Dr. Rachael Sussman, a urologist/urogynecologist at MedStar Georgetown University Hospital, answers our questions about menopause and urinary incontinence.
A Quick Note: Genitourinary syndrome of menopause (GSM) is not commonly discussed. At Let’s Talk Menopause, we want to talk about GSM because 84% of all women will experience it and most symptoms do not resolve if untreated. Women do not need to suffer in silence or embarrassment as there are plentiful treatment options available.
GSM is caused by the decline in estrogen that thins the vulva-vaginal wall, including the urethra and bladder. Symptoms include chronic genital, sexual, and urinary issues such as painful or uncomfortable sex, recurrent UTIs, low libido, vaginal dryness or decreased lubrication, increased urinary leaks, and urgency and/or incontinence.
The most common urinary issues I see are urinary leakage, frequency & urgency, and recurrent urinary tract infections (UTIs). Women should seek care if they are getting frequent UTIs, see blood in their urine, feel they’re urinating too frequently or urgently, are experiencing pain with urination, or leaking urine. Please never accept these conditions as an unavoidable part of being female.
A significant one. There are two types of leakage: stress and urgency incontinence. Stress incontinence happens when you leak because of a movement such as a laugh, a cough, a sneeze, or maybe a trampoline jump! Some women may leak from the simple exertion of moving from sitting to standing. During perimenopause and after, pelvic floor muscles may weaken which makes it more difficult to hold the urine back with a sudden movement.
Urgency incontinence is different. This is leakage associated with an overwhelming urge to urinate that you cannot stop. Women may feel they have to go, usually followed by a dash to the bathroom; leakage may happen right as you get to the bathroom door or begin to pull down your pants. There are estrogen receptors in the walls of the vagina as well as the urethra and the bladder, so when those receptors are less saturated the tissue will feel more irritated (just as it would with thinning, dry skin). This can cause you to feel the need to urinate more often, more urgently, and sometimes cause leakage on the way to the bathroom.
Declining estrogen levels also play a role in recurrent UTIs because when you have less estrogen, the pH balance in the vagina changes. The tissue becomes thin so the cells are not as plumped-up together. In the bladder this allows spaces for bacteria to grow and overpopulate; it also makes the vagina a less favorable environment for the good bacteria that prevent infections (i.e.lactobacillus) and creates a more favorable environment for the bad bacteria that cause urinary infections (i.e. E. coli).
It is not uncommon for a patient to come in and say, “I’m having recurring UTIs, but all of the cultures come back negative.” That is a clear example of GSM. Patients will say, “I feel this constant awareness of my urethra and my bladder that I never felt before.” GSM again. Declining estrogen levels do impact vaginal and bladder health.
No! Urinary leakage does not have to be part of life. I see patients for lots of things such as kidney stones or blood in their urine, but because I’m focused on pelvic health and urinary issues I will ask each patient about their urination, UTIs, and leakage. Not all doctors–even urologists–will do this, but they should. Some women will answer “no” when you ask them if they’re incontinent, but “yes” if I ask them if they ever experience leaks. And because embarrassment is a factor, doctors need to ask as many patients won’t mention it otherwise.
There is such a lack of education about all of the things that can be done to treat urinary issues. Women should not be resigned to feeling that leaking is simply part of the game. So yes, urinary issues do rise with aging and declining estrogen, but leaving these issues undiscussed and untreated is not something women should accept as their fate.
With stress incontinence, the first line of treatment would be pelvic floor exercises to improve muscle strength. Kegel exercises can be done at home, or a patient can opt to work with a pelvic floor physical therapist.
Due to the fact that stress incontinence is a structural problem, treatment options involve procedures not medications. It all comes down to the mobility of a woman’s urethra, ultimately impacting its ability to fully close.
Incontinence inserts, such as the Poise Impressa or reusable incontinence pessaries, work well, especially for women who leak when running or playing sports. These inserts do not absorb liquid like a tampon. Rather, they push against the urethra providing the extra lift it needs to close.
The next layer of care is urethral bulking. Plastic surgeons can put filler in your lips or face to plump them up. Similarly, urologists can put filler in the urethra to narrow it and prevent leakage. This is a great treatment as 80% of patients report a significant reduction in leakage.
Midurethral slings are the mainstream, home-run treatment for urinary incontinence. A sling is a small piece of polypropylene mesh that’s placed under the urethra to provide the support it needs to fully close. They have a 90% success rate and can last for 20+ years.
Urgency incontinence is treated differently from stress incontinence. When looking at treatment options, the first thing to look at is certain known food triggers: coffee, soda, tea, spicy food, acidic food, artificial sweeteners, alcohol, and tobacco.
The next step would be to prescribe vaginal estrogen as it’s effective in treating overactive bladder. Vaginal estrogen differs from hormone replacement therapy (HRT) as it is inserted directly into the vagina. The estrogen does not circulate systematically throughout the body – it remains localized to the vaginal area. It plumps the cells up and reduces the gaps that line the bladder, thus reducing the chance of infection.
After that, it’s really therapies like working on urge suppression, re-wiring or training the brain that the urge to go does not demand the mad dash for the bathroom. It’s a bit like original potty training in that the brain (not urgency) tells the bladder when it’s time to go. With a bladder spasm or sudden urge to urinate, it’s actually better not to run but to, instead, take some deep breaths and do a few quick squeezes of the pelvic floor muscles which can send a signal to your brain to tell your bladder to stop squeezing. Then you can head to the bathroom at a time when it’s more controlled. A good pelvic floor PT can help with these techniques.
It helps to understand normal bladder anatomy– when we feel the urge to urinate what should happen is the bladder senses it is full but it should NOT squeeze. What should happen is that your brain ultimately signals the bladder when there is a good time to go. But in overactive bladder, which may present as urinary urgency, there is a disconnect between the brain and the bladder so that instead of the bladder signaling that it is getting full, the bladder muscle itself begins to squeeze. It goes rogue. This is why it suddenly feels so urgent. That’s how babies urinate before being trained (aka ‘social continence’); it’s just an unthinking reflex. Continence comes from the brain ultimately overriding that reflex to have more control over when and where. As people age, often the brain’s ability to inhibit that reflex declines.
The next step to treat urgency incontinence is medications, and there are two classes from which to choose. The first, anticholinergics, inhibit or block the receptors on the bladder that cause it to squeeze. The second, beta-3 agonists, promote bladder relaxation. Each medication works well alone, but they are sometimes prescribed together to complement one another.
If these medications aren’t ideal for a patient, there are even more options. Botox is one of them. Again, it’s a technique urologists borrow from plastic surgeons. Botox can be used to paralyze the muscles of the bladder. This is a short, in-office procedure, and the results can last from 6 - 9 months. This is a good option for patients who don’t want to take daily medication.
Another option is sacral neuromodulation, in essence a pacemaker for the bladder. This is an FDA-approved technique and is particularly useful in patients who struggle to fully empty their bladder or who experience fecal incontinence as it can help with these issues too.
Another technique is taken from acupuncture. A thin needle is placed into the tibial nerve (near the ankle). Then a small amount of electrical current is applied to stimulate the nerves in the ankle that travel back up to the bladder which helps to “reset" them and results in decreased urgency and urination. Clinical trials show this is effective in treating overactive bladder.
As a doctor, I feel it’s so important to lay out all of these options upfront with patients so they don’t feel disheartened if one method fails to work. There are so many options to effectively treat leaks and incontinence. I encourage patients to work closely with a doctor to find the best method for them.
Rachael D. Sussman, MD, is a urologist/urogynecologist at MedStar Georgetown University Hospital Urology. She focuses on urinary dysfunction, incontinence, pelvic organ prolapse and other pelvic floor disorders. She is an expert in minimally invasive and vaginal surgery.
Dr. Sussman’s philosophy of care is to approach her patients as teammates, working together to ensure that their specific needs, lifestyles, personal preferences, cultures and goals are taken into consideration when deciding on a treatment plan.