Urologic Dysfunction After Menopause

Urologic dysfunction after menopause includes UTI, bladder control problems, and bladder prolapse.

• Urologic conditions that can occur around the time a woman goes through menopause include
  • bladder control problems,
  • bladder prolapse (descent of the bladder into the vagina due to weakening of the pelvic tissues), and
  • urinary tract infections.
• The level of estrogen in a woman's body decreases during menopause. The role this hormone plays in urologic dysfunction continues to be studied.
• While some researchers have found that estrogen loss may influence a woman's urologic function, the evidence is in no way conclusive, and other factors, such as the effects of childbirth on the body, have not been discounted.
• The good news for women is that a variety of treatments exist for all of these conditions, and women with urologic dysfunction can find relief and improved quality of life by seeking qualified medical care.
• Antibiotics are the medication of choice for urinary tract infections.

Illustration of the female urinary tract system

Urinary tract infections

Urinary tract infections are divided into two categories. A lower urinary tract infection is sometimes referred to as cystitis and involves the lining of the urethra and irritation of the bladder. An upper urinary tract infection is called pyelonephritis and involves the kidneys of the upper urinary tract.

Urinary tract infections are most often caused by bacteria entering the urinary tract through poor hygiene or sexual intercourse. Low estrogen levels result in vaginal dryness and atrophy, which allow bacteria to enter the bladder, causing infection. Some researchers suggest that delayed urination and dehydration resulting in decreased urinary output may also contribute toward the development of urinary tract infections.

Bladder control problems

Bladder control problems, or urinary incontinence, occur with greater frequency in both men and women as they age. Many people aged 65 years and older experience bladder control problems that can range from a little leakage to uncontrollable wetting. The problem is more common in women than in men. Studies have suggested that a significant percentage of women older than 60 years and living at home have some form of incontinence.

Bladder control problems have many possible causes, including reduced levels of estrogen in the body. For menopausal women, contributing factors may be nerve damage from childbirth, pelvic surgery, and weakened pelvic floor muscles.

Bladder prolapse

Prolapsed bladder is a problem unique to women because of a woman's anatomy. The front wall of the vagina helps keep a woman's bladder in place. If and when the tissues of the vagina wall are weakened from the stress of childbirth, changes during menopause, or repeated physical straining due to constipation or heavy lifting, the bladder can prolapse or descend into the vagina.

Urinary tract infections

Symptoms of a lower urinary tract infection include painful, frequent, urgent, or hesitant urination; lower abdominal pain; and fever. Urine may appear cloudy and have a foul smell. Blood may be present in the urine. Painful urination is known as dysuria.

Symptoms of an upper urinary tract infection include

• a fairly high fever (101 F),
• shaking chills,
• nausea,
• vomiting, and
• flank pain.

Bladder control problems

The most common types of bladder control problems for menopausal women are stress incontinence and urge incontinence. Women first notice stress incontinence as the leakage of urine that occurs with an increase in intra-abdominal pressure such as that which occurs when they laugh, cough, exercise, or even stand up quickly.

Urge incontinence, sometimes called irritable bladder, manifests as a strong, sudden urge to urinate. Sometimes women with this type of incontinence feel the need to urinate so urgently that they wet themselves.

Bladder prolapse

The physical problems and resulting symptoms created by a prolapsed bladder range from mild to severe according to the degree or grade of prolapse. Pelvic pain, low back pain, difficulty urinating, stress incontinence, and painful intercourse are just a few possible symptoms of prolapsed bladder.

A woman with a low grade of prolapse may experience no symptoms at all. A severely prolapsed bladder can cause painful, bleeding tissue to protrude from the vagina.

Urinary tract infection

A medical evaluation is recommended within 24 hours of experiencing symptoms of a urinary tract infection.

Bladder control problems

The most unfortunate aspect of bladder control problems is that too many women suffer in silence. Bladder control problems can be minimized, and often eliminated, with a variety of treatments. These include

• practicing Kegel exercises to strengthen the muscles of the pelvic floor (these exercises are typically taught to women preparing for childbirth),
• giving up caffeinated beverages that irritate the bladder, and
• exploring a variety of surgeries.

The important message for women struggling with bladder control problems is that seeking medical care as early as possible can not only provide answers but also greatly improve their quality of life.

Bladder prolapse

Women experiencing even minor symptoms of bladder prolapse should seek medical care as early as possible to help minimize the severity of prolapse. By practicing prevention techniques, for example, women can avoid or decrease the long-term problems of bladder prolapse.

Women who are struggling with bladder control problems or bladder prolapse may want to consider seeing a physician. Questions women may want to ask to include the following:

• How often do you treat this problem in other patients?
• What nonsurgical treatments are available, and how successful are these therapies?
• What can I do to maximize my improvement with this condition?
• Is there lifestyle or dietary changes that you would recommend?

The initial exams and tests for all urinary problems after menopause are essentially the same. The doctor first asks about symptoms, medical and surgical history, medications, and habits, such as smoking, drinking caffeine, and exercising.

Women also undergo a physical exam. Depending on symptoms, the physical exam can include a vaginal, pelvic, and rectal exam.

For all conditions, but particularly for urinary tract infections, women are asked to provide a urine sample. Most often, women are asked to provide a "clean catch" sample, which means collecting the urine midstream after cleansing the area around the urethra. The following aspects of the urine are examined:

• Amount and appearance of the urine
• The chemistry of the urine, called a urinalysis, includes tests to determine whether blood is present in the urine
• Microscopy of the urine to check for infection or abnormalities
• Culture of the urine (allowing a small amount of urine to sit in a sterile dish for a few days to check for bacteria growth)

Urinary tract infections

In most cases, a urinalysis provides the doctor with all the information needed to treat a urinary tract infection. In some cases, the urine is cultured to see what kind of bacteria is responsible for the infection. This information helps the doctor determine what type of antibiotic the infection will respond best to. If a more complicated infection is suspected, such as pyelonephritis or kidney failure, a woman may be asked to undergo blood tests. Severe urinary tract infections usually require intravenous (IV) antibiotics and possibly a hospital stay.

Bladder control problems

The number and type of tests women undergo depend on the type of bladder control problem and the severity.

• Postvoid residual measurements determine how well the bladder is emptied when a woman urinates. This is performed in two different ways. A catheter may be inserted into the bladder after a woman urinates to see if any urine remains or ultrasonography may be used to take a picture of the bladder to calculate how much urine remains in the bladder.
• Cotton swab tests check the urethra for hypermobility. Hypermobility occurs in many women with stress incontinence. As a woman lies on the exam table, the doctor inserts a well-lubricated, sterile, cotton-tipped applicator through the urethra into the bladder neck. Hypermotility is present of the swab moves excessively when the woman is asked to cough or bear down (these methods cause increased pressure within the abdomen).
• Urodynamic tests check bladder and sphincter muscle strength and function and are often described as an ECG of the bladder. These tests are typically performed in a series and can determine if the bladder fills and empties normally. These tests can also show if the sensation of bladder fullness matches the bladder being full.
• Cystoscopy is an outpatient procedure that allows the doctor to see the inside of the bladder by inserting a thin tube into the urethra and up into the bladder. This test is often performed when there is blood in the urine (hematuria) or bladder pain is present.

Bladder prolapse

The primary way to diagnose bladder prolapse is through a physical exam of the female genitalia to see if the bladder has entered the vagina, which confirms the diagnosis. Other tests may be performed to determine the grade of bladder prolapse:

• Urodynamic tests check bladder and sphincter muscle strength and function. These tests are typically performed in a series and can determine if the bladder fills and empties normally. These tests can also show if the sensation of bladder fullness matches the bladder actually being full.
• Cystoscopy (described above) may be used to visualize the bladder surface.
• Voiding cystourethrogram provides the doctor with a view of how the urinary anatomy functions with a series of X-ray films taken while a woman urinates.
• X-ray films of other parts of the abdomen may be taken to rule out other causes of symptoms.

Urinary tract infections

Urinary tract infections should not initially be self-treated at home; however, the following measures can be taken to reduce the discomfort that accompanies urinary tract infections:

• Take pain-relieving medication, such as ibuprofen (Advil, Motrin), naproxen (Aleve), or acetaminophen (Tylenol).
• Place a hot water bottle on the abdomen to ease the pain.
• Continue to drink plenty of water.
• Avoid coffee, alcohol, and spicy foods that can irritate the bladder.

Bladder control problems

Women can help minimize symptoms of bladder control problems by doing some or all of the following:

• Avoid foods and drinks that irritate the bladder. These include alcohol, caffeine, carbonated drinks, chocolate, spicy foods, citrus fruits, and acidic fruits and juices.
• Drink plenty of fluids but do not drink too many. Six to eight cups a day is enough unless a woman is losing fluids due to exercise or heat.
• Urinate regularly and do not delay urinating or having a bowel movement.
• Maintain a healthy weight.
• If necessary, wear absorbent pads and change them often.
• Practice Kegel exercises to strengthen pelvic floor muscles. Kegel exercises are often taught in childbirth classes and involve contracting pelvic floor muscles for 10 seconds and then relaxing for 10 seconds. Repeat the exercise 10 to 20 times three times a day. Doing this exercise correctly ensures a woman is working the proper muscles. To find the muscles, a woman can place her first and second fingers into her vagina and squeeze as if holding in urine. The muscles a woman feels tighten around the fingers are the muscles that she should be contracting and relaxing during Kegel exercises.
• Keep a voiding or urination diary to track voiding patterns. Write down the time of the urge to urinate, strength of pain or urge, time of urination, volume of urination, amount of leakage, and types and amounts of fluids consumed and when. This can help the doctor determine the precise cause of the dysfunction, as well as help, predict which therapies may be most successful.

Bladder prolapse

If a woman has mild-to-moderate bladder prolapse, her doctor may recommend avoiding heavy lifting or straining as well as performing Kegel exercises. A woman may also be instructed to increase fiber in her diet to reduce constipation.

Urinary tract infections

Both simple and complicated urinary tract infections are typically treated with antibiotics as an outpatient treatment. The type of antibiotic and length of treatment depends on lower versus upper urinary tract infection and severity of infection. If a woman is very ill and has other symptoms, such as vomiting causing dehydration, kidney stones, or a urinary catheter in place, she may be hospitalized to receive intravenous (IV) antibiotics.

Bladder control problems

People with bladder control problems have a wide range of treatment options available to them, based on the type of incontinence and severity. A woman's involvement in the treatment impacts her success.

For urge incontinence, the treatment addresses the underlying cause. A woman may be instructed to limit fluid intake, try behavioral therapy, use timed voiding and bladder training techniques, and/or practice pelvic floor exercises.

Medical treatment may not cure stress incontinence but may improve symptoms in 88% of those who have the condition. Medical approaches include achieving weight loss and practicing Kegel exercises. A woman may be instructed to strengthen pelvic floor muscles using a device called a weighted vaginal cone. The doctor may also recommend using a urethral plug. This tampon-like device is inserted into the urethra to block urine flow. A pessary, a device inserted into the vagina to support the bladder, may also be suggested.

Bladder prolapse

Treatment for prolapsed bladder depends on the grade. Grade 1, or the least severe, may require no treatment at all other than to avoid heavy lifting and straining. Medical treatments for more severe prolapse include using a pessary inserted into the vagina to support the bladder, using electrical stimulation to target and strengthen pelvic muscles, using biofeedback to monitor pelvic floor muscle activity, and tailoring exercises to strengthen these muscles.

Urinary tract infection

Antibiotics are the medication of choice for urinary tract infections. The doctor may also prescribe phenazopyridine (Pyridium) to relieve the burning pain during urination that can occur until antibiotics take effect.

Some research suggests that estrogen replacement therapy may reduce urinary tract infections in menopausal women and this issue continues to be researched. For some women, local estrogen therapy as either tablet (Vagifem) or creams (Premarin, Estrace) may reduce the frequency of urinary tract infections in women with vulvar-vaginal atrophy resulting from low estrogen levels.

Bladder control problems

• Anticholinergic and spasm-relieving drugs may be prescribed for urge incontinence. These suppress bladder contraction and relax the bladder's smooth muscle. These medications include
  • darifenacin (Enablex), 
  • flavoxate (Urispas),
  • hyoscyamine (Anaspaz, Levbid, Levsin),
  • oxybutynin (Ditropan, Ditropan XL, Oxytrol),
  • solifenacin (VESIcare),
  • tolterodine (Detrol, Detrol LA), and
  • trospium (Sanctura).
• Some tricyclic antidepressants have strong anticholinergic effects and may be prescribed for incontinence. These include imipramine (Tofranil, Tofranil PM).
• The antidepressant duloxetine (Cymbalta) is also sometimes used to treat stress incontinence.
• Adrenergic agonists such as midodrine (ProAmatine) and pseudoephedrine (Sudafed) can increase internal sphincter tone and may be prescribed for stress incontinence. These medications can have serious side effects, such as high blood pressure, and are not for everyone.
• Bethanechol (Urecholine) has been FDA approved for overflow incontinence but has not yet had consistent success in clinical practice. No other medications are known to treat overflow incontinence at this time.
• Estrogen replacement therapy or topical estrogen cream may be suggested to improve bladder function. The application of estrogen cream to the vagina and urethral area may help reduce urinary frequency and urgency and offers little absorption into the rest of the body; however, the safety and efficacy of estrogen therapy continue to be researched.

Bladder prolapse

Estrogen replacement therapy, administered orally as a pill or topically as a patch or a cream, may be recommended for bladder prolapse to strengthen the vaginal muscles. The topical cream offers little absorption into the rest of the body, so it avoids the side effects and potential risks of estrogen therapy while providing a potent dose to the vaginal area. However, the safety and efficacy of estrogen therapy continue to be researched.

Urinary tract infections

Surgery is generally not required for urinary tract infections unless an anatomic abnormality is discovered.

Bladder control problems

Surgery for bladder control problems can correct an anatomical problem or implant a device to alter bladder muscle function. Most people do not need surgery, but most who do undergo surgery become dry. Surgery does not work for everyone and carries the possibility of complications, so it is best advised by a urologic surgeon. Types of operations include the following:

• Altering the bladder neck to change how urine is released from the bladder
• Repairing or supporting severely weakened pelvic floor muscles
• Removing a blockage
• Implanting a "sling" around the urethra
• Implanting a device to stimulate nerves and increase awareness of the need to urinate
• Injecting collagen, a naturally occurring material, around the urethra adds bulk to the area and compresses the urethra, thus increasing the resistance to urine flow (used to treat stress incontinence)
• Enlarging the bladder (considered the last resort)

Bladder prolapse

Surgery is often recommended when a prolapsed bladder cannot be managed with a pessary or other approaches. Procedures vary depending on the grade of prolapse. Generally, the prolapsed bladder is repaired through an incision into the vaginal wall. The prolapsed area is closed and the wall is strengthened. Depending on the severity, the procedure can be performed with local, regional, or general anesthesia.

Electrical stimulation and biofeedback techniques offered by doctors and physical therapists may help strengthen the pelvic muscles in cases of bladder control problems and prolapsed bladder.

Electrical stimulation targets muscles in the vagina and pelvic floor with a probe attached to a device that delivers painless electrical currents that contract the muscles. This can also be performed through the pudendal nerve with a probe placed outside the body.

Biofeedback uses a sensor to monitor muscle activity in the vagina and pelvic floor. Based on the information provided through biofeedback, a doctor or physical therapist can recommend exercises to strengthen these muscles.

Urinary tract infection

Completing the entire course of antibiotics prescribed by the doctor is extremely important, even if the woman feels better. A woman may also be asked to return to the doctor for a follow-up urinalysis. If a woman experiences a return of symptoms or new symptoms, she should call her health care professional immediately. These symptoms include

• fever or pain with urination continuing 2 days after antibiotic treatment;
• inability to keep medication down or severe side effects of medication;
• nausea or vomiting related to foods, fluid, or medication;
• flank pain, shaking chills, or high fever related to kidney involvement; or
• worsening of any symptoms after 2 days of antibiotic treatment.

Bladder control problems/bladder prolapse

Keep follow-up appointments with the doctor and continue seeking medical care if a first approach does not work.

Urinary tract infections

• Wipe from the front to the back after going to the bathroom to prevent bacteria from being moved from the anus to the urethra.
• Empty the bladder regularly and completely, especially after sexual intercourse.
• Drink plenty of fluids including cranberry juice. Studies have shown cranberry juice reduces the ability of bacteria to stick to bladder cells, thus reducing the chance that urinary tract infections will occur.
• Quit smoking. Smoking irritates the bladder and has been shown to cause bladder cancer in some patients.

Bladder control problems

• Drink plenty of fluids, but avoid alcohol and caffeine.
• Avoid spicy foods or citrus foods and drinks that can irritate the bladder.
• Urinate regularly.
• Practice Kegel exercises regularly.
• Quit smoking. Smoking irritates the bladder and has been shown to cause bladder cancer in some patients.
• Maintain a healthy weight with a healthy diet and regular physical activity.

Bladder prolapse

• Eat a high-fiber diet and drink plenty of fluids to reduce the risk of constipation.
• Seek medical attention for long-term constipation.
• Avoid heavy lifting.
• Maintain a healthy weight as obesity is a risk factor for bladder prolapse.
• Quit smoking. Smoking irritates the bladder and has been shown to cause bladder cancer in some patients.

Urinary tract infection

While urinary tract infection treatment is generally uncomplicated, if not treated promptly, these infections can cause permanent scarring of the urinary tract.

• In a very severe infection, pyelonephritis can allow the spread of bacteria to the bloodstream and cause a severe infection (sepsis) requiring hospitalization.
• An estimated 1% to 3% of people with pyelonephritis die. Although death is rare in otherwise healthy people, factors associated with poor outcomes or death include
  • poor health,
  • kidney stones,
  • recent hospitalizations,
  • diabetes,
  • sickle cell disease,
  • cancer, or
  • chronic kidney disease.

Bladder control problems

The good news for women with bladder control problems is that while treatment may not result in a cure, symptoms are reduced in most cases.

• An estimated 90% of people with stress incontinence experience either improvement or cure.
• An estimated 44% of people with urge incontinence experience a cure and
• 83% have an improvement in symptoms.

Bladder prolapse

Most cases of the prolapsed bladder are mild and can be treated with or without surgery.

• Severely prolapsed bladders can be completely corrected with surgery.
• This condition is rarely life-threatening.