Monday, October 13, 2014

How to deal with urinary problems at menopause?

Menopause and urinary symptoms at a glance:

·         Changes in a woman’s urinary function often accompany menopause. A primary cause is urogenital atrophy, which is the deterioration of the urinary tract and vagina.

·         These urinary changes occur for two reasons: Menopause reduces the amount of the female hormone estrogen, and a lack of estrogen reduces the urinary tract’s ability to control urination. Advanced age, which usually coincides with menopause, also has various debilitating effects on the pelvic area organs and tissues.

·         Symptoms include the need to urinate more frequently, the inability to control urination (incontinence), dryness and itching in the vagina, and increased urinary tract infections.

·         Frequent urination is the need to urinate more than you normally would. The urge can strike suddenly and can cause you to lose control of your bladder. It can feel uncomfortable, like your bladder is extremely full. This is also referred to as having an overactive bladder. According to a 2009 study, urinating every two hours or more is considered to be frequent urination.

·         Treatments vary and include dietary changes, strengthening exercises, topical estrogen for the vagina, and surgery.

·         In this post, we will review the causes, other than urinary tract infection, which has been already separately reviewed in one of the previous posts:

Causes of menopausal urinary symptoms

When menopause occurs, estrogen production is reduced, which is the major cause of urogenital atrophy. Atrophy means a wasting away of muscle mass, and urogenital atrophy involves atrophy of the vagina as well as atrophy of the urinary tract.

The lack of estrogen weakens the bladder (which holds urine) and the urethra, the tube that carries urine out of the body, compromising their ability to control urinary functions. Reduced estrogen also alters the acidity of the vulva and the vagina, which can make the area more prone to infection by bacteria or yeast overgrowth.

Menopausal urinary symptoms can also be caused by pelvic organ prolapse, in which one or more organs of the pelvic area drops down into the vagina. This can be due to stress from vaginal childbirth that becomes evident after menopause. Such stress may also cause damage to pelvic floor muscles, also resulting in urinary problems. Whether specific urinary symptoms are related to menopause, aging or a combination of the two is the subject of continuing study.

Menopause urinary symptoms

Symptoms associated with urogenital atrophy can range from minor inconveniences to emotional distress. Unlike other symptoms of menopause, such as hot flashes, urogenital atrophy symptoms can become worse as the woman ages.

The most common urinary tract problem that urologists see in their offices are women with frequency of urination and the severe urge to urinate, a non-ending feeling of a fullness of the bladder. Many of these women tell horror stories about having to go to the bathroom every 15 minutes, 30 minutes or an hour. Everyday. And many women say they do not even make it to the bathroom, causing not only embarrassing social moments, but psychological pain as well.

Many women have had multiple tests, x-rays, drugs, urethral stretching (dilatation) and still continue with this major annoyance. While most cases are not serious, and not life-threatening they are life-style threatening. It is often embarrassing, uncomfortable, a major nuisance, and affects activities of daily living. The first stop is a health care professional.

Symptoms related to urinary atrophy are:
·         Stress incontinence: the leaking of urine due to the stress of laughing, coughing or sudden movement
·         Urge incontinence (irritable/overactive bladder): the sudden, strong urge to urinate, which can result in a loss of bladder control before one can reach a bathroom.
·         Overflow Incontinence - two seemingly opposite problems: the bladder does not empty sufficiently (either due to a weak bladder muscle or a non-relaxing urethra), while experiencing leakage when the bladder becomes so full that urine is forced to leak out.
·         An increased frequency in the need to urinate
·         Waking up several times during the night to urinate (nocturia).

Symptoms related to vaginal atrophy are:
·         A reduction in the fullness of the vulva and the vagina
·         Dryness, itching and burning in the vagina or on the vulva
·         Pain during sexual intercourse
·         Vaginal bleeding
·         An increase in urinary tract infections due to a change in the acidity of the vagina.

Urinary symptoms of pelvic organ prolapse are urge incontinence and painful urination.

Hormonal treatments

As lack of estrogen is the primary cause of urogenital atrophy, the treatments for it in postmenopausal women involve hormone therapy (HT). These can help restore the vagina to premenopausal condition and relieve many symptoms of urogenital atrophy.

Systemic HT (taken orally and affecting the whole system) may reduce the urinary symptoms of urgency, frequency, nocturia and painful urination, but there is continuing debate about the effectiveness of systemic HT in treating urogenital atrophy.

Local estrogen, applied externally, is helpful in relieving the symptoms of urinary urgency, frequency and stress incontinence, and can also help prevent urogenital atrophy and the recurrence of urinary tract infections.

The most common treatment for vaginal atrophy symptoms is low-dose vaginal estrogen replacement, utilizing creams, tablets or vaginal rings.

However, some women are not able to have HT for any menopausal urinary symptoms such as women with breast cancer. For symptoms of vaginal atrophy, they can use vaginal moisturizers for normal relief and vaginal lubricants to relieve dryness prior to intercourse.

Behavioral Modification

Behavioral modification can be very effective in managing overactive bladder symptoms, including urinary urgency, frequency, and urgency incontinence. The goal of behavioral modification is to retrain the bladder and to help you regain control over how often you need to urinate.

Another important aspect of treatment is fluid and dietary management. Remember—what goes in, must come out! Therefore, drinking large amounts of fluids or drinking frequently may cause you to void more frequently. Most women should drink eight 8-ounce glasses of fluid per day (64 ounces total). If you are having problems with urinary frequency, try to drink smaller amounts of fluids spread out evenly throughout the day. Water or milk are the beverages of choice.

Drinks that contain a lot of acid (e.g. carbonated beverages, coffee and tea) can irritate the bladder and increase urgency and frequency. Vitamin C (ascorbic acid) is another common bladder irritant and should be avoided.

Non-hormonal Treatments

Non-hormonal treatments for bladder control symptoms, including those related to pelvic organ prolapse and weakening of the pelvic floor muscles, can involve lifestyle changes and medical procedures. These include:

·         Bladder-training techniques that increase the capacity to hold urine, control the timing of urination, and control body functions with the help of a machine (called biofeedback).

·         Acupuncture - an ancient Chinese form of healing that has been used to treat illness for centuries. According to the Journal of Chinese Medicine, acupuncture can help with frequent urination and an overactive bladder in women. Urinary incontinence and frequent urination can potentially be eased by manipulating specific acupuncture points.

·         Maintaining a healthy weight.

·         Constipation can also contribute to frequent urination by putting pressure on the bladder, so increasing your fiber intake to maintain regularity may be helpful.

·         Avoiding stress to the pelvic area and doing Kegel exercises. Kegel exercises strengthen the pelvic floor muscles. These exercises can help control stress urinary continence, urge urinary incontinence, overactive bladder, fecal incontinence and can help slow the progression of vaginal prolapsed. Kegel exercises must be done correctly and regularly to work.

·         Applying pelvic floor therapy. Pelvic floor therapy consists of a series of visits to a physical therapist with specialized training in the treatment of pelvic floor problems. The physical therapist uses a combination of the techniques listed below depending on the type of urogynecological condition present.

·         Electrical stimulation of the bladder muscles. A device that can be used intravaginally or externally that delivers a gentle electrical current to activate or relax the nerves and muscles in the pelvis.

·         Manual therapy: pressure applied to and released from muscles in spasm to relax them and increase blood flow to the area for healing.

·         Joint and tissue mobilization: gentle manipulation to help calm the muscles and nerves of the pelvis.

Overactive bladder medications

There are several brands of overactive bladder medications on the market to treat urge urinary incontinence. These medications work by relaxing the bladder muscle. Side effects are usually mild and include dry mouth, dry eyes, blurred vision, urinary retention, constipation, dizziness or drowsiness. Changing the brand or dose of medication can decrease side effects. The different brands of overactive bladder medications include:
·         (tolterodine tartrate) Detrol
·         (oxybutynin) Ditropan
·         (darifenacin) Enablex
·         (oxybutynin) Oxytrol
·         (trospium) Sanctura
·         (solifenacin) Vesicare

Marijuana and Urinal problems

Several recent studies confirmed the suggestion that that medical marijuana might be very useful for treating urinary disorders such as overactive bladder and urinary incontinence.

In a groundbreaking study published in the May 2012 edition of International Urogynecology Journal, a team of British researchers observed interactions between cannabinoids – the active ingredients of marijuana – and their receptors located on various parts of the bladder. By administering cannabis compounds to human cell lines, they were able to modulate the transmission of outgoing signals that are usually sent from the bladder to the brain – signals involved with the urge to urinate. The research was spurred by a previous study conducted on patients with multiple sclerosis, who reported improvements in their urinary incontinence episodes after being treated with cannabis extracts.

Another older study found that daily treatment with pure THC (Marinol) resulted in a reduction in overactive bladder symptoms in 15 patients with spinal cord injuries. The symptoms of overactive bladder are thought to arise from abnormal signaling between the bladder and the brain, which happen to be the very same signals that were found to be affected by cannabinoids in this study.

Surgical Treatments

InterStim Therapy

InterStim Therapy is an FDA-approved treatment for urinary urgency, frequency, urge incontinence and retention. The InterStim is a small device that is implanted under the skin of one of the upper buttocks. It works by gently stimulating the sacral nerves to help the bladder function more normally.

BOTOX (botulinum toxin type A)

Currently Botox is considered investigational in the management of urge urinary incontinence. It can be very effective in patients with neurogenic bladder or with urge incontinence not responsive to anticholinergic medications.

Sources and Additional Information:

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