Can urinary incontinence be related to genitourinary syndrome of perimenopause?

Urinary Incontinence and Genitourinary Syndrome of Menopause

Yes, urinary incontinence is directly related to genitourinary syndrome of menopause (GSM) and is a common symptom of this condition. 1, 2

Understanding the Connection

Genitourinary syndrome of menopause (GSM) is characterized by a collection of symptoms affecting the genitourinary tract due to estrogen deficiency during perimenopause and menopause. The relationship between GSM and urinary incontinence is well-established:

• Pathophysiology: Estrogen receptors are present throughout the urogenital tissues, including the bladder, urethra, and pelvic floor muscles. Declining estrogen levels during perimenopause lead to:

  • Thinning of urethral and bladder epithelium
  • Decreased urethral closure pressure
  • Changes in pelvic floor muscle tone
  • Alterations in vaginal microbiota 3

• Common urinary symptoms of GSM include:

  • Urinary urgency and frequency
  • Stress urinary incontinence
  • Urge incontinence
  • Recurrent urinary tract infections
  • Dysuria (painful urination) 4, 5

Evidence Supporting the Connection

The 2024 JAMA Network Open guidelines clearly state that topical estrogen is effective for reducing recurrent urinary tract infections in postmenopausal women, addressing a key component of GSM 1. This recommendation is based on evidence from 30 randomized controlled trials and a large retrospective observational study.

Research specifically examining the relationship between menopause and urinary symptoms confirms that vaginal estrogen improves dysuria, frequency, urge and stress incontinence, and recurrent UTI in menopausal women 2.

Treatment Approaches for GSM-Related Urinary Incontinence

First-Line Treatments:

1. Vaginal Estrogen Therapy:

   • Local vaginal estrogen is the most effective treatment for GSM-related urinary symptoms 1, 2
   • Available forms include vaginal rings, inserts, or creams 1
   • Particularly effective for stress incontinence, unlike transdermal patches which may worsen incontinence 1

2. Non-Hormonal Options:

   • Vaginal moisturizers and lubricants
   • Pelvic floor physical therapy for concomitant pelvic floor dysfunction 4

Additional Considerations:

• Methenamine hippurate (1g twice daily) can be considered for recurrent UTIs in patients with GSM 1
• Increased water intake (additional 1.5L daily) may help reduce UTIs in healthy women 1
• Cranberry products containing proanthocyanidin (36mg) may reduce recurrent UTIs in some women 1

Important Clinical Considerations

• Systemic vs. Local Estrogen: While local vaginal estrogen improves urinary symptoms, systemic hormone therapy may actually worsen urinary incontinence 1, 2

• Safety Profile: Local vaginal estrogen has minimal systemic absorption and no concerning safety signals regarding risk of stroke, venous thromboembolism, invasive breast cancer, colorectal cancer, or endometrial cancer 1

• Breast Cancer Patients: Recent evidence supports using vaginal estrogen therapy for breast cancer patients with genitourinary symptoms when nonhormonal treatments fail 1

• Emerging Therapies: Newer treatments being investigated include vaginal DHEA and laser therapy, though the latter requires more robust evidence before widespread adoption 4, 6

Clinical Approach

1. Identify symptoms of GSM including urinary complaints (incontinence, frequency, urgency, recurrent UTIs)
2. Consider vaginal atrophy examination and assessment of pelvic floor function
3. Start with local vaginal estrogen therapy as first-line treatment for GSM-related urinary symptoms
4. Consider additional therapies like methenamine hippurate for recurrent UTIs if needed
5. Monitor response to treatment and adjust as necessary

By addressing the underlying estrogen deficiency with appropriate local therapy, many women will experience significant improvement in both the genital and urinary symptoms associated with GSM.