Ankara University Faculty of Medicine, and all of the patients gave their written informed consent (No. 51–1249).
Patient demographics, surgical details, follow-up, and disease-related data were recorded. To be eligible, patients had to meet the following inclusion criteria: 1) age >18 years; 2) no pregnancy and not within 6 months postpartum; 3) no history of previous GI, anorectal, or urogynecological surgery, including hysterectomy for endometriosis or symptomatic prolapse; 4) no primary malignant tumors; 5) no (functional) GI disease according to the Rome criteria (irritable bowel syndrome, IBD, or chronic diarrhea); 6) no chronic therapy with medicine that may affect bowel functions (antidiarrheal, laxative, or purgative medications); 7) no additional complicating or disabling disease that necessitated nursing help (eg, mental illness, proprioception, or locomotor disorders); 8) no cancer treatment within 24 weeks before the first interview; and 9) no admittance to a hospital for serious disease (eg, cancer treatment, major surgery involving major resections, or admittance to intensive care units) during the study period. Patients with postoperative abscess, hematoma, bleeding, deep surgical site infection, or ileus that necessitated intervention were excluded from the study.
Assessment of Constipation
Constipation was defined according to the Rome II criteria.8 The Rome II Diagnostic Criteria for the Definition of Constipation as a Symptom Complex is specified as 2 or more of the following symptoms in the preceding 12 months for ≥12 weeks, which need not be consecutive: 1) straining for >25% of defecations, 2) lumpy or hard stools for >25% of defecations, 3) sensation of incomplete evacuation for >25% of defecations, 4) sensation of anorectal obstruction/blockage for >25% of defecations, 5) manual maneuvers to facilitate for >25% of defecations (eg, digital evacuation or support of the pelvic floor), and/or 6) <3 defecations per week. In addition, loose stools are not present, and there are insufficient criteria for irritable bowel syndrome. The constipation score was derived based on a previously developed constipation scoring system.9 (The global constipation severity score was obtained by adding each individual score (minimum score = 0; maximum score = 30), and a score of >15 was the definition of constipation).
Assessment of Obstructed Defecation
Participants were defined as having obstructed defecation syndrome if they met 2 or more of the following outlet symptoms ≥25% of the time during bowel movements over the past 3 months: 1) an urge for a bowel movement, but no stool is passed (more than once a wk); 2) time spent at the toilet for each defecation (>10 min for each episode); 3) sensation of anorectal obstruction/blockage for >25% of defecations; 4) a need to press on or around the bottom or vagina to try to remove stool to complete the bowel movement; or 5) a number of attempts to defecate but no stool is passed (more than 3 times per day).
Assessment of Anal Incontinence
Participants were defined as having incontinence to flatus if there was the presence of uncontrolled passage of flatus at least once a month over the past 3 months. Fecal incontinence was defined as recurrent uncontrolled passage of fecal material (leakage of loose and formed feces) at least once per month or necessity of usage of a pad for fecal leakage at least once per month.
Assessment of Urinary Incontinence
All of the symptoms were defined according to the standardization of terminology proposed by the International Continence Society.10 The International Continence Society definition of urinary incontinence, “the complaint of any involuntary leakage of urine,”10 was used in this study. Stress urinary incontinence was defined as the symptom of involuntary leakage on effort, exertion, sneezing, or coughing. Urge urinary incontinence was defined as leaking or losing urine associated with an urge to urinate so strong and sudden that the participant could not reach the toilet fast enough. Participants were classified as having mixed incontinence if they had symptoms of both stress and urge incontinence.
Abdominal and Vaginal Hysterectomy
Selection of surgical approach (abdominal or vaginal hysterectomy) was made according to the preference of the surgeon. The operation and perioperative treatment were performed according to a standardized protocol. None of the hysterectomies were performed in a supracervical manner. Short-term complications were registered in patient charts.
Women who agreed to participate in this study were requested to answer a structured questionnaire, thoroughly explained by a trained research assistant and administered preoperatively in a face-to-face interview. Information regarding medical, surgical, gynecological, and obstetric histories was obtained. The questionnaire contained items to identify constipation, obstructed defecation, anal incontinence, and urinary incontinence. The complete data set and the questionnaire included 52 questions (including the demographics and the surgical data set). A pilot study was conducted before the present study to ensure the comprehensibility of the items in the questionnaire. The same patients were subsequently evaluated at 1, 2, 3 and 4 years postoperation by telephone conversation using the identical questionnaire. The research assistant was not involved in the surgical care.
A sample size of 97 achieved 80% power to detect a 15% increase for de novo new-onset outcomes using a 1 degree of freedom χ2 test with a significance level of 0.05.
Frequency (percentage) for categorical variables or mean (SD) or median (minimum–maximum) for continuous variables were used for descriptive statistics. To assess the differences between repeated measures with time, the Cochran Q test or Friedman test was performed with their post hoc tests. A p < 0.05 was considered statistically significant.
The associations of each independent variable (age, marital status, presence of comorbidity, job status, gravidity, parity, child weight, type of delivery, responsible person at labor, instrumental delivery, presence of previous surgery, age at menarche, presence of menopause, age at menopause, hormone replacement therapy, hysterectomy type, and diagnosis) with the clinical outcomes (constipation, obstructed defecation, anal incontinence, and urinary incontinence) were univariately estimated by means of the χ2 test (with Yates correction when required), Fisher exact test, Student t test, and Mann–Whitney U test, where appropriate. On completion of the univariate analyses, we selected variables for the multiple analysis. Any variable for which the univariate test had a p < 0.15 was considered as a candidate for the multiple logistic regression analysis. Measure of agreement between binary variables was evaluated by κ statistics.
During the study period, 378 adult women were eligible and willing to participate. Patients (n = 327) who had completed each of the 4 annual postoperative follow-ups were included in this study. To evaluate the influence of hysterectomy on each selected symptom, analyses were carried out on patients who had no previous symptoms with the designated symptoms of constipation, obstructed defecation, anal incontinence, and urinary incontinence. The mean age of the participants was 49 years (range, 39–90 y), and the median parity was 3. Of the women interviewed, 262 had abdominal and 65 had vaginal hysterectomy. In the abdominal hysterectomy group, 157 patients underwent concomitant bilateral salpingo-oophorectomy, and 4 patients underwent unilateral salpingo-oophorectomy, whereas none of these procedures were performed in the vaginal hysterectomy group. The predominant indications for hysterectomy were uterine fibroids in 201 patients (61.5%), menometrorrhagia in 98 patients (30.0%), benign ovarian process in 23 patients (7.0%), and abdominal pain in 5 patients (1.5%). The sociodemographic features of patients are shown in Table 1.
Constipation and the Constipation Severity Score
Of 327 women, 245 had no preoperative constipation. In these 245 patients, the percentage with constipation was significantly increased in each of the 4 follow-up years compared with the preoperative value, with a high of 8.6% in the third year (Table 2). In addition to this, the mean constipation severity score was also significantly increased in each of the 4 postoperative years, with a high of 0.85 in the second year (Table 2). Although both of these measures were still significantly elevated compared with preoperative status in the fourth year, there was a declining trend in this year.
Univariate analysis revealed that new onset (de novo) constipation was higher in those patients who underwent abdominal hysterectomy as compared with vaginal hysterectomy (13% vs 2.2%; p = 0.04). All of the other independent variables failed to reach statistical significance. The type of hysterectomy, diagnosis, and hormone replacement therapy were considered as candidate variables for multiple analysis. Although the type of hysterectomy was found to be significant according to the likelihood ratio test (p = 0.02), it failed to reach significance when tested by the Wald test (p = 0.07; OR = 6.6 (95% CI, 0.9–49.8)).
Obstructed Defecation Syndrome
There were 269 women who had no previous symptom of obstructed defecation syndrome. The percentages for the presence of obstructed defecation were significantly higher for each of the 4 postoperative years compared with the preoperative value (Table 2). According to univariate analysis, none of the independent variables were significantly associated with the clinical outcomes. Measure of agreement between constipation and obstructed defecation was moderate (ĸ = 0.66; p < 0.001).
Of the 327 women, 252 had no previous symptoms regarding either gas or fecal incontinence. Incontinence to gas and feces, combined or alone, was significantly increased compared with the preoperative value for each of the 4 postoperative years (Table 2). Both flatual and fecal incontinence were highest in the second and third postoperative years (Table 2). Univariate analysis revealed no statistical significance between the independent variables and anal incontinence.
There were 99 patients who had no previous symptoms of stress, urge, or mixed urinary incontinence. Urinary incontinence of any kind was significantly increased compared with the preoperative value in each of the 4 postoperative years (Fig. 1 and Table 2). Univariate analysis revealed no statistical significance between the independent variables and clinical outcomes.
No Preoperative Symptoms for All of the Selected Items
Patients who had no preoperative symptom (n = 70) for any of the selected symptoms showed a significant increase in 1 or more symptoms at each of the 4 postoperative years (Fig. 2 and Table 2). Univariate analysis revealed no statistical significance between independent variables and urinary incontinence. There was no statistically significant difference between patients who had no preoperative symptom (n = 70) for any of the selected symptoms and other patients in terms of age (48.80 ± 7.62 and 49.76 ± 6.64; p = 0.32).
In addition, there were no demographic differences between the patients included (n = 327) vs excluded (n = 51) from the study. Moreover, within the 327 patients, there were no demographic differences between the patients who had no preoperative symptoms for each pelvic disorder compared with the patients who had preoperative pelvic floor symptoms.
Hysterectomy may cure various gynecologic disorders, but it is not without its drawbacks. Reviewing the literature, the functional outcomes regarding pelvic floor disorders have been equivocal, although the long-term results associated with hysterectomy for benign indications are unclear.3,11 The main reasons for these still existing controversies may be the nature of the studies (ie, retrospective, case–control, or population-based studies), the lack of clear criteria for pelvic floor disorders, and the small number of eligible patients within each study. The main finding of this prospective study involving 327 women was that hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions for at least the subsequent 4 years in women who had no previous symptoms from the selected symptoms.
Constipation is common, especially in middle-aged women. The reported prevalence ranges from 2% to 28% and mainly depends on the used definition.12,13 The results of our study demonstrated that both the incidence of new-onset constipation and the constipation severity score were significantly increased after the removal of the uterus for benign pathologies, with some (nonsignificant) improvement by the fourth postoperative year. This improvement might be the result of patient dietary and lifestyle alterations. Several authors have addressed the effect of hysterectomy on the occurrence of constipation and concurred with the results of the present study.2,14–16
Opposing findings on the incidence of constipation after hysterectomy have been presented as well. In a prospective, observational, multicenter study with 3-year follow-up, Roovers et al17 found only 2% de novo constipation after hysterectomy. However, they reported a 6.6-fold increased risk of the development of constipation in patients who underwent subtotal abdominal hysterectomy. The main reason for these findings may be their restrictive definition of constipation that might underestimate the number of constipated patients. Comparing patients undergoing elective hysterectomy with matched nonsurgery control subjects in a prospective study, Sperber et al18 reported no difference between the groups at any follow-up point in functional constipation, frequency of stools, straining, feeling of obstruction, or need to manually evacuate the stool. However, one must keep in mind that this was a subgroup analysis with short follow-up periods (3 and 12 months). Moreover, the baseline sociodemographic variables between patients undergoing hysterectomy and nonsurgical control subjects were significantly different: the age, marital status, country of study population, and type of surgery were not homogenous. Another prospective cohort study investigated 76 abdominal and 44 vaginal hysterectomy patients with benign conditions.19 A 3-year, postoperative follow-up period revealed no association between hysterectomy and constipation, aggravation of constipation, or rectal emptying difficulties.
Obstructed defecation syndrome considerably affects the quality of life and is also common. Our previous study evaluating 4002 women in face-to-face interviews revealed a prevalence of 26.8% obstructed defecation.13 However, this has not been examined previously in detail after hysterectomy. One of the main findings of the present study was that the presence of obstructed defecation was significantly increased for ≥4 years after hysterectomy in women who had no previous symptoms. This is in agreement with previous publications as well.3,15,16,20–22 In a population-based cohort of middle-aged and older women, Varma et al23 reported that ≈60% of the 2109 women had obstructive defecation in the previous 12 months. Daily, weekly, monthly, and less-than-monthly obstructive defecation was reported by 2%, 10%, 13%, and 34% of women. Furthermore, multivariate analysis revealed a 2-fold greater odds for obstructive defecation after vaginal or laparoscopic hysterectomy, and it was 4-fold increased odds elsewhere.24 As well, obstructed defecation occurs in approximately one third of the adult population affected by constipation, with a higher frequency among women.25,26 Our findings also support these findings in that there was a significant association between constipation and obstructed defecation.
Another main finding of our study was the increased frequency of new-onset anal incontinence. Incontinence to both gas and feces was significantly increased after hysterectomy. This is in good agreement with the literature. Previous studies demonstrated that abdominal and vaginal hysterectomies were associated with an increased risk of mild anal incontinence symptoms at the 3-year follow-up.19 As anticipated, patients with a reported history of obstetric sphincter injury were at particular risk for posthysterectomy fecal incontinence. Moreover, another study revealed that women might be more at risk for developing fecal incontinence even 10 years after vaginal hysterectomy as compared with abdominal hysterectomy.27
Controversial reports exist and no consensus has been reached regarding the effects of hysterectomy on urinary incontinence in literature. Some researchers report no detrimental effects of hysterectomy or even some benefits,4,7,28–30 and some report the opposite.27,31 Even the same authors have come to opposite conclusions in different studies.32 Moreover, 2 nationwide cohort studies revealed contradictory results to some extent using different registries with the same study periods in Sweden.5,32 Lakeman et al27 reported that significantly more women had been treated for micturition symptoms within 10 years after vaginal hysterectomy as compared with abdominal hysterectomy. This might be explained by the greater degree of traction on the pelvic viscera and increased potential for nerve damage using the vaginal approach. Nevertheless, the results of the present study documented that stress and urge urinary incontinence were increased after hysterectomy.
Hysterectomy changes the anatomic relationship of the pelvic organs and leads to an instability of pelvic compartments. This may result in abnormal descent of the rectum, bladder, and small intestines within the pelvis. Moreover, the dissection planes for hysterectomy are in a close relation to the pelvic plexus and endopelvic fascia that contain nerve fibers that are responsible for anorectal innervation. Sharp and blunt dissections may interfere with these nerves and result in pelvic floor dysfunctions.2,7,33,34 However, evaluating the anorectal sensorimotor functions prospectively with a short follow-up, Bharucha et al35 reported that anal resting and squeeze pressures were not different before versus 1 year after a vaginal hysterectomy in a small number of subjects. In addition, van Hoboken et al36 found that colorectal motor and sensory function is generally well preserved in women with constipation after hysterectomy and concluded that pelvic floor dysfunction is unlikely to be caused by iatrogenic neuronal damage in these patients. Others also supported these findings.18 Therefore, it is highly likely that topographic anatomic changes after the removal of uterus, rather than nerve damage, alter the function of the adjacent organs and cause various pelvic floor dysfunctions.
Our study had several limitations that should be considered when interpreting the results. First, this was a cross-sectional study on patients who were admitted to the hospital for benign gynecological problems. Therefore, the incidence of pelvic floor dysfunctions did not resemble the general population. Second, of 327 patients, ≈75% had no previous symptoms for constipation, anal incontinence, or obstructed defecation. A total of 30% had no previous symptoms for urinary incontinence, and only these patients were included in our analyses. This figure also reflects the women lost to follow-up. Third, the type of surgery was not randomized, but was decided by the surgeon. Fourth, the follow-up interviews and questioning were performed by telephone conversation only on an annual basis, which might have influenced the responses of the participants. Fifth, there was no comparison with the normal population, and some of these conditions would be expected to worsen with ageing over 4 years, even without hysterectomy. Sixth, we lacked validated measures to assess the severity of symptoms.
The results of this prospective longitudinal study revealed that hysterectomy for benign gynecologic pathologies had a significant negative impact on pelvic floor functions in patients who had no previous symptoms. An increase in pelvic floor dysfunction might be reasonably expected to adversely affect the functional capacity and well-being of the patient and potentially require additional treatment, although our study did not specifically address this. Embarrassment, distress, and loss of self-assurance are likely to affect patient daily activities, physical and mental health, social interactions, and general well-being. This is becoming much more important and must be considered as a part of the quantitative measures of any treatment and, therefore, must be discussed with the patient during consultation for consent.
1. Miner PB Jr. Economic and personal impact of fecal and urinary incontinence
. Gastroenterology. 2004;126(1 suppl 1):S8–S13.
2. Taylor T, Smith AN, Fulton PM. Effect of hysterectomy
on bowel function. BMJ. 1989;299300–301.
3. Roovers JP, van der Bom JG, Huub van der Vaart C, Fousert DM, Heintz AP. Does mode of hysterectomy
influence micturition and defecation? Acta Obstet Gynecol Scand. 2001;80945–951.
4. de Tayrac R, Chevalier N, Chauveaud-Lambling A, Gervaise A, Fernandez H. Is vaginal hysterectomy
a risk factor for urinary incontinence
at long-term follow-up? Eur J Obstet Gynecol Reprod Biol. 2007;130258–261.
5. Engh MA, Otterlind L, Stjerndahl JH, Löfgren M. Hysterectomy
: a study from the Swedish national register for gynecological surgery. Acta Obstet Gynecol Scand. 2006;85614–618.
6. Virtanen H, Mäkinen J, Tenho T, Kiilholma P, Pitkänen Y, Hirvonen T. Effects of abdominal hysterectomy
on urinary and sexual symptoms. Br J Urol. 1993;72868–872.
7. Thakar R, Ayers S, Clarkson P, Stanton S, Manyonda I. Outcomes after total versus subtotal abdominal hysterectomy
. N Engl J Med. 2002;3471318–1325.
8. Thompson WG, Longgstreth GF, Drossman DA, Heaton KW, Irvien EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999;451143–1147.
9. Agachan F, Chen T, Pfeifer J, Reissman P, Wexner SD. A constipation
scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum. 1996;39681–685.
10. Abrams P, Cardozo L, Fall M, et al. Standardisation Sub-Committee of the International Continence SocietyThe standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology. 2003;6137–49.
11. Forsgren C, Lundholm C, Johansson AL, Cnattingius S, Zetterström J, Altman D. Vaginal hysterectomy
and risk of pelvic organ prolapse and stress urinary incontinence
surgery. Int Urogynecol J. 2012;2343–48.
12. Talley NJ. Definitions, epidemiology, and impact of chronic constipation
. Rev Gastroenterol Disord. 2004;4(suppl 2):S3–S10.
13. Kepenekci I, Keskinkilic B, Akinsu F, et al. Prevalence of pelvic floor disorders
in the female population and the impact of age, mode of delivery, and parity. Dis Colon Rectum. 2011;5485–94.
14. Prior A, Stanley KM, Smith AR, Read NW. Relation between hysterectomy
and the irritable bowel: a prospective study. Gut. 1992;33814–817.
15. Heaton KW, Parker D, Cripps H. Bowel function and irritable bowel symptoms after hysterectomy
and cholecystectomy: a population based study. Gut. 1993;341108–1111.
16. van Dam JH, Gosselink MJ, Drogendijk AC, Hop WC, Schouten WR. Changes in bowel function after hysterectomy
. Dis Colon Rectum. 1997;401342–1347.
17. Roovers JP, van der Bom JG, van der Vaart CH. HysVA Study GroupHysterectomy does not cause constipation
. Dis Colon Rectum. 2008;511068–1072.
18. Sperber AD, Morris CB, Greemberg L, et al. Constipation
does not develop following elective hysterectomy
: a prospective, controlled study. Neurogastroenterol Motil. 2009;2118–22.
19. Forsgren C, Zetterström J, Lopez A, Nordenstam J, Anzen B, Altman D. Effects of hysterectomy
on bowel function: a three-year, prospective cohort study. Dis Colon Rectum. 2007;501139–1145.
20. Gurnari M, Mazziotti F, Corazziari E, et al. Chronic constipation
after gynaecological surgery: a retrospective study. Ital J Gastroenterol. 1988;20183–186.
21. Taylor T, Smith AN, Fulton M. Effects of hysterectomy
on bowel and bladder function. Int J Colorectal Dis. 1990;5228–231.
22. Clarke A, Black N, Rowe P, Mott S, Howle K. Indications for and outcome of total abdominal hysterectomy
for benign disease: a prospective cohort study. Br J Obstet Gynaecol. 1995;102611–620.
23. Varma MG, Hart SL, Brown JS, Creasman JM, Van Den Eeden SK, Thom DH. Obstructive defecation in middle-aged women. Dig Dis Sci. 2008;532702–2709.
24. Klingele CJ, Bharucha AE, Fletcher JG, Gebhart JB, Riederer SG, Zinsmeister AR. Pelvic organ prolapse in defecatory disorders. Obstet Gynecol. 2005;106315–320.
25. Rao SS, Tuteja AK, Vellema T, Kempf J, Stessman M. Dyssynergic defecation: demographics, symptoms, stool patterns, and quality of life. J Clin Gastroenterol. 2004;38680–685.
26. Surrenti E, Rath DM, Pemberton JH, Camilleri M. Audit of constipation
in a tertiary referral gastroenterology practice. Am J Gastroenterol. 1995;901471–1475.
27. Lakeman MM, van der Vaart CH, Roovers JP. A long-term prospective study to compare the effects of vaginal and abdominal hysterectomy
on micturition and defecation. BJOG. 2011;1181511–1517.
28. Virtanen H, Mäkinen J, Tenho T, Kiilholma P, Pitkänen Y, Hirvonen T. Effects of abdominal hysterectomy
on urinary and sexual symptoms. Br J Urol. 1993;72868–872.
29. Kjerulff KH, Langenberg PW, Greenaway L, Uman J, Harvey LA. Urinary incontinence
in a large prospective cohort study in American women. J Urol. 2002;1672088–2092.
30. Gustafsson C, Ekström A, Brismar S, Altman D. Urinary incontinence
: three-year observational study. Urology. 2006;68769–774.
31. Andersen LL, Alling Møller LM, Gimbel HM. Objective comparison of subtotal vs. total abdominal hysterectomy
regarding pelvic organ prolapse and urinary incontinence
: a randomized controlled trial with 14-year follow-up. Eur J Obstet Gynecol Reprod Biol. 2015;19340–45.
32. Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy
and risk of stress-urinary-incontinence
surgery: nationwide cohort study. Lancet. 2007;3701494–1499.
33. Aigner F, Zbar AP, Ludwikowski B, Kreczy A, Kovacs P, Fritsch H. The rectogenital septum: morphology, function, and clinical relevance. Dis Colon Rectum. 2004;47131–140.
34. Kelly JL, O’Riordain DS, Jones E, Alawi E, O’Riordain MG, Kirwan WO. The effect of hysterectomy
on ano-rectal physiology. Int J Colorectal Dis. 1998;13116–118.
35. Bharucha AE, Klingele CJ, Seide BM, Gebhart JB, Zinsmeister AR. Effects of vaginal hysterectomy
on anorectal sensorimotor functions: a prospective study. Neurogastroenterol Motil. 2012;24235–241.
36. van Hoboken EA, Timmermans FG, van der Veek PP, Weyenborg PT, Masclee AA. Colorectal motor and sensory function after hysterectomy
. Int J Colorectal Dis. 2014;29505–510.