CHILD SEXUAL ABUSE

show significant differences in contrast to bowel and urinary function, which did. Matched pairs formed the basis of the comparison. Matching was carried out to keep the cases as similar as possible to the controls in respect of practice and area of domicile, as well as age and sex (the controls might not necessarily have been the same sex). Irritable bowel effects and previous main operations posed a problem. The controls were asked to describe their present bowel function in the period under review; the cases were asked this and to note if changes were due to the hysterectomy, likewise with previous operations. In the event, in the hysterectomy group there were only two cases of a previous diagnosis of the irritable bowel syndrome with no change in bowel habit and there were only three women who had had previous major pelvic surgery, only one of whom was constipated. Only two women had their hysterectomy by the vaginal route so that the result of the comparison reflects almost entirely abdominal hysterectomy, and the possible contributory role of traction or other aspects of a perineal approach do not emerge in our study. Thirty three patients had an additional oophorectomy, half performed unilaterally and half bilaterally. Though the additional procedure might act hormonally, it might also affect pelvic function by being a more extensive operative dissection. The question of urological function being disturbed obviously heightens the debate. All our critics agree with us that hysterectomy causes a urological problem, though they then vary, in the main claiming that urinary dysfunction is solely attributable to the radical operation. Only the group from Birmingham conceded that the problem can arise with the less extensive operation. ' Our results also show that there was a urinary problem as well as a bowel one. Thirty seven women had increased frequency after hysterectomy, 27 of whom had a permanent change. Furthermore, there was a disturbance of both systems after the operation, some of which subsequently resolved. This suggests a recovery, which is more likely the result of nerve damage than hormonal failure as a hormonally induced problem would be expected to become progressive, especially if these patients are prone, as we were reminded by Mr Versi, to an earlier menopause. We discussed the possible mechanismspsychological, hormonal, and neural-and thought that a neural mechanism was the best explanation. The phenomenon has been seen by others, who found that the severity varied with the extent of the surgery done,2 which agrees with our hypothesis. A mechanism for similar pelvic nerve disturbance has been described by Catchpole in the performance of a low anterior resection.3 It is supported by our experience with a group of patients with intractable constipation after hysterectomy in whom studies have shown motility changes in the left colon but no upset in pelvic floor and sphincter function.4 We are aware of the work of Snooks et al' and the effect of the pelvic neuropathy of childbirth on the anal sphincter, but this leads, in our experience, to faecal incontinence, not constipation. We agree that the time is ripe for gynaecologists to set up prospective studies of the sequelae of hysterectomy, though we would warn of the possibility of reporting bias in such studies. We hoped to draw attention to a problem that we believe exists. In some of our 91 cases the bowel problem was reasonably obvious. Not a few gastroenterologists and surgeons have patients subsequently referred with a more severe bowel dysfunction which may be a late outcome related to the general effect that we are describing here. Such patients eventually are seen with intractable constipation, the symptoms suggesting a degree of obstruction to the left colon, and often paradoxically with constipation in the presence of an empty rectum; they may eventually need surgery. In Edinburgh 34 such patients have been investigated for this syndrome.