Management of urinary incontinence in postmenopausal women: An EMAS clinical guide


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Introduction: The prevalence of urinary incontinence and of other lower urinary tract symptoms increases after menopause and affects between 38 % and 55 % of women aged over 60 years. While urinary incontinence has a profound impact on the quality of life, few affected women seek care.

Aim: The aim of this clinical guide is to provide an evidence-based approach to the management of urinary incontinence in postmenopausal women.

Materials and methods: Literature review and consensus of expert opinion.

Summary recommendations: Healthcare professionals should consider urinary incontinence as a clinical priority and develop appropriate diagnostic skills. They should be able to identify and manage any relevant modifiable factors that could alleviate the condition. A wide range of treatment options is available. The first-line management includes lifestyle and behavioral modification, pelvic floor exercises, and bladder training. Estrogens and other pharmacological interventions are helpful in the treatment of urgency incontinence that does not respond to conservative measures. Third-line therapies (e.g. sacral neuromodulation, intravesical onabotulinum toxin-A injections, and posterior tibial nerve stimulation) are useful in selected patients with refractory urge incontinence. Surgery should be considered in postmenopausal women with stress incontinence. Midurethral slings, including retropubic and transobturator approaches, are safe and effective and should be offered.

1. Introduction

1.1. Definitions and epidemiology

Urinary incontinence (UI) is defined as a “complaint of involuntary loss of urine” [1]. The prevalence of the condition increases with age, and it is reported to affect 58%–84% of elderly women [2]. The reported prevalence of UI varies widely because of the different definitions and assessment tools for diagnosis employed [3]. The general prevalence is reported to be between 38 % and 55 % in women over 60 years [4]. Despite this high prevalence, UI remains underdiagnosed and undertreated. Up to half of women may not report incontinence to their healthcare provider and this may be due to embarrassment or to the belief that UI is a normal part of aging.

Several types of incontinence exist, and a simplified clinical classification can be found in Table 1. Stress urinary incontinence (SUI) is defined as involuntary loss of urine with increases in abdominal pressure such as during exercise or coughing [1]. The main etiology is a poorly functioning urethral closure mechanism and a loss of anatomic urethral support. Urge urinary incontinence (UUI) is characterized by a sudden compelling desire to pass urine that is difficult to postpone [1]. In neurologically intact women, UUI is an idiopathic condition. However, it is common in women with systemic neurologic disorders (e.g. Parkinson's disease, multiple sclerosis, pelvic, or spinal nerve injury). UUI is part of a broader entity known as overactive bladder syndrome, which is defined as urinary urgency with or without urgency incontinence, frequently associated with increased daytime frequency and nocturia, in the absence of proven urinary infection or other diseases [5]. The symptoms of overactive bladder are due to involuntary contractions of the bladder detrusor muscle during the filling phase of the micturition cycle. These involuntary contractions are indicated as “detrusor overactivity” and are related to acetylcholine-induced stimulation of bladder muscarinic receptors [6]. Notably, while the overactive bladder is a clinical diagnosis, detrusor overactivity is identified with a urodynamic assessment. Many women with incontinence experience coexisting stress and urgency symptoms, called mixed urinary incontinence (MUI).

1.2. Age- and menopause-related modifications of the lower genitourinary tract
1.3. The role of the microbiome in postmenopausal women

2. Diagnosis and assessment of urinary incontinence

3. Management of incontinence

3.1. Conservative management

3.1.1. Lifestyle interventions and behavioral therapies
3.1.2. Pelvic floor muscle training

3.2. Medical interventions

3.2.1. Pharmacological approaches Estrogens and selective estrogen receptor modulators Non-estrogen targeted pharmacological therapies Drug treatments for UUI and overactive bladder Combining pharmacological therapies. Treatment of refractory UUI and overactive bladder

3.2.2. Laser treatment

3.2.3. Surgical approaches Mid-urethral slings Urethral bulking injections Retropubic suspension

5. Conclusions

Urinary incontinence is common in women at midlife and beyond. Incontinence causes embarrassment and depression and limits activities and social interactions. Many effective treatment options exist. Healthcare professionals are in a key position to assess and manage the problem. Successful treatment depends on an accurate diagnosis of the type of incontinence, identification, and treatment of any modifiable contributing factors, and a personalized therapeutic approach. Specialist referral is mandatory for the management of complex cases. Effective and personalized care of urinary incontinence should be a healthcare priority so that women do not suffer unnecessarily from this common debilitating condition.


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Table 1 Urinary incontinence: simplified clinical classification and pathophysiology.
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Many menopausal women experience bladder weakness. There are signs that hormonal changes - deficient estrogen levels - affect the abdominal muscles and cause the bladder to change position, resulting in urinary discharge. And sometimes with scars and there are Scar Treatment Creams that can remove them reasonably quickly. Estrogen treatment in the form of creams or vaginal suppositories has helped me manage my menopausal symptoms. Ask your doctor what the best treatment for you is. Add some Kegel exercises to your morning routine. A few minutes a day of training the pelvic floor can reduce the risk of leaks or even eliminate them.
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