Urogenital disorders in menopause

Urogenital disorders in the climacteric period is a symptomatic complex of secondary complications associated with the development of atrophic and dystrophic processes in estrogen-dependent tissues and structures of the lower third of the genitourinary tract: bladder, urethra, vagina, pelvic ligament apparatus and pelvic floor muscles.

Epidemiology

Urogenital disorders in 30% of women appear to 55 years and in 75% - to 70 years.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Pathogenesis

It is necessary to examine for the presence of urogenital atrophy of all women in the climacteric period, since the pathogenesis of urogenital disorders is due to a deficiency of sex hormones.

[10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20]

Symptoms of the urogenital disorders in menopause

Symptoms of urination disorders that worsen the quality of women's life are related to urogenital disorders in the menopause, if they coincide with the onset of menopause by the time of their onset.

• Syndrome of mandatory violations of urination in the climacteric period - a combination of frequent day and night urination, mandatory urge to urinate with or without urine incontinence against the background of vaginal atrophy.
• Stress incontinence (urinary incontinence) is an involuntary loss of urine associated with physical stress, confirmed by objective research and causing social or hygienic problems.

Clinically, urogenital disorders are characterized by vaginal and urogenital (symptoms of urination) symptoms.

Vaginal symptoms:

• dryness, itching and burning in the vagina;
• dyspareunia (soreness in sexual intercourse);
• recurrent discharge from the genital tract;
• contact bleeding;
• omission of the anterior and / or posterior walls of the vagina.

Urination disorders:

• pollakiuria (frequent urination - more than 6 times a day);
• nocturia (any awakening at night for urination without predominance of night diuresis over daytime);
• cystalgia (frequent painful urination in the absence of objective signs of a bladder injury);
• urinary incontinence;
• imperative urge to urinate with or without urine.

Forms

Urogenital disorders are classified by severity.

• An easy degree: the symptoms of vaginal atrophy are combined with pollakiuria, nicturia and cystalgia.
• Moderate: symptoms of vaginal and cystourethral atrophy are accompanied by urinary incontinence under stress.
• Severe symptoms are characterized by a combination of symptoms of vaginal and cystourethral atrophy, stress urinary incontinence and / or urinary incontinence syndrome.

[21], [22], [23], [24], [25], [26]

Diagnostics of the urogenital disorders in menopause

• pH of the vaginal content: varies from 6.0 to 7.0.
• Colposcopy: thinning of the vaginal mucosa with unevenly weak coloration of Lugol's solution, extensive capillary network in submucosal layer.
• The index of vaginal health is from 1 to 4.
• Complex microbiological investigation (culture diagnostics and microscopy of smears of vaginal discharge, stained by Gram). In the culture study, the species and quantity composition of the vaginal microflora is determined, and the microscopic examination evaluates the following criteria:
  • the state of the vaginal epithelium;
  • presence of leukocyte reaction;
  • composition of vaginal microflora (qualitative and quantitative characteristics of morphological types of bacteria).
• Magnetic resonance imaging.

In the presence of symptoms of cystourethral atrophy, an additional assessment is necessary:

• diaries of urination (frequency of daytime and nighttime urination, loss of urine under tension and / or with urgent urge to urinate);
• data of a complex urodynamic study (physiological and maximum bladder volume, maximum urinary flow rate, maximum urethral resistance, urethral resistance index, presence or absence of sudden upsurge of urethral and / or detrusor pressure). To assess the intensity of urogenital disorders, it is recommended to use a 5-point scale D. Barlow (1997):
  • 1 point - minor disorders that do not affect the daily life;
  • 2 points - discomfort, periodically affecting daily life;
  • 3 points - expressed relapsing disorders affecting everyday life;
  • 4 points - the expressed frustration influencing an everyday life from day to day;
  • 5 points - extremely pronounced disorders, constantly affecting everyday life.

[27], [28], [29], [30]

Differential diagnosis

Differential diagnosis of urogenital disorders is carried out with the following diseases:

• specific and nonspecific vaginitis;
• cystitis;
• diseases that lead to a violation of the innervation of the bladder;
• diabetes mellitus;
• encephalopathy of various genesis;
• diseases or injuries of the spine and / or spinal cord;
• Alzheimer's disease;
• Parkinson's disease;
• violation of cerebral circulation.

Indications for consultation of other specialists

• Urologist: signs of chronic cystitis, episodes of urinary retention.
• Neuropathologist: diseases of the central and / or peripheral nervous system.

[31], [32], [33], [34], [35], [36]

Treatment of the urogenital disorders in menopause

The goals of the therapy are to reduce the symptoms of vaginal and cystourethral atrophy in order to improve the quality of life of women in the climacteric period.

Indications for hospitalization

Hospitalization is indicated for patients with urinary incontinence under stress for surgical treatment.

Non-drug treatment

Use of biological feedback and electrostimulation of the pelvic floor muscles.

Drug therapy

With urogenital disorders, pathogenetic systemic and / or local hormone replacement therapy is performed. Schemes of system HRT are described in detail above.

Local therapy is performed if the patient is unwilling to receive systemic therapy or having contraindications to systemic therapy.

Combined (systemic and local) therapy is indicated with insufficient effectiveness of systemic therapy.

In the presence of the syndrome of imperative disorders of urination, additionally, drugs that exert spasmolytic effects on detrusor, which normalize the tone of the bladder and urethra, are also used.

• M-holinoblokatory:
  • oxybutynin 5 mg 1-3 times a day inside before meals, or
  • Tolterodin 2 mg twice a day, or
  • trospium chloride 5-15 mg in 2-3 divided doses.
• α-adrenoblockers (with infravesical obstruction):
  • tamsulosin 0.4 mg once a day inside after breakfast, or
  • terazosin 1-10 mg once a day inside before bedtime (taking the drug starting at 1 mg / day and gradually increasing the dosage to the desired result, but not more than 10 mg per day under the control of blood pressure).
• α1-adrenomimetics increase the tone of the urethra and neck of the bladder, they are used in the treatment of stress urinary incontinence:
  • midodrin 2.5 mg 2 times a day inward, a course of 1-2 months.
• M-holinomimetiki increase the detrusor tone, they are prescribed for hypo- and atony of the bladder:
  • distigmine bromide 5-10 mg once a day in the morning 30 minutes before meals. The duration of therapy is set individually.

[37], [38], [39], [40], [41]

Surgery

In case of stress urinary incontinence, operative treatment is indicated. The most rational and minimally invasive is the operation TVT or TVT-O (imposition of a free synthetic loop under the middle third of the urethra by vaginal access) or the introduction into the paraurethral space of the DAM gel (+).

Prevention

• Maintaining a healthy lifestyle.
• Use of biological feedback and electrostimulation of the pelvic floor muscles.
• The use of hormone replacement therapy with the onset of perimenopause.

[42], [43], [44], [45], [46], [47], [48]

Forecast

The forecast is favorable.

[49], [50], [51], [52], [53], [54]