{"paper_id":"0187d8fe-1bc6-4088-b394-639744cfddb2","body_text":"Remedy Publications LLC., | http://clinicsinsurgery.com/\nClinics in Surgery\n2019 | Volume 4 | Article 26171\nChange in Lower Urinary Tract Symptoms after \nHysterectomy in Uterine Adenomyosis and Uterine Myoma \nPatients- A Prospective and Comparative Study with 1-year \nFollow-up\nOPEN ACCESS\n *Correspondence:\nXin Yang, Department of Obstetrics \nand Gynecology, Peking University \nPeople's Hospital, Xicheng District, \nBeijing, 100044, China,\nE-mail: xinyang_2003@sina.com\nReceived Date: 27 Aug 2019\nAccepted Date: 03 Oct 2019\nPublished Date: 14 Oct 2019\nCitation: \nTan C, Yang X, Wang Y, Qian S. \nChange in Lower Urinary Tract \nSymptoms after Hysterectomy in \nUterine Adenomyosis and Uterine \nMyoma Patients- A Prospective and \nComparative Study with 1-year Follow-\nup. Clin Surg. 2019; 4: 2617.\nCopyright © 2019 Xin Yang. This is an \nopen access article distributed under \nthe Creative Commons Attribution \nLicense, which permits unrestricted \nuse, distribution, and reproduction in \nany medium, provided the original work \nis properly cited.\nResearch Article\nPublished: 14 Oct, 2019\nAbstract\nObjective: 1) To compare the different effects of adenomyosis (study group) and uterine myoma \n(control group) on lower urinary tract symptoms (LUTS). 2) To compare the impact of hysterectomy \non Lower Urinary Tract Symptoms (LUTS) between patients with uterine adenomyosis and uterine \nmyoma. Who planned to undergo hysterectomy due to menorrhagia or acquired dysmenorrhea \nduring Jan 2012 to Dec 2017 were recruited for this study Bristol Female Lower Urinary Tract \nSymptoms questionnaire and urinary distress inventory-6 (UDI-6) were conducted to assess the \nlower urinary tract symptoms of the patients before surgery, and one month and one year after the \nsurgery.\nResult: 1) The prevalence rate of LUTS before surgery was 51.0% overall, 55.5% in the study group \nand 47.4% in the control group; The prevalence rate of LUTS 1-year after surgery was 56.5% (59.8% \nin the study group and 51.8% in the control group) with no significant difference compared with the \nprevalence rate before surgery. The prevalence rate of urgency in study group (24.5%) is significantly \nhigher than the rate in control group (12.4%). 2) For the study group, the prevalence rate of urinary \nsymptoms such as frequency and urgency was significantly reduced at the 1-month follow up. \nAt1-yearpost operation, the prevalence rate of urinary frequency and urgency was still lower than \nbaseline (frequency: 1-year 21.6% vs. baseline 31.4%; and urgency: 1-year 19.6% vs. baseline 24.5%). \n3) The UDI-6 score showed a significant reduction in the total score as well as all breakdown items \nat the 1-month follow-up; The results of the 1-year-follow-up were comparable with the results \nbefore the surgery. 4) The prevalence rate of Stress Incontinence (SUI) was slightly increased in \nboth groups (study group: 1-year 20.6% vs. baseline 16.7%; control group: 1-year 22.6% vs. baseline \n19.0%), and the urinary incontinence symptom score in the UDI-6 of both group was increased at \nthe 1-year followup (study group: 1-year 1.79 ± 1.30 vs. baseline 2.09 ± 1.15; control group: 1-year \n2.17 ± 0.59 vs. baseline 1.62 ± 1.02).\nConclusion: Compared with patients with uterine myoma, patients with uterine adenomyosis are \nmore likely to have LUTS, especially urgency. LUTS of uterine adenomyosis and myoma patients \nwere significantly improved at 1 month after hysterectomy but were not significantly improved after \n1 year; additionally, stress incontinence was worsened after 1 year.\nCheng Tan, Xin Yang*, Yanjie Wang and Shuqin Qian\nDepartment of Obstetrics and Gynecology, Peking University People's Hospital, China\nIntroduction\nUterine adenomyosis refers to heterotopy of endometrial cells above the position 2.5 mm \nbelow the endometrium-muscular layer junction, which may cause menorrhagia and acquired \ndysmenorrhea. Studies so far show that uterine adenomyosis may cause lower urinary tract \nsymptoms and Overactive Bladder Symptoms (OAB). Some research has indicated that uterine \nadenomyosis may relate to the occurrence of lower urinary tract symptoms [1-2]. However, uterine \nadenomyosis very often occurs with uterine fibroids, which makes it difficult to do a comparative \nstudy of the two diseases. Our study was based on pathological diagnosis, and a characteristic of \nthis study was that all the examined samples were from patients who underwent total hysterectomy; \ntherefore, the pathologist was able to get data from the full sample to help with the diagnosis and to \nreduce the influence of uterine fibroids as much as possible. Hysterectomy is the principal operative \ntreatment for uterine adenomyosis and has been proven to be safe  and effective. However, so far \nthere is no conclusion concerning the impact of hysterectomy on lower urinary tract symptoms. \n\nXin Yang, et al., Clinics in Surgery - Gynecological Surgery\nRemedy Publications LLC., | http://clinicsinsurgery.com/\n 2019 | Volume 4 | Article 26172\nOur study used validated questionnaires to examine the occurrence \nand changes and characteristics of the lower urinary tract symptoms \nof uterine adenomyosis patients before and after surgery with uterine \nfibroid patients as the control group, and the possible causes were \nanalyzed.\nData and Methodology\nThis study was examined and approved by the Ethics Committee \nof Peking University’s People’s Hospital. A total of 367 cases of \npatients who planned to undergo hysterectomy due to menorrhagia \nand/or dysmenorrhea during 2012-2017 were recruited for this \nstudy; patients with acute and chronic urinary tract infection, pelvic \norgan prolapse and malignant tumors were excluded. After surgery, \nall uterine samples were sent for pathological examination and 102 \npatients with uterine adenomyosis without uterine fibroids or had \na maximal myoma volume less than 1 cm\n3 were confirmed and \nconstituted the study group, 137 patients were confirmed to have \nuterine fibroids without uterine adenomyosis, and these patients \nformed the control group. Another 133 cases were excluded for various \nreasons (Figure1). After an explanation of the objectives and methods \nof this study was given, patients completed two questionnaires, the \nBristol Female Lower Urinary Tract Symptoms questionnaire and the \nUrogenital Distress Inventory-6 (UDI-6), regarding their personal \ninformation before surgery and underwent a follow-up interview 1 \nmonth and 1 year after surgery. Overactive Bladder Symptom Score \n(OABSS) ≥ 3. Other clinical data were collected by the research \nteam who were blinded to the results of the questionnaires. Data \nwere analyzed with SPSS 16, and the analytical approaches include \nchi-square test, Fisher’s exact test and the Mann-Whitney U test. \nAnalytical results with p<0.05 were considered significantly different.\nResult\nA total of 367 patients who were diagnosed as having \nuterine fibroids or uterine adenomyosis and planned to undergo \nhysterectomy met the recruitment criteria. Among them, 13 patients \nhad difficulties in doing the follow-up survey and 17 patients refused \nto participate, and they were excluded from the study. The remaining \n337 patients underwent total hysterectomy in our hospital, and all \nuterus samples were examined pathologically and classified into \nthree groups: 102 patients with uterine adenomyosis without uterine \nfibroids or with maximal myoma volumes less than 1 cm\n3 constituted \nthe study group; 137 patients with uterine fibroids without uterine \nadenomyosis or adenomyoma constituted the control group; and 97 \npatients with uterine fibroids of maximal volumes larger than 1 cm\n3 \nand with uterine adenomyosis or adenomyoma were excluded. In the \nstudy group, 24 cases used the levonorgestrel -releasing Intrauterine \nSystem [LNG-IUS] and took it out for reasons including (1) spotting \nand irregular bleeding, 10 cases (47.7%); (2) persistent and intolerable \nlower abdominal or back pain, 8 cases (33.3%); and (3) IUD falling \nout or moving down, 6 cases (25.0%). All patients underwent \nhysterectomy, including 197 cases of laparoscopic hysterectomy, 23 \ncases of total abdominal hysterectomy, and 12 cases of laparoscopic-\nassisted vaginal hysterectomy. No serious complications occurred \nduring the perioperative period. There were no significant \ndifferences (p>0.05) between the study group and the control group \nin demographic characteristics such as age, body mass index and \nnumber of parities (Table 1). There was no significant difference in \nuterine volume between the two groups (study group: 473.6 ± 394.4 \ncm³, and control group: 411.7 ± 487.8 cm³, p>0.05). After surgery, \nurinary retention occurred in 1 patient who was capable of voluntary \nmicturition after 14 days with an indwelling catheter without severe \ncomplications. The prevalence rate of lower urinary tract symptoms \nfor all patients at baseline was 51.0%; the prevalence rate of the study \ngroup was 55.9% and that of the control group was 47.4% with no \nsignificant difference. The prevalence rate of each symptom is listed \nin Table 2.\nLower urinary tract symptoms were evaluated in both the study \ngroup and the control group before surgery, and the results showed \nthat the prevalence rate of urinary urgency in the study group was \nhigher than that in the control group (study group: 24.5% and control \ngroup: 12.4%, p=0.02). Based on the Overactive Bladder Symptom \nScore (OABSS), the OAB prevalence rate in the study group was \nhigher than that in the control group (study group 12.7%, control \ngroup 6.6%, p=0.03), and the prevalence rate of other lower urinary \ntract symptoms showed no obvious differences (Table 2). The severity \nof lower urinary symptoms was assessed through the UDI-6, which is \na shorter version of the PFDI-20 about lower urinary tract symptoms, \nincluding irritation symptoms, urinary incontinence symptoms and \nobstruction symptoms. There were significant differences in the UDI-\n6 scores between the study group and the control group before the \nsurgery (study group: 5.86 ± 1.93 and control group: 5.22 ± 1.69, \nP-0.017), especially irritation symptoms (study group: 2.51 ± 0.91 and \nFigure 1: A 133 cases were excluded for various reasons.\nstudy Group\nn=102\ncontrol Group\nn=137 P Value\nAge 46.7 ± 8.3 47.1 ± 9.7 0.738\nBody Mass Index (BMI) 26.5 ± 5.9 25.7 ± 5.7 0.292\nParities (n) 1 (1-3) 1 (1-4) 0.782\ncesarean deliveries (n, %) 37 (36.3%) 41 (29.9%) 0.301\nDiabetes (n) 9 (8.8%) 15 (10.9%) 0.589\nUterine volume (cm³) 473.6 ± 394.4 411.7 ± 487.8 0.294\nResistance index  of the uterine artery 0.75-1.14 0.63-1.45 0.473\nIndwelling catheter (days) 4 (3-5) 4 (3-14*) 0.618\nTotal 102 137 N/A\nTable 1: General information of the study group and the control group.\n\nXin Yang, et al., Clinics in Surgery - Gynecological Surgery\nRemedy Publications LLC., | http://clinicsinsurgery.com/\n 2019 | Volume 4 | Article 26173\ncontrol group: 1.83 ± 0.58, P-0.009). Urinary incontinence symptom \nand Obstruction symptom showed no significant differences between \nstudy group and control group (Table 3). One month after the \nsurgery, a second assessment of the LUTS of the study group and the \ncontrol group indicated that the prevalence rate of frequency and \nurgency among study group was significantly lower than the baseline. \nThe prevalence rate of nocturia, SUI, UUI and OAB was lower than \nbaseline without significant difference (Table 3); the total score of \nUDI-6 and the scores of the entire breakdown items showed apparent \nimprovements compared with baseline. As for the control group, the \nprevalence rate of LUTS was comparable to the baseline. One year \nafter the surgery, we performed a third assessment of the LUTS. The \nprevalence rate of LUTS for all patients was 56.5% (study group: 59.8% \nand control group: 51.8%); the prevalence rate of frequency, urgency \nand nocturia was still lower than baseline but without significant \ndifferences. The SUI and OAB were even higher than baseline. The \nUDI-6 of the study group showed a significant reduction of the total \nscore as well as all breakdown items at the 1-month follow up. The \nresults of the 1-year follow up were comparable with the results before \nsurgery. The urinary incontinence symptom score was increased at \nthe 1-year follow up (Table 3).\nDiscussion\nLower urinary tract symptom is a general term for storage \nsymptoms, urination symptoms and post-micturition symptoms, \nand the prevalence rate of LUTS throughout the world is rather \nhigh. According to the study of Irwin DE, lower urinary tract \nsymptoms will affect over 150 million women in 2018 [2]. Recent \nstudies have shown that the prevalence rate of lower urinary tract \nsymptoms among uterine adenomyosis patients is higher than \ngeneral population. However, But et al.  [3] found that uterine \nadenomyosis patients experience higher OAB prevalence rates than \ncontrols (healthy women taking ultrasound examination). Total \nprevalence rate of lower urinary tract symptoms before surgery was \n51.0% in this study, which is slightly higher than the data from the \nsurvey done by Irwin De [4]. In that dataset, the prevalence rate of \nthe study group was 55.9% and that of the control group was 47.4%, \nwith no significant difference between these two groups (p=0.197). \nComparing the uterine fibroid and uterine adenomyosis patients, the \nuterine volumes of both groups in this study showed no significant \ndifference; however, the prevalence rates of precipitant urination and \nOAB showed significant differences between the two groups. UDI-\n6 indicated that the irritation symptoms of uterine adenomyosis \npatients were worse, indicating that the cause of lower urinary tract \nsymptoms among uterine adenomyosis patients may not only be \ndue to the increased pressure by the enlarged uterus on the urinary \nbladder; there might be other reasons. One of the possible reasons is \nthe “vascular steal theory” proposed by Arleo and Tal, suggesting that \nincreased uterine blood perfusion and thus reduced blood perfusion \nin the urinary bladder causes lower urinary tract symptoms [8]. \nHowever, this study did not find any evidence proving that uterine \nadenomyosis patients experience more uterine blood perfusion \ncompared with uterine fibroid patients. Another possible reason may \nbe the excessive expression of pelvic local inflammatory factors and \ncell factors due to uterine adenomyosis (interleukin-1, interleukin-6, \ninterleukin-8, monocyte chemotactic protein-1 and tumor necrosis \nfactor tumor necrosis factor-alpha), which affect urinary bladder \nfunction. Total hysterectomy improves the local internal environment \nof the pelvic cavity and thus improves urinary bladder function.\nThe Levonorgestrel-Releasing Intrauterine System (LNG-IUS) \nhas been proven to be effective in improving the LUTS among patients \nwith adenomyosis [9], and indeed, the LNG-IUS showed good effects \non adenomyosis and relieved the LUTS. However, the LNG-IUS is \nnot suitable for all patients with adenomyosis, especially patients \nwith a large uterus or heavy menstrual bleeding. Hysterectomy is \nstill a common surgical treatment for uterine adenomyosis and has \nbeen proven to be safe and effective, particularly for patients without \nSymptoms\nBaseline 1 month after surgery 1 year after surgery\nStudy group Control group Study group Control group Study group Control group\nFrequency 31.4%\n(32)\n27.0%\n(37)\n18.6%c\n(19)\n19.0%\n(26)\n21.6%\n(22)\n24.1%\n(33)\nUrgency 24.5%\n(25)\n12.4%※\n(17)\n12.7%c\n(13)\n10.9%\n(15)\n19.6%\n(20)\n21.2%c\n(29)\nNocturia 36.3%\n(37)\n39.4%\n(54)\n32.4%\n(33)\n33.6%\n(46)\n29.4%\n(30)\n32.8%\n(45)\nStress incontinence 16.7%\n(17)\n19.0%\n(26)\n11.8%\n(12)\n13.1%\n(18)\n20.6%\n(21)\n22.6%\n(31)\nUrge incontinence 10.8%\n(11)\n5.8%\n(8)\n6.9%\n(7)\n6.6%\n(9)\n8.8%\n(9)\n6.6%\n(9)\nOAB 12.7%\n(13)\n6.6%\n(9)\n8.8%\n(9)\n7.3%\n(10)\n16.7%\n(17)\n13.1%c\n(18)\nTable 2: Prevalence rates of lower urinary tract symptoms before and after surgery.\n※represent statistical difference (p<0.05) between the study group and the control group at baseline.\nc represent statistical difference (p<0.05) compared with baseline in the same group.\nUDI-6\nMean ± SD\nBaseline 1 Month after Surgery 1 year after surgery\nStudy group Control group Study group Control group Study group Control group\nIrritation symptom 2.51 ± 0.91 1.83 ± 0.58※ 1.71 ± 0.36c 1.75 ± 0.46 2.21 ± 1.35 2.11 ± 0.75c\nUrinary incontinence symptom 1.79 ± 1.30 1.62 ± 1.02 1.06 ± 1.09c 1.21 ± 0.58c 2.09 ± 1.15 2.17 ± 0.59c\nObstruction symptom 1.55 ± 0.73 1.75 ± 0.95 1.16 ± 1.57c 1.21 ± 1.36c 1.53 ± 0.88 1.39 ± 0.53c\nTotal score 5.86 ± 1.93 5.22 ± 1.69※ 3.10 ± 1.88c 4.16 ± 1.28※c 5.64 ± 2.10 5.66 ± 1.39c\nTable 3: Comparison of the UDI-6 in the study group before and after surgery.\n※represent statistical difference (p<0.05) between the study group and the control group at baseline.\na represent statistical difference (p<0.05) between the study group and the control group at 1 month post-op.\nb represent statistical difference (p<0.05)  between the study group and the control group at 1 year post-op.\nc represent statistical difference (p<0.05) compared with baseline in the same group.\n\nXin Yang, et al., Clinics in Surgery - Gynecological Surgery\nRemedy Publications LLC., | http://clinicsinsurgery.com/\n 2019 | Volume 4 | Article 26174\nfertility desire [4]. Some research found that the lower urinary tract \nsymptoms change after total hysterectomy. Parys B found that \npatients undergoing hysterectomy experience higher prevalence rates \nof lower urinary tract symptoms after surgery than before surgery, \nbut Griffith-Jones reached the opposite conclusion [5-7]. However, \nthe above studies did not pertain specifically to uterine adenomyosis \npatients. The impact of hysterectomy on lower urinary tract \nsymptoms in uterine adenomyosis patients is still open to question. \nThrough the comparisons of hysterectomy and the levonorgestrel-\nreleasing intrauterine system, S. Helliövara-Peippo found that total \nhysterectomy increased the risk of urinary incontinence [7]. In this \nstudy, we found that total hysterectomy can remarkably improve \nlower urinary tract symptoms in uterine adenomyosis patients in the \nshort period but cannot improve the long-term outcome. The key \nindicator UDI-6 total score declined by 47%, and all items showed \napparent improvement at 1 month after surgery\nIt is noteworthy that the UDI-6 scores of both the study group \nand the control group before surgery were low, which indicates that \nthe patients' lower urinary tract symptoms were not severe. This had \nto do with the fact that lower urinary tract symptoms were not the \npatients' key reason for visiting our hospital; most patients came for \nabnormal uterine bleeding and acquired dysmenorrhea. Although \nlower urinary tract symptoms of patients were not severe before \nsurgery, there was an apparent improvement after surgery, indicating \nthat attention should be paid to lower urinary tract symptoms among \nuterine adenomyosis patents and that efforts should be made to \nimprove such symptoms after surgery. The merit of this study lies in \nthe prospective design that enabled the selection of reliable survey \nquestionnaires to evaluate the patients' lower urinary tract symptoms \nand block the interference of uterine fibroids. One limitation of this \nstudy was the lack of objective indicators for evaluation of lower \nurinary tract symptoms such as a urinary diary and urodynamics. The \nother limitation was that our study used volume to describe the size of \nuterus, not weight, which is more accurate. Follow-up surveys will be \nconducted for these patients in future studies, and clinical tests will be \nexpanded to verify the conclusion.\nConclusion\nCompared with patients with uterine myoma, patients with \nuterine adenomyosis are more likely to have LUTS, especially \nurgency. LUTS of uterine adenomyosis and myoma patients were \nsignificantly improved at 1 month after hysterectomy but were not \nsignificantly improved after 1 year; additionally, stress incontinence \nwas worsened after 1 year.\nReferences\n1. Ekin M, Cengiz H, Öztürk E, Kaya C, Yaşar L. Genitourinary symptoms in \npatients with adenomyosis. Int Urogynecol J. 2013;24(3):509-12.\n2. Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. \nPopulation-Based Survey of Urinary Incontinence, Overactive Bladder, \nand Other Lower Urinary Tract Symptoms in Five Countries: Results of \nthe EPIC Study. Eur Urol. 2006;50(6):1306-14.\n3. But I, Pakiž M, Rakic S. Overactive bladder symptoms and uterine \nadenomyosis is there any connection?. Eur J Obstet Gynecol Reprod Biol. \n2011;156(1):109-12.\n4. Farquhar C, Brosens I. Medical and surgical management of adenomyosis. \nBest Pract Res Clin Obstet Gynaecol. 2006;20(4):603-16.\n5. Parys BT, Woolfenden KA, Parsons KF. Bladder dysfunction after \nsimple hysterectomy: urodynamic and neurological evaluation. Eur Urol. \n1990;17(2):129-33.\n6. Griffith-Jones MD, Jarvis GJ, Mcnamara HM. Adverse urinary \nsymptoms after total abdominal hysterectomy--fact or fiction? Br J Urol. \n1991;67(3):295-7.\n7. Heliövaarapeippo S, Halmesmäki K, Hurskainen R, Teperi J, Grenman \nS, Kivelä A, et al. The effect of hysterectomy or levonorgestrel-releasing \nintrauterine system on lower urinary tract symptoms: a 10-year follow-up \nstudy of a randomised trial. BJOG. 2010;117(5):602-9.\n8. Arleo EK, Tal MG. Fibroid-induced acute urinary retention: treatment \nby uterine artery embolization. Int Urogynecol J Pelvic Floor Dysfunct. \n2008;19(1):161-5.\n9. Ekin M, Cengiz H, Ayağ ME, Kaya C, Yasar L, Savan K. Effects of the \nlevonorgestrel-releasing intrauterine system on urinary symptoms \nin patients with adenomyosis. Eur J Obstet Gynecol Reprod Biol. \n2013;170(2):517-20.","source_license":"CC0","license_restricted":false}