Menopause incontinence is a pathological condition associated with menopause, a complication of the urinary tract. It is manifested by true incontinence – the discharge of portions of urine without the urge to urinate – and incontinence – the inability to restrain the emptying of the bladder with a strong urge. The diagnosis is established on the basis of the results of the patient’s survey, gynecological examination with functional tests. For differential diagnosis, pelvic ultrasound, cystoscopy and laboratory urine analysis are prescribed. Treatment of mild cases is conservative, with severe involuntary urination, surgical intervention is indicated.
ICD 10
N39.3 Involuntary urination
General information
Menopause incontinence is a late manifestation of the urogenital syndrome, which also includes other urination disorders and is associated with involutive changes in the pelvic organs. Incontinence is always a pathological condition requiring treatment, and not an age-related physiological norm. Incontinence in menopause is a common problem in modern gynecology, in premenopause this pathological condition occurs in 10% of women, in postmenopause (aged 55-60 years) the proportion of patients is 35-50%. With early (up to 40 years) menopause caused by premature ovarian insufficiency or their removal, the violation is registered more often – up to 80% of women are subject to it. Mild or moderate degree of disorder is observed in 93% of patients, severe disorder is noted in 7% of cases.
Causes
Incontinence is a polyethological disorder caused by a permanent increase in intra-abdominal pressure, pelvic organ prolapse and violation of the innervation of the urinary tract. The leading provoking factor of urinary incontinence during menopause is due to the physiological age–related extinction of the ovaries of hypoestrogenism and associated atrophic changes in the structures of the genitourinary tract. Other causes of this pathology include:
- Obstetric and gynecological factors. They include multiple or severe childbirth, as well as childbirth with a large fetus due to damage to the nerves supporting the structures of the pelvis. The risk increases with the provision of obstetric benefits (episiotomy, fetal extraction using obstetric forceps or vacuum extractor).
- Disorders of nervous regulation. Incontinence develops as a consequence of lesions of the nervous system: brain injuries, damage to peripheral nerves during pelvic organ surgery, strokes, Parkinson’s disease, multiple sclerosis. A common cause of urodynamic disorder is diabetes mellitus – the effect of hyperglycemia on the nervous system leads to a violation of the neurogenic regulation of urination.
- Other diseases and conditions. Abdominal obesity, chronic constipation and respiratory tract diseases, accompanied by a strong prolonged cough, have a negative impact due to the constant increase in pressure on the pelvic floor and the development of genital prolapse. Urinary incontinence can also lead to a sharp weight loss.
- Heavy physical activity. Prolonged hard physical labor, professional sports provoke incontinence due to the weakening of the supporting pelvic structures under the influence of permanent pressure.
The most significant predisposing condition for the development of incontinence is genetically determined undifferentiated connective tissue dysplasia, against which genital prolapse is most often formed. Thus, the likelihood of incontinence in menopause increases in women with varicose veins, hemorrhoids, hernias, excessive joint mobility, a tendency to dislocations, as well as pelvic organ prolapse in blood relatives.
Pathogenesis
Normally, the process of urination is completely controlled. Urine retention is ensured by the normal operation of the detrusor and sphincter of the bladder, reliable support of the urinary apparatus from the pelvic floor muscles and the genitourinary diaphragm, adequate nervous regulation of urine accumulation. An important role is assigned to the state of the structures of the urethra: the fullness of the epithelium, a sufficient amount of mucus, preservation of muscle tone, elasticity of the walls and good blood filling. All mechanisms of urination control depend on the level of estrogens.
The urothelium has morphological similarity with the epithelium of the vagina, therefore it reacts sensitively to hormonal changes. The lack of sex hormones potentiates atrophy of the mucous membranes of the urinary tract. Hormonal status affects the composition of connective tissue – as a result of estrogen deficiency, the amount of collagen increases, the structure of its fibers changes, which causes a decrease in the strength and plasticity of ligaments and muscles. Due to hypoestrogenism, the number of adrenoreceptors involved in the neurogenic regulation of urine accumulation and evacuation decreases.
Estrogen deficiency affects the state of the urinary organs: muscle tone and elasticity of the urethral walls decrease, urothelium atrophies, mucus production decreases, vascularization of connective tissue and detrusor trophic worsens. The supporting structures are negatively affected – the pelvic floor muscles become flabby, the ligamentous apparatus loses strength, which leads to the lowering of the vaginal walls and the development of a cystocele.
As a result of these changes, maintaining the balance between intravesical and urethral pressure under stress is disrupted, involuntary loss of urine occurs. The condition is aggravated by the addition of neurogenic disorders (hyperactive bladder), expressed in an involuntary reduction of detrusor and caused by a decrease in the number of adrenoreceptors, increased sensitivity of the atrophic urothelium to the pressure of minimal urine volumes, a change in the position of the pelvic organs.
Classification
There are three most common forms of incontinence: stress (stress incontinence), urgent (urge incontinence) and mixed. Stress incontinence is associated with a weakening of the supportive apparatus, occurs without an urge with an effort that increases intra-abdominal pressure, occurs in 19-55% of cases. Urgent incontinence is detected in 11-20% of patients, due to a violation of nervous regulation, while involuntary urination occurs under the influence of imperative urge. 30% of patients have a mixed form of the disorder with the presence of both components. According to the severity of symptoms, the division according to D. V. Kan (1978) is most often used into three degrees of stress-type pathology:
- Mild. The loss of urine is insignificant (calculated in a few drops), it is detected only with a sharp intense increase in intra–abdominal pressure – cough, heavy physical exertion.
- Moderate. Involuntary urination is noted even with small loads – walking, lifting a small weight.
- Heavy. Control over urination is practically lost, urine loss occurs at rest, the bladder can empty completely.
There are also generally accepted classifications of the International Society for Urinary Incontinence. According to the division according to the severity of anatomical disorders, there are 4 types of incontinence, depending on the degree of omission of the bladder at rest and under stress. According to the daily volume of lost urine, it is recommended to allocate 4 stages: I – up to 2 ml, II – 2-10 ml, III – 10-50 ml, IV – over 50 ml.
Symptoms
Menopause incontinence develops gradually, sometimes immediately with the onset of menopause, but more often after 2-5 years. The precursors of pathology are usually sensory signs of urogenital syndrome: a feeling of dryness and burning in the area of the external genitalia, increased urge to urinate during the day with the separation of small portions of urine (pollakiuria), soreness in the lower abdomen, pain in the urethra during urine discharge (cystalgia), increased nighttime urge (nocturia). At first, these manifestations are not accompanied by a loss of control over urination, incontinence joins later.
In the initial stages, symptoms of stress incontinence are observed, drip loss occurs due to strong tension – lifting a heavy load, running, strong coughing, sneezing and laughing. Over time, episodes are repeated with less stress, for example, when walking calmly, during sexual intercourse. The volume of lost urine increases. As the disease progresses, the symptoms of urgent incontinence are added – a sudden “urgent” desire to urinate, which arose spontaneously or under the influence of a provoking factor (for example, physical exertion), leads to urination, despite attempts to restrain the contraction of the bladder.
Complications
Menopause incontinence worsens the quality of life of mature and elderly women in both physical and psychological aspects. With a disorder of moderate severity, the quality of life decreases by 16%, with severe forms – by 70%. Constant irritation with urine leads to inflammation of the skin of the perineum, as a result of the spread of infection through the urothelium, recurrent urethritis, cystitis develop, with the ascending nature of the process – pyelonephritis. Chronic urinary tract infection is observed in 87% of women suffering from moderate to severe incontinence. Urine leakage is accompanied by an unpleasant smell and wet clothes, which leads to forced social isolation of patients, often contributes to the development of depression.
Diagnostics
Diagnostic measures are carried out by a urogynecologist or jointly by a gynecologist and a urologist. In the course of research, the cause and severity of the pathological condition are being clarified. Differential diagnosis of urinary incontinence during menopause is carried out with involuntary urination with dislocation of the bladder that occurred before menopause, neurological pathologies, urinary tract infections, bladder cancer, urolithiasis and urinary fistulas. Mandatory methods of examination of women with urinary incontinence include:
- Collecting anamnesis. The analysis of the patient’s survey data allows us to draw conclusions about the type of incontinence, the severity of the pathology. For an objective assessment of the condition and observation of the dynamics, the patient is recommended to keep a urination diary.
- Gynecological examination. Maceration of the skin of the perineum, involuntary urination during a cough test and a Valsalva test objectively confirm urinary incontinence. According to the signs of atrophy of the mucous membranes of the urogenital tract (thinning of the epithelium, dryness, bleeding of the mucous membranes), an estrogen-deficient nature of the disorder can be assumed. Displacements of the bottom of the bladder relative to the pubic joint, cystocele, urethrocele indicate a violation of urination due to weakening of muscles and ligaments.
Bacterial urine culture is performed to exclude infection. In order to clarify the functional state of the urinary tract and differential diagnosis, pelvic ultrasonography, urethrocystoscopy and urodynamic research methods are recommended. If neurogenic dysfunction is suspected, a neurologist’s consultation is required.
Treatment
Treatment is carried out by a urogynecologist. Conservative therapy is effective in moderate and mild pathology. The correction of menopause incontinence is carried out pharmacologically and by electromagnetic action on the neuromuscular apparatus. Surgical intervention is indicated in case of ineffectiveness of other methods of stress incontinence with pronounced omission of urinary organs. Before correction, it is recommended to use individually selected sanitary pads. The following methods can be used during treatment:
- Drug therapy. The main method of treating stress urinary incontinence during menopause is estrogen replacement therapy. With a mixed form of incontinence, M-cholinolytics, α-adrenomimetics and antidepressants are additionally prescribed.
- Physical therapy. To strengthen the supporting apparatus of the pelvic floor, improve blood supply to the pelvic organs, restore the tone of the closing mechanism of the urinary system, physical therapy (Kegel, Yunusov, Atabekov gymnastics) is used. For the same purpose, electromyostimulation of the perineal muscles is used.
- Urogynecological pessaries. Recommended for the treatment of incontinence due to genital prolapse. Devices of various shapes are installed in the vagina to fix the organs of the urogenital tract in a normal position.
- Extracorporeal magnetic and electrical stimulation. They are shown in order to restore innervation, normalize the functions of the closure apparatus.
- Injection therapy. It is prescribed for mild forms of stress incontinence. It provides for the introduction of volume-forming drugs into the paraurethral region in order to compress the urethra and increase intraurethral pressure.
- Surgical treatment. The simplest and most effective intervention is loop urethropexy (sling operations). In case of incontinence associated with severe genital prolapse, surgical reconstruction of the pelvic floor is performed.
For any type of incontinence, a diet is prescribed with a restriction of the amount of liquid consumed, drinks and food that irritate the urinary tract – alcohol, coffee, carbonated water, salty, spicy. Additionally, bladder training is carried out, aimed at “planned” urination.
Prognosis and prevention
With mild forms of incontinence, adequate conservative treatment can achieve good results in 42-82% of cases. Sling operations eliminate the problem in 90% of patients, but 6-30% have relapses. The success of treatment largely depends on the timing of its start. Some methods are effective for the prevention of incontinence: it is advisable to do physical exercises in premenopause, and replacement therapy is better to start with sensory manifestations of urogenital syndrome. Preventive measures also include the fight against excess weight, timely treatment of diseases of the gastrointestinal tract and respiratory tract, stabilization of blood glucose levels in diabetes mellitus.