A hysterectomy is a surgical procedure to remove the uterus, a hollow, muscular organ where a baby grows during pregnancy. After this surgery, menstruation ceases, and pregnancy is no longer possible. Hysterectomies are common, with about half a million performed annually in the U.S., typically for conditions like abnormal bleeding, fibroids, or cancer. As with any surgical procedure, there is a possibility of infection occurring afterward.
Types of Infections After Hysterectomy
Infections after a hysterectomy can manifest in several ways, affecting different areas of the body. Surgical site infections (SSIs) are common, occurring at the incision area. These can be superficial, involving only the skin, or deeper, affecting fascia and muscle. Wound infections occur in about 1.6% to 3% of abdominal hysterectomies and can present as cellulitis (redness and swelling) or an incisional abscess (collection of pus).
Another common type is vaginal cuff cellulitis, an infection of the superficial tissues at the vaginal surgical margin created when the uterus and cervix are removed. This infection often involves bacteria such as Staphylococcus or Streptococcus. Urinary tract infections (UTIs) are also frequently observed after hysterectomy, often linked to the use of catheters during or after surgery. These can be lower UTIs affecting the bladder and urethra, or upper UTIs involving the kidneys and ureters.
Pelvic cellulitis, a deeper infection, typically presents 5 to 10 days after surgery and involves diffuse tenderness and swelling in the pelvic area. This infection is often polymicrobial, meaning it involves multiple types of bacteria, including aerobic and anaerobic species. In rare cases, pelvic cellulitis or a pelvic hematoma can progress to a pelvic abscess, which is a collection of pus in the pelvis. These abscesses are uncommon, occurring in less than 1% of patients undergoing gynecologic surgery, but they are serious complications.
Recognizing Symptoms of Infection
Prompt identification of infection symptoms after a hysterectomy is important for timely medical intervention. General signs often include fever above 100.4°F (38°C), chills, fatigue, and a general feeling of being unwell. While a low-grade fever can be a normal inflammatory response, a persistent or higher fever warrants medical attention.
Localized symptoms provide specific clues about the infection’s location. For surgical site infections, patients might notice increased pain, redness, swelling, or warmth around the incision. There may also be red streaks extending from the wound, or pus and discharge with a foul odor draining from the site. Swollen lymph nodes in the neck, armpits, or groin can also indicate a localized infection.
Urinary tract infections present with distinct symptoms, such as a burning or itchy sensation during urination, an increased urge to urinate with little output, and pain or pressure in the back or lower abdomen. The urine itself might appear cloudy, dark, or bloody, or have an unusual or strong odor. If any of these symptoms, especially a fever above 100.4°F (38°C), new or worsening pain, or unusual discharge, are experienced, consulting a healthcare provider is advised.
Factors That Increase Risk
Several factors can increase the risk of infection after a hysterectomy. Patient-specific elements play a significant role. These include obesity, diabetes (especially with poorly controlled blood sugar), compromised immune systems, and use of systemic corticosteroids. Pre-existing infections like pelvic inflammatory disease or bacterial vaginosis also contribute. Some studies indicate a higher risk for younger women under 45.
Surgical factors also influence infection risk. Abdominal hysterectomies, with larger incisions, generally have higher infection rates than laparoscopic or vaginal approaches. Longer operative times (over 3 hours) are associated with increased risk. Excessive blood loss (over 500 mL) and the need for blood transfusions also elevate risk. Wound contamination during the procedure is another contributing factor.
Preventing and Treating Infections
Preventing infections after a hysterectomy involves pre-operative, intra-operative, and post-operative strategies. Administering prophylactic antibiotics before surgery is standard practice. Common choices include first or second-generation cephalosporins, sometimes with metronidazole. For penicillin allergies, alternatives like clindamycin or vancomycin may be used. Additional antibiotic doses may be given if the procedure is prolonged (over 3-4 hours) or involves significant blood loss (over 1500 mL).
Proper surgical technique also helps minimize infection risk. This includes maintaining strict hand hygiene, minimizing operating room traffic, and ensuring sterile environments. Some approaches, like laparoscopic and vaginal hysterectomies, are associated with lower infection rates compared to abdominal procedures due to smaller incisions. Controlling blood sugar levels for diabetic patients and preventing hypothermia during surgery further reduce risk.
Once an infection is established, treatment primarily involves antibiotic therapy. The specific antibiotic chosen depends on the infection type and suspected bacteria, often a broad-spectrum antibiotic. For localized surgical site infections like incisional abscesses, wound drainage may be necessary alongside antibiotics. Pelvic abscesses may also require drainage, often guided by ultrasound or CT, especially if large or unresponsive to antibiotics. Patients should follow all medical advice, including completing the full course of antibiotics, and maintain good post-operative hygiene, keeping incision sites clean and dry, and avoiding strenuous activity or vaginal insertion for several weeks.