Urogenital disorders in menopause

Urogenital disorders in the climacteric period are a symptom 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: the bladder, urethra, vagina, ligamentous apparatus of the small pelvis and muscles of the pelvic floor.

Epidemiology

Urogenital disorders appear in 30% of women by the age of 55 and in 75% by the age of 70.

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Pathogenesis

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

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Symptoms urogenital disorders in menopause

Symptoms of urinary disorders that worsen the quality of life of women are considered urogenital disorders in the climacteric period if they occur at the same time as the onset of menopause.

• Urge urination syndrome in menopause is a combination of frequent daytime and nighttime urination, imperative urge to urinate with or without urinary incontinence against the background of vaginal atrophy.
• Stress urinary incontinence (urinary incontinence due to stress) is an involuntary loss of urine associated with physical exertion, confirmed by objective examination and causing social or hygienic problems.

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

Vaginal symptoms:

• dryness, itching and burning in the vagina;
• dyspareunia (pain during intercourse);
• recurrent vaginal discharge;
• contact bleeding;
• prolapse of the anterior and/or posterior vaginal walls.

Urination disorders:

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

Forms

Urogenital disorders are classified according to severity.

• Mild degree: symptoms of vaginal atrophy are combined with pollakiuria, nocturia and cystalgia.
• Moderate: symptoms of vaginal and cystourethral atrophy are accompanied by stress urinary incontinence.
• Severe forms are characterized by a combination of symptoms of vaginal and cystourethral atrophy, stress urinary incontinence and/or urge urinary dysfunction syndrome.

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Diagnostics urogenital disorders in menopause

• Vaginal pH: varies between 6.0 and 7.0.
• Colposcopy: thinning of the vaginal mucosa with uneven weak staining with Lugol's solution, extensive capillary network in the submucosal layer.
• Vaginal Health Index from 1 to 4.
• Comprehensive microbiological examination (cultural diagnostics and microscopy of vaginal discharge smears stained by Gram). During the cultural examination, the species and quantitative composition of the vaginal microflora is determined, during the microscopic examination, an assessment is made according to the following criteria:
  • the state of the vaginal epithelium;
  • the presence of a leukocyte reaction;
  • the composition of vaginal microflora (qualitative and quantitative characteristics of morphological types of bacteria).
• Magnetic resonance imaging.

If symptoms of cystourethral atrophy are present, it is additionally necessary to evaluate:

• urination diaries (frequency of daytime and nighttime urination, urine loss during straining and/or urgent urination);
• data from a comprehensive urodynamic study (physiological and maximum bladder volume, maximum urine flow rate, maximum urethral resistance, urethral resistance index, presence or absence of sudden increases in urethral and/or detrusor pressure). To assess the intensity of urogenital disorders, it is recommended to use the 5-point scale of D. Barlow (1997):
  • 1 point - minor disorders that do not affect everyday life;
  • 2 points - discomfort that periodically affects everyday life;
  • 3 points - severe recurrent disorders affecting everyday life;
  • 4 points - severe disorders affecting daily life from day to day;
  • 5 points - extremely severe disorders that constantly affect everyday life.

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Differential diagnosis

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

• specific and non-specific vaginitis;
• cystitis;
• diseases leading to disruption of the innervation of the bladder;
• diabetes mellitus;
• encephalopathy of various origins;
• diseases or injuries of the spine and/or spinal cord;
• Alzheimer's disease;
• Parkinson's disease;
• cerebrovascular accident.

Indications for consultation with other specialists

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

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Treatment urogenital disorders in menopause

The goals of 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 stress urinary incontinence for surgical treatment.

Non-drug treatment

Using biofeedback and electrical stimulation of the pelvic floor muscles.

Drug therapy

In case of urogenital disorders, pathogenetic systemic and/or local hormone replacement therapy is performed. The schemes of systemic HRT are described in detail above.

Local therapy is carried out if the patient does not want to receive systemic therapy or if there are contraindications to systemic therapy.

Combined (systemic and local) therapy is indicated when systemic therapy is insufficiently effective.

In the presence of imperative urination disorder syndrome, additional medications are used that have an antispasmodic effect on the detrusor, thus normalizing the tone of the bladder and urethra.

• M-anticholinergics:
  • oxybutynin 5 mg 1-3 times a day orally before meals, or
  • tolterodine 2 mg 2 times a day, or
  • trospium chloride 5-15 mg in 2-3 doses.
• α-blockers (for infravesical obstruction):
  • tamsulosin 0.4 mg once daily orally after breakfast, or
  • terazosin 1–10 mg once a day orally before bedtime (start taking the drug with 1 mg/day and gradually increase the dosage to the desired result, but not more than 10 mg per day under the control of blood pressure).
• α1-adrenergic agonists increase the tone of the urethra and bladder neck and are used in the treatment of stress urinary incontinence:
  • midodrine 2.5 mg 2 times a day orally, course 1–2 months.
• M-cholinomimetics increase the tone of the detrusor, they are prescribed for hypo- and atony of the bladder:
  • distigmine bromide 5-10 mg once a day in the morning orally 30 minutes before meals. The duration of therapy is determined individually.

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Surgical treatment

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

Prevention

• Maintaining a healthy lifestyle.
• Using biofeedback and electrical stimulation of the pelvic floor muscles.
• Use of hormone replacement therapy with the onset of perimenopause.

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Forecast

The prognosis is favorable.

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