Urinary Incontinence And Menopause Changes

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Why does urinary incontinence happen during menopause? 

There are a few different types of urinary incontinence. The type of incontinence will guide what treatment a doctor considers appropriate for a patient who is having bladder control issues. 

Common Types Of Incontinence In Menopause 

There are a few different types of incontinence that can affect the daily life of women during this time. 

Stress Incontinence 

This is a common form of incontinence among menopausal women. It occurs when there is involuntary leakage of urine during activities that put pressure on the bladder. This can include coughing, sneezing, laughing, exercising, or lifting heavy objects. 

Urge Incontinence (Overactive Bladder) 

This type involves a sudden, intense urge to urinate potentially followed by an involuntary loss of urine. 

The bladder muscle contracts at inappropriate times, regardless of the volume of urine in the bladder. 

This bladder dysfunction means loss of bladder control at unpredictable times. So, even if the bladder is not full, the muscles can contract and urine may leak out.

Mixed Incontinence 

Mixed Incontinence is the most common type of urinary incontinence in females. This is a combination of stress and urge incontinence. Women with mixed incontinence experience symptoms of both types of incontinence, such as urine leakage with coughing or sneezing and a sudden, strong urge to urinate that is hard to control. 

Less Common Types Of Urinary Incontinence In Menopause 

There are different types of urinary incontinence that can happen during menopause. Some less common types of urinary incontinence in menopause include functional incontinence and overflow incontinence. In functional incontinence, physical or mental impairments prevent a person from reaching the toilet in time. Overflow incontinence occurs when the bladder cannot empty properly, leading to frequent or constant dribbling of urine. 

How Is Stress Incontinence Different From Overactive Bladder? 

There are some key differences between stress incontinence and overactive bladder. 

Trigger

In stress incontinence, physical movements or activities put pressure on the bladder causing the leakage. On the other hand, overactive bladder is characterized by an overactive bladder muscle causing a sudden urge to urinate.

Type of Incontinence

Stress incontinence involves leakage due to physical stress, whereas overactive bladder is mainly defined by the frequent and urgent need to urinate, which can lead to urgency and leakage. 

Underlying Causes

The causes of stress incontinence are usually related to physical changes affecting the pelvic floor or sphincter, while overactive bladder is related to the function of the bladder muscle and can have a variety of underlying causes. For most overactive bladder the cause is unknown.

Why Does Urinary Incontinence Happen During Menopause? 

The menopause transition can be difficult. Urinary incontinence during menopause may happen partially because of changes in hormone levels, especially a decrease in estrogen. Other contributing factors are aging, pelvic floor muscular weakness and other comorbidities (such as diabetes). 

Estrogen is a hormone that, among other things, helps to keep the bladder and urethra healthy. There are estrogen receptors on the base of the bladder and on the urethra. 

Overactive Bladder And Menopause: The Connection 

Hormonal Changes

Menopause leads to a decrease in estrogen levels. Estrogen helps maintain the strength and flexibility of tissues in the urinary tract and pelvic floor. With lower estrogen levels, these tissues may weaken, and the vaginal tissue may thin and become less elastic. This can contribute to overactive bladder symptoms. 

Physical Changes

During and after menopause, the pelvic floor muscles can weaken. This weakening can affect bladder control, leading to symptoms of an overactive bladder. 

Bladder Sensitivity

Some women may experience increased bladder sensitivity and reduced bladder capacity after menopause, which can lead to more frequent urination and urgency, key symptoms of an overactive bladder. 

Idiopathic Overactive Bladder

Idiopathic means there is no identifiable cause for the overactive bladder.

What Is Overactive Bladder? 

The bladder is the organ in the body which holds urine. In overactive bladder, often called OAB, the nerve signals between the brain and bladder may not work properly. These signals may indicate the need to empty the bladder even when it is not full. 

Some patients may feel the need to go to the bathroom very often, even if their bladder is not full. This is referred to as urinary frequency. 

Sometimes, a patient might feel a sudden and strong need to urinate, which is hard to control. This is called urinary urgency. The patient may not make it to the bathroom in time and can have urinary leakage. This can happen both during the day and at night. This is different from nocturia which is just getting up to use the bathroom at night and not necessarily having leaking.

People with overactive bladder may find this problem really affects their daily life, like making it hard to do normal activities or causing embarrassment. 

Overactive Bladder Risk Factors 

There are different things in a person’s medical history that can put them at higher risk for having overactive bladder. Some of the risk factors below have been previously mentioned.

Idiopathic: Idiopathic overactive bladder is the most common type.

Age: Although overactive bladder is not a normal part of just getting older, the risk of developing overactive bladder increases with age.

Hormonal Changes: Especially during menopause in women. 

Neurological Disorders: Conditions like stroke and multiple sclerosis can contribute to overactive bladder symptoms and would be considered neurogenic detrusor overactivity (NDO). 

Diabetes: This condition can cause overactive bladder. 

Urinary Tract Infections: These can cause symptoms similar to overactive bladder and can lead to the development of OAB. 

Weight Gain: Weight gain can also contribute to OAB.

Bladder Conditions: Such as tumors or bladder stones. 

Obstructions: Factors like constipation, or previous surgery for incontinence can interfere with urine flow 

Medications: Some can increase urine production or require taking them with lots of fluids. 

Excessive Consumption: High intake of fluids, especially bladder irritants like caffeine or alcohol. 

Cognitive Decline: Due to aging, which may affect bladder control. 

Mobility Issues: Difficulty walking can lead to urgency if reaching the bathroom quickly is a challenge.

Incomplete Bladder Emptying: This can lead to little urine storage space, contributing to overactive bladder symptoms. 

Overactive Bladder Treatment Options 

People who have overactive bladder issues can talk to their doctor who can discuss treatment options available to them. These can help manage bladder leakage episodes and and other urinary symptoms associated with overactive bladder. 

The following treatment pathways have been taken from the American Urological Association Guidelines and urologist recommendations on overactive bladder. 

The Doctor May Recommend Behavioral Therapies 

The first step in trying to help urinary incontinence from overactive bladder are the behavioral modifications listed below. 

Pelvic Floor Muscle Exercises (Kegel Exercises): Strengthening the pelvic floor muscles to help control bladder contractions. Having a physical therapist who is well versed in how to improve bladder muscle strength and lack of bladder control would be helpful.

Healthy Weight Maintenance: Weight loss can help ease symptoms, especially if there’s also stress urinary incontinence. 

Scheduled Toilet Trips: Lifestyle changes and adjustments like urinating on a set schedule, rather than waiting for the urge, can help avoid a leakage episode.

Bladder Training & Fluid Management: Delaying voiding when feeling an urge to urinate, gradually increasing the time between urination. Also, avoiding over drinking, but being careful to not become dehydrated.

Limiting Bladder Irritants: Again, lifestyle changes like limiting food and drinks that irritate the bladder like coffee can be helpful.

Absorbent Pads: These are to help protect clothing in patients who have not found a therapy to control symptoms. 

Then, The Doctor May Try Medications 

When lifestyle changes are not providing enough improvement, then medications can be added to lifestyle management.

Vaginal Estrogen Therapy: In post-menopause, this helps to stimulate estrogen receptors on the pelvic floor and bladder which can help to improve symptoms. 

Oral Medications To Relax the Bladder: There are two classes of medications – anticholinergics and beta 3 agonists

• Anticholinergic medications are taken once to 3 times daily, depending on the medication.

• Beta 3 agonists are taken once daily.

If a treatment or the combination of treatments is not working for overactive bladder, then a doctor may consider these minimally invasive treatment options.

• Chemodenervation: A medication that is placed directly into the bladder to help block nerve signals that trigger unexpected wetting.
• Percutaneous Tibial Nerve Stimulation (PTNS): This is electrical stimulation that is placed externally near the ankle which sends impulses up the spine to help regulate overactivity of the bladder. 
• Implantable PTNS: This is a small device implanted near the ankle which sends impulses to the spinal cord to help reduce bladder overactivity. 
• Sacral Nerve Stimulation: This is an implantable device near the upper buttock that   regulates nerve impulses to the bladder, similar to how a pacemaker regulates heart rhythm. 

The doctor will determine which therapies are right for the patient.

In very rare cases with severe, complicated overactive bladder, surgical options are available.

● Surgery to Increase Bladder Capacity: Using parts of the bowel to replace a portion of the bladder.

● Bladder Removal: Removing the bladder and constructing a replacement or an opening in the body to collect urine.

Works Cited:

Cameron AP, Chung DE, Dielubanza EJ, et al. The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder. J Urol. Published online April 23, 2024.

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