Pelvic floor and sexual health outcomes after cesarean hysterectomy for placenta accreta spectrum

Abstract Objective(s) To estimate the incidence of urinary incontinence, pelvic organ prolapse, and sexual dysfunction in a cohort of patients who had undergone hysterectomy for placenta accreta spectrum (PAS). Additionally, to understand whether certain surgical factors contributed to these outcomes. Methods This was a retrospective cohort study of patients who underwent a cesarean hysterectomy for PAS between January 2018 and August 2023 at a single urban academic institution. Patients were recruited 6 months or more following surgery performed by the dedicated accreta team. The survey consisted of validated questionnaires (Pelvic Floor Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), and clinical data were abstracted from the medical record. Patients who reported pre‐existing incontinence or who were not sexually active were excluded from these respective outcomes. Two‐sided tests of significance were used with an alpha level of 0.05. There was no adjustment for multiple comparisons. Results During the study period, 100 patients underwent a hysterectomy for PAS of which 64 completed the survey. Participants had a median age of 36 at the time of surgery and a median of 2 prior cesarean deliveries. The majority of cases were scheduled ( n = 44, 68.8%) and underwent a supracervical hysterectomy ( n = 40, 62.5%). Cystotomy occurred in 12.5% ( n = 8/64) of cases. Following hysterectomy, approximately 31% ( n = 20/64) of participants had at least one symptom of prolapse, 39.3% ( n = 24/61) had symptoms of stress urinary incontinence, and 23.0% ( n = 14/61) had symptoms of urge incontinence. Twenty percent of patients ( n = 13/64) reported chronic pelvic pain, while 48.0% ( n = 25/52) reported at least occasional dyspareunia. Rates of stress incontinence ( p = 0.048) and pelvic pain ( p = 0.047) were reported more frequently in patients who had experienced cystotomy. There was no difference in outcomes when comparing the type of hysterectomy (i.e., total vs. supracervical) or the urgency of the surgical case. Conclusion In this cohort of patients who underwent hysterectomy for placenta accreta, there was a high rate of symptoms of prolapse, urinary incontinence, pelvic pain, and dyspareunia, especially in those with intraoperative bladder injury. These results should be used to counsel patients prior to surgery. Placenta accreta centers of excellence should consider offering referral to urogynecology postoperatively for all patients, and especially for those with intraoperative bladder injury.