Hysterectomy and the risk of urinary incontinence: a systematic review and meta-analysis.

Hysterectomy is one of the most prevalent surgical procedures in gynecology, ranking as the second most common operation globally, following cesarean section. This surgery provides a definitive treatment option for various benign conditions, including cervical lesions, endometrial lesions, uterine fibroids, and adenomyosis ( 1 , 2 ). Among the different surgical techniques, laparoscopic hysterectomy (LH) stands out as the most frequently performed method, accounting for 59% of cases, followed by vaginal hysterectomy (VH) at 25% and abdominal hysterectomy (AH) at 17% ( 3 , 4 ). While VH is typically recommended as the first-line approach, LH has increasingly supplanted AH in clinical practice due to its minimally invasive nature and associated benefits ( 5 , 6 ). Despite the effectiveness of hysterectomy in treating benign conditions, it has been recognized to disrupt the pelvic floor’s anatomy and supportive structures, potentially leading to significant structural and functional alterations. These changes may manifest as alterations in bladder and bowel functions, as well as sexual dysfunction and dyspareunia ( 7 – 9 ). One of the most significant long-term complications associated with hysterectomy is urinary incontinence (UI), a condition that can severely affect an individual’s quality of life. UI is identified as one of the five major health issues confronting individuals today, contributing to psychological conditions such as depression and loneliness, while also imposing considerable social and financial burdens on healthcare systems. The most prevalent subtype of UI is stress urinary incontinence (SUI), which accounts for approximately 45.9% of cases, followed by urgency urinary incontinence at 31.1% and mixed urinary incontinence at 18.1% ( 10 ). A considerable body of research has examined the relationship between hysterectomy and the risk of developing UI, particularly SUI. Many studies indicate an association between hysterectomy and an increased risk of urinary incontinence, with heightened odds reported among women aged 60 years or older ( 11 , 12 ). However, these findings are not entirely consistent, as some studies have shown no significant association between hysterectomy and the increased risk of UI ( 3 , 13 ). To better elucidate the relationship between hysterectomy and the risk of urinary incontinence, we conducted a systematic review and meta-analysis of existing evidence derived from comprehensive observational studies.

This study was conducted in accordance with the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( 14 ). The research protocol was pre-registered on the International Prospective Register of Systematic Reviews (PROSPERO) platform, with the approval number CRD42024587774. We conducted a systematic search of PubMed, Embase, and the Cochrane Library for studies published from the inception of these databases until December 14, 2025. The search strategy utilized both Medical Subject Headings (MeSH) and relevant keywords, including “hysterectomy”, “hysterectomy*”, “urinary incontinence”, and their variants. Details of the search strategy can be found in supplementary Supplementary Table 1–S3 . We included observational studies based on the following inclusion criteria: (1) observational design; (2) investigation of the association between hysterectomy and the risk of UI. Exclusion criteria included: (1) studies not reporting odds ratios (OR) with corresponding 95% confidence intervals (CIs); (2) unavailable full texts; (3) conference abstracts, study protocols, letters to the editor, and studies lacking outcomes of interest. Two reviewers (WLP and GJ) independently performed the study selection based on the established inclusion and exclusion criteria. Initially, they excluded duplicates and irrelevant articles based on titles and abstracts. Subsequently, they retrieved and reviewed the full texts of potentially eligible articles to identify all qualifying studies. Any disagreements were resolved through consultation with a third reviewer (GLL). Data extraction was performed independently by the two reviewers in accordance with established guidelines for systematic reviews and meta-analyses. We extracted the following data: first author, year of publication, sample size, age, study region, and study type. Discrepancies were resolved through discussion with BXC to reach a consensus. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS), which evaluates three key aspects: selection, comparability, and exposure ( 15 ). Studies were assigned a star rating from 0 to 9, with a higher number of stars indicating superior study quality. Scores of 0-3, 4-6, and 7-9 were categorized as low, moderate, and high quality, respectively. For cross-sectional studies, we utilized the Agency for Healthcare Research and Quality (AHRQ) criteria to assess quality ( 16 ). Scores of 0-3, 4-7, and 8-11 were classified as low, medium, and high quality, respectively. The overall certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system ( 17 , 18 ). According to the GRADE system, evidence derived from observational studies starts with a low-quality rating, with potential gradations of high, moderate, low, or very low for specific outcomes. Urinary incontinence was analyzed as a dichotomous outcome, and the odds ratio (OR) was selected a priori as the common effect measure ( 19 ). This choice was based on standard meta-analytic guidance for dichotomous outcomes, for which ORs and risk ratios are commonly used relative effect measures. Ratio measures are typically analyzed on the logarithmic scale; therefore, reported ORs and 95% confidence intervals (CIs) were transformed into log ORs and corresponding standard errors for pooling. The pooled estimates were then back-transformed and presented as ORs with 95% CIs. We did not combine different effect measures as if they were directly interchangeable; studies without extractable ORs or sufficient information for conversion were excluded from the quantitative synthesis. Heterogeneity was assessed using the χ 2 test and I 2 statistic. A fixed-effect model was used when heterogeneity was low (P ≥ 0.10 and I 2 < 50%); otherwise, a random-effects model was applied. Sensitivity analysis was conducted to assess the robustness of the pooled estimates. Publication bias was evaluated by visual inspection of funnel plots and Egger’s regression test. Subgroup analyses were performed according to urinary incontinence subtype, geographical region, and surgical route. All statistical analyses were conducted using Stata version 14.0.

A total of 1,980 records were identified through the search. After screening titles and abstracts, 47 articles were deemed potentially relevant. Following full-text review, 12 studies reporting UI incidence were included. The selection process is illustrated in Figure 1 . The selection process. This meta-analysis encompassed 12 studies involving 146,759 individuals who underwent hysterectomy, published up to December 14, 2025 ( 3 , 11 , 20 – 29 ). Detailed characteristics of the included studies are presented in Table 1 , while excluded studies are listed in Supplementary Table 4 . Characteristics of the included studies. NA, not application. Using the NOS criteria, the average score for the included observational studies was 5.11, with all studies scoring 4 or above, indicating moderate to high quality. Additionally, three cross-sectional studies were assessed, yielding an average score of 3.67, as detailed in Supplementary Tables 5–S6 . Of the 12 included articles, 3 studies only reported specific subgroup results ( 20 , 23 , 29 ), and nine studies reported the association between hysterectomy and UI risk ( 3 , 11 , 16 , 22 , 24 – 28 ). The pooled analysis revealed a significant association, with an odds ratio (OR) of 1.31 (95% CI 1.03-1.66, I 2 =88.5%, P  = 0.029, N = 9), supported by robust sensitivity analyses (results in Supplementary Table 7 , Supplementary Figure 1 ). Given the substantial heterogeneity observed in the primary analysis, exploratory univariable meta-regression was performed to examine whether selected study-level characteristics contributed to between-study variability. As shown in Table 2 , publication year was not significantly associated with the effect estimate (coefficient = -0.011, 95% CI: -0.101 to 0.078, P = 0.773). Similarly, neither log-transformed sample size (coefficient = 0.020, 95% CI: -0.198 to 0.237, P = 0.836) nor mean/median age (coefficient = -0.024, 95% CI: -0.059 to 0.011, P = 0.150) significantly explained the observed heterogeneity. These findings suggest that the substantial heterogeneity was unlikely to be attributable to a single study-level factor and may instead reflect combined clinical and methodological differences across studies ( Figure 2 ). Exploratory univariable meta-regression for potential sources of heterogeneity. Forest plot for odds of UI in participants underwent hysterectomy. Subgroup analyses indicated a slight increase in UI risk across stress urinary incontinence, urge urinary incontinence, and mixed urinary incontinence ( Table 3 ). A significantly elevated risk of UI was observed in individuals undergoing abdominal hysterectomy; however, no increased risk was found in those undergoing vaginal or laparoscopic hysterectomy. Additionally, hysterectomy was associated with a markedly significant risk of UI in Asia, while no such risk was observed in Europe and North America ( Table 3 ). Subgroup analyses suggested that the association between hysterectomy and urinary incontinence varied across regions and surgical routes. A higher risk was observed in studies conducted in Asia, whereas no statistically significant association was detected in studies from Europe or North America. However, these subgroup findings should be interpreted cautiously because each subgroup included a limited number of studies, and regional differences in patient characteristics, clinical practice, surgical indications, follow-up duration, and reporting of urinary incontinence may have influenced the estimates. Therefore, these findings should be considered exploratory rather than confirmatory. The subgroup analysis for UI in participants underwent hysterectomy. The GRADE level of evidence for UI risk associated with hysterectomy was very low, as was the evidence for stress and mixed UI. The risk of urge UI was classified as low. For vaginal and laparoscopic hysterectomies, evidence certainty was very low, while abdominal hysterectomy risk was rated as low. The certainty of evidence for UI risk varied across regions, with very low certainty for Europe and North America and low for Asia. GRADE levels for outcomes are summarized in Table 4 . GRADE certainty of evidence. (UI, urinary incontinence, * Downgraded by one level if >25% of participants in this comparison were from studies at high risk of bias. † Downgraded by one level if heterogeneity (I 2 )>50%). Visual inspection of the funnel plot revealed approximate symmetry regarding the relationship between hysterectomy and UI risk. Egger’s test indicated no significant publication bias in the included studies for headache risk ( P  = 0.797>0.05) ( Supplementary Figure 2 ).

Our meta-analysis included 12 studies encompassing 146,759 individuals who underwent hysterectomy, providing a detailed exploration of the relationship between hysterectomy and the risk of urinary incontinence (UI). The results indicate a significantly heightened risk of UI in individuals who underwent hysterectomy compared to those who did not, thus suggesting that hysterectomy could serve as an independent risk factor for UI. Noteworthy is the consistency of this association across various subgroup analyses, particularly concerning abdominal hysterectomies and various demographics in Asia, all of which consistently demonstrated a significant link between hysterectomy and an elevated risk of UI. Previous meta-analyses conducted as early as 2000 examined the connection between hysterectomy and UI risk, drawing on a range of study designs: eight cross-sectional studies, two prospective cohort studies, one case-control study, and one randomized controlled trial ( 12 ). In those earlier analyses, women with a history of hysterectomy exhibited increased odds of urinary incontinence, particularly noting a staggering 60% rise in odds for women aged 60 and older, however, odds were not increased for women younger than 60 years. Our pooled analysis corroborates this historical data, reinforcing the association previously identified while integrating additional insights from 12 studies published post-2008. By analyzing a total of 146,759 individuals who underwent hysterectomy, our findings enrich the understanding of the hysterectomy UI connection. The persistence of this significant association across various geographical regions-Asia, South America, and Oceania-underscores the robustness of the relationship between hysterectomy and the heightened risk of urinary incontinence. Understanding the physiological implications of hysterectomy is crucial, as it represents a substantial surgical intervention with the potential to instigate chronic or progressive complications, such as urinary incontinence. The surgical procedure may disrupt pelvic nerves and supportive structures, increasing the risk of UI ( 30 , 31 ). In particular, total hysterectomy, which involves the removal of essential ligamentary support such as the sacral and cardinal ligaments, modifies the anatomical relationships within the pelvis, including the positioning of the bladder and the urethral angle. Such surgical trauma can compromise both urethral support and sphincter innervation, heightening the likelihood of stress urinary incontinence (SUI) ( 32 ). Observations of prolonged sacral nerve root latencies immediately following the procedure suggest that the detrimental impacts on continence may not manifest until several years post-surgery. Comparatively, individuals with a prior hysterectomy exhibit significantly lower mean Valsalva leak point pressures, which correlate with an increased risk of severe SUI ( 11 ). Additionally, pre-existing factors such as pregnancy, childbirth, pelvic organ surgeries, and urinary tract infections can aggravate bladder inflammation and irritation, further contributing to the risk of UI ( 33 – 36 ). It is noteworthy that many risk factors for UI overlap with those leading to hysterectomy, resulting in some women presenting with incontinence symptoms before the procedure. Therefore, implementing preoperative screening and management strategies for urinary tract infections is vital for reducing the risk of postoperative incontinence, alongside employing surgical techniques designed to minimize pelvic floor trauma and ensuring comprehensive postoperative care. The regional subgroup analysis suggested a higher risk of urinary incontinence among studies conducted in Asia. However, this finding should not be interpreted as definitive evidence of a true regional difference. The number of studies within each regional subgroup was limited, and differences in healthcare systems, surgical practice, indications for hysterectomy, follow-up duration, baseline pelvic floor health, and methods used to ascertain urinary incontinence may have contributed to the observed variation. In addition, cultural differences in symptom reporting and healthcare-seeking behavior may influence the recorded prevalence of urinary incontinence. Therefore, the Asian subgroup finding should be regarded as exploratory and hypothesis-generating. The strengths of our meta-analysis lie in the incorporation of 12 relevant observational studies, which provides a thorough evaluation of the association between hysterectomy and UI. While prior meta-analyses have examined this connection, our study delivers deeper insights into this complex relationship. Despite these strengths, several limitations should be acknowledged. First, substantial heterogeneity was observed in the primary analysis, which may limit the interpretability and generalizability of the pooled estimate. Potential sources of heterogeneity include differences in study design, population characteristics, geographical region, age distribution, menopausal status, surgical route, follow-up duration, definitions or ascertainment methods for urinary incontinence, and covariate adjustment strategies. Although subgroup analyses and exploratory meta-regression were performed, these analyses did not fully explain the observed between-study variability. Therefore, the pooled estimate should be interpreted as an average association across clinically and methodologically heterogeneous observational studies rather than as evidence of a uniform effect in all populations. Second, because all included studies were observational, residual confounding cannot be excluded. Important factors associated with both hysterectomy and urinary incontinence, including parity, age, BMI, menopausal status, pelvic organ prolapse, surgical indication, previous pelvic floor surgery, and baseline urinary symptoms, were not consistently adjusted for across the included studies. Pre-existing urinary incontinence was not uniformly assessed or controlled in all studies. This is clinically relevant because some women may have had urinary symptoms before hysterectomy, and failure to account for baseline incontinence could lead to overestimation or underestimation of the association between hysterectomy and subsequent urinary incontinence. Accordingly, our findings should be interpreted as indicating an association rather than establishing a causal relationship. Future prospective studies with standardized baseline assessment of urinary symptoms and comprehensive adjustment for pelvic floor-related confounders are warranted.

In conclusion, our meta-analysis indicates a significant association between hysterectomy and the risk of urinary incontinence. The early detection of these conditions is essential for initiating effective intervention strategies and improving long-term patient outcomes. Furthermore, advancements in surgical techniques coupled with adequate postoperative care hold promise for mitigating the risk of urinary incontinence following hysterectomy. Continuous research in this area is necessary to optimize surgical practices and ultimately enhance patient care.