Pelvic Pain In a review of 418 women in whom hysterectomy was performed for a variety of nonmalignant conditions, 18% had chronic pelvic pain. Preoperative laparoscopy was performed in only 66% of these patients. After hysterectomy, there was a significant reduction in symptoms that was associated with an improvement in the patient’s quality of life (13). In a review of 104 patients who underwent hysterectomy for chronic pelvic pain that was believed to be of uterine origin, 78% experienced improvement in their pain after follow-up for a mean of 21.6 months (14). However, 22% of patients had no improvement in or exacerbation of their pain. Hysterectomy should be performed only in those patients whose pain is of gynecologic origin and does not respond to nonsurgical treatments (12) (see Chapter 16).
In the past, hysterectomy was performed as primary treatment of cervical intraepithelial neoplasia. More conservative treatments, such as laser or loop electrosurgical excision procedure (LEEP), can be effective in treating the disease, making hysterectomy unnecessary in most women with these conditions (see Chapter 19). For patients with recurrent high-grade dysplasia who do not desire to preserve fertility, hysterectomy may be an appropriate treatment option. After hysterectomy, these patients are at increased risk for vaginal intraepithelial neoplasia.
Genital Prolapse Hysterectomy for symptomatic genital prolapse accounts for about 14.5% of hysterectomies performed in the United States (1). Unless there is an associated condition requiring an abdominal incision, vaginal hysterectomy is the preferred approach for genital prolapse. Uterine prolapse typically is not an isolated event and most often is associated with a variety of pelvic support defects. Each defect must be corrected to optimize the surgical outcome and decrease the risk of developing future pelvic support defects.
Obstetric Emergency Most emergency hysterectomies are performed because of postpartum hemorrhage resulting from uterine atony. Other indications include uterine rupture that cannot be repaired or a pelvic abscess that does not respond to medical therapy. Hysterectomy may be required for patients with placenta accreta or placenta increta.
Pelvic inﬂammatory disease can be treated successfully with antibiotics. The uterus, tubes, and ovaries rarely need to be removed in a patient with pelvic inﬂammatory disease that is refractory to intravenous antibiotic therapy (see Chapter 18). Whether one proceeds with conservative surgical management, abscess drainage, or organ removal is a subjective decision that must be based on the individual. If accessible, some pelvic abscesses may be drained successfully by percutaneous catheter drainage guided by ultrasonography or computed tomography (CT) scanning. Surgical intervention is necessary if the patient has acute abdominal findings associated with peritonitis and signs of sepsis in the presence of a ruptured tubo-ovarian abscess. For the patient who desires future fertility, consideration should be given to unilateral salpingectomy or salpingo-oophorectomy or bilateral salpingo-oophorectomy without hysterectomy. For the patient in whom bilateral salpingo-oophorectomy is required, the uterus can be left in place for possible ovum donation and in vitro fertilization.