Hysterectomy is a surgical procedure to remove the uterus, and sometimes other female reproductive organs. It is one of the most common gynecological surgeries, with over 600,000 performed annually in the US. There are several types of hysterectomy that are performed depending on factors like the surgical approach and extent of organ removal. Physical therapy both before and after hysterectomy aims to improve patient strength, mobility, and recovery through exercises targeting the core, pelvic floor, breathing, and circulation. Complications can include infection, incontinence, and prolapse, so physical therapy also focuses on preventing and managing these issues.

4. *Hysterectomy: It is the surgical removal of the uterus.
It may also involve removal of the cervix, ovaries, Fallopian
tubes, and other surrounding structures.
-Hysterectomy is a major surgical procedure that has
risks and benefits. It affects the hormonal balance and overall
health of patients.
*Hysterectomy can be done through abdominal
approach (Abdominal hysterectomy), vaginal
approach (Vaginal hysterectomy) or Laparoscopic.
-Hysterectomy is the most common surgical procedure
worldwide in gynecology (Hammer et al., 2015), Approximately 600,000 hysterectomies
are performed annually in the United States, with a cost of approximately $5 billion per year.

5. -Subtotal hysterectomy (Supracervical hysterectomy)→ Removal of the uterine
body and preservation of the cervix, It is usually done in some cases of postpartum
hemorrhage and rupture of the uterus or if there is extensive adhesions around the cervix.
-Total hysterectomy→ Removal of the entire uterus (Body and Cervix) and it is better
than subtotal hysterectomy.
-Panhysterectomy→ Total hysterectomy with bilateral salpingo-oophorectomy (Total
hysterectomy with bilateral removal of fallopian tubes and ovaries).
-Radical hysterectomy (Wertheim’s operation)→ Panhysterectomy with removal of
the upper vagina and lymph nodes.
-Ultraradical hysterectomy (Pelvic excenteration)→
*Anterior pelvic excenteration→ Wertheim’s operation with removal of the bladder
with implantation of the ureters at the colon or skin.
*Posterior pelvic exenteration→ Wertheim’s operation with removal of the rectum
with implantation of the colon at the skin.
Types of abdominal hysterectomy:

7. *Indications of Abdominal Hysterectomy:
A)Obstetrical Indications →
-Uncontrollable postpartum hemorrhage
-Rupture or perforation of the uterus
-Morbidly adherent Placenta (Placenta accrete)
-Septic abortion
-Couvelaire’s uterus
B)Gynecological Indications →
-Dysfunctional uterine bleeding
-Inflammatory: cases such as in genital tuberculosis
-Neoplastic:
*Benign→ Uterine fibroids and benign ovarian tumors
*Malignant→Cervical, ovarian and endometrial carcinoma
-Displacement: Some cases of uterine prolapse
-Some cases of endometriosis and adenomyosis

9. *Advantages of Subtotal (Supracervical) Hysterectomy:
*Advantages of Total Hysterectomy:
-It avoids the risk of cervicitis or cervical stump carcinoma
that may be developed after subtotal hysterectomy.
-It provides better drainage of the operation area through
the vagina. So, there is less risk of a pelvic hematoma.
-If the cervix is lacerated or infected, the source of irritant
discharge is removed.
-It is easier and quicker than total hysterectomy.
-There is less danger of injured bladder or ureter.
-There is less danger of pelvic infection.
-It has less operative and postoperative morbidity.
-The cervix acts as a support for the vaginal vault.
-The cervix provides discharges to lubricate the vagina.

10. *Indications of Vaginal hysterectomy:
-Some cases of uterine prolapse or chronic uterine inversion.
-Some cases of small fibroids, adenomyosis and abnormal uterine bleeding.
-Some cases of uterine body cancer. However, the uterus should be normal in
size or slightly enlarged up to 12 weeks and is not surrounded by adhesions.
-Schauta operation→ Radical vaginal hysterectomy, which may be done in
cases of cervical carcinoma, but the lymph nodes may be difficult to be removed.

11. *Advantages Vaginal Hysterectomy:
-Absence of abdominal scar.
-lower incidence of intestinal complications and peritonitis.
-An associated genital prolapse can be treated at the same time.
*Disadvantages Vaginal Hysterectomy:
-It requires a skilled surgeon.
-It is unsafe and difficult in the presence of pelvic adhesions.
-The ovaries can not be removed in some cases.
-It can not be done if the size of the uterus is larger than
14 weeks of pregnant uterus unless the uterus is bisected
before its removal.
-It is the highest in blood loss.
-Vaginal Vault prolapse is more likely to occur than after abdominal hysterectomy.

13. Complications of Hysterectomy
*Intraoperative (during operation):
-Hemorrhage.
-Visceral injury: Intestine, bladder or ureters.
-Anaesthetic hazard: atelectasis, pulmonary edema,
embolism.
*Postoperative (-Immediate -Late -Remote):
➢ Immediate postoperative
-Primary hemorrhage → hypovolemic shock.
-Urinary: Retention due to pain and spasm, Cystitis and Anuria
may be due to inadequate fluid replacement (prerenal) or ureteric
obstruction (postrenal).

14. ➢ Late postoperative
-Incontinence:
▪ Overflow due to prolonged overdistension of the bladder.
▪ Stress due to prolonged catheterization and weak pelvic floor muscles.
▪ True → If occurs immediately after operation, it is caused by injury to the bladder or ureter.
If occurs 7–14 days after operation, it is due to
sloughing and necrosis either of the bladder or ureters.
-Pyrexia → fever may be due to:
▪ Cystitis (due to catheterization)
▪ Abdominal wound infection
▪ Thrombophlebitis
▪ Vault cellulitis, hematoma
▪ Pneumonia and peritonitis
-Hemorrhage (Reactionary→ within the first 24 hours after the operation or
secondary→ occurs between 7–14 days after operation and is due to sepsis).

15. ➢ Remote postoperative
-Complications of the abdominal scar such as Keloid
formation, Incisional pain and Incisional hernia → more
with mid-line vertical incision than with low transverse one.
-Vaginal Vault prolapse and Pelvic organ prolapse.
-Vaginal discharge due to vault infection.
-Depression and psychiatric symptoms.
-Dyspareunia either due to tender scar in the vaginal vault or an adherent ovary
to the vaginal vault.
-Prolapse of the fallopian tube through the vaginal vault.
-Low Back Pain may be experienced due to prolonged lying on a flat
table during the operation, chronic pelvic cellulitis, myofascial
mechanical consequences and osteoporosis.
-Menopausal symptoms if the two ovaries are removed in young women
as: osteoporosis, hot flushes, hypertension, stress incontinence and androgenic alopecia.

16. *Aims of Preoperative Physical Therapy:
-To provide the basic information to the patient regarding the operation.
-To provide psychological support and reassurance.
-To improve cardiopulmonary fitness and to prevent the development of DVT.
-To increase the power and strength of the local core muscles (Diaphragm, Transversus
abdominis, Pelvic floor and Lumbar multifidus).
-To increase the strength and power of the abdominal muscles (Rectus abdominis, external
and internal obliques).
-To Prepare the patient for the physiotherapy program after the operation.
▪ Physical capacity appears to be an important predictor for postoperative recovery after
major abdominal surgeries such as abdominal hysterectomy.
▪ Especially in elderly patients, physical capacity is often reduced due to a lack of
regular physical activity before surgery.

17. *Preoperative Physical Therapy treatment:
-Counseling, Psycho-Physical Therapy holistic approach and
patient education.
-Diaphragmatic breathing exercises, deep inspirations with
aid of incentive spirometry and forced expiration techniques.
-Huffing and Coughing for 5 min per day.
-Advice to walk for a minimum of 30 min daily.
-Lower limb circulatory exercises (ankle rotations and
pumping, static quadriceps contractions and bridging)
for 5-10 min per day.

18. -Pelvic floor muscle training.
-Core training and dynamic
abdominal exercises such as:
abdominal crunches and abdominal
twist.
-Bed mobility and changing
positions such as: Scooting up or
down, Scooting sideways, Rolling
over, Twisting and reaching, Lifting
hips (as in bridging), Moving from
sitting to lying down in bed, Moving
from lying down to sitting up in bed.

19. *Aims of Postoperative Physical Therapy:
-To prevent and/or treat the respiratory complications of anaesthesia.
-To prevent the development of DVT and varicose veins.
-To improve the power of the local core muscles and prevent their wasting.
-To regain the power of the abdominal muscles (Rectus abdominis, external
and internal obliques), prevent their wasting and reduce the incidence of incisional hernia.
-To prevent and/or manage the pelvic floor related dysfunctions such as: incontinence and
pelvic organ prolapse.
-To prevent and/or correct the postural problems.
-To manage the menopausal symptoms such as: osteoporosis, obesity
and hypertension.
-To reduce the incisional pain and improve its healing.
-To manage scar complications such as: hypertrophic scar and its
related musculoskeletal complications ( Shoulder tip pain and chronic low back pain ).

20. *Postoperative Physical Therapy treatment:
*Week 1
▪ The same program as in post-cesarean delivery. But without strong focus on upper limb
exercises (there is no need for lactation except in cesarean hysterectomy).
-Advice on scar management.
-Pelvic floor strengthening exercises.
-Pain control modalities such as LASER and high frequency TENS.
-Breathing exercises, Elevation exercises and Elastic stocking.
-Advice about the most comfortable positioning.
-Simple mobility exercises such as rolling over and walking.
-Transversus abdominis strengthening exercises
-Lower limb strengthening and range of movement exercises.
-The patient may stay in the hospital for 5-7 days depending on
the type of hysterectomy and the recovery rate.

21. *Weeks 2-6
▪ Symptoms should now be reducing, and the patient feel able to gradually
return to normal daily activities. The following treatments may include:
-Postural correction exercises and Progressing all strengthening exercises.
-Progressing transverse abdominis exercises.
-Carrying out pelvic floor exercises in more functional positions.
-Including more functional activities relating to your hobbies or work.
*Week 7 onwards
▪ ADLs should now be with a little, or no pain, driving again usually can take up to 3 months
and lifting heavy objects should be avoided for up to 6 months.
-Starting dynamic abdominal exercises such as: abdominal crunches
especially those focus on lower abdominal muscles and twist.
-Scar mobilization techniques can be started.
-Graded weight-bearing aerobic & light resisted exercises should be a regimen to reduce
menopausal osteoporotic and cardiovascular complications specially if ovaries were removed.