Urinary & Pelvic Health

Why These Issues Arise

Declining estrogen affects urinary and pelvic health significantly. Estrogen supports the health of bladder and urethral tissues, pelvic floor muscles, and vaginal tissue—when levels drop, these structures weaken or become more sensitive.

Types of Urinary Incontinence

1. Stress Incontinence

• Symptoms: Leaking urine with coughing, sneezing, laughing, exercising, or lifting
• Cause: Weak pelvic floor muscles and/or urethral sphincter (often from childbirth, aging, estrogen loss)
• Prevalence: Most common type in perimenopausal women

2. Urge Incontinence (Overactive Bladder)

• Symptoms: Sudden, intense urge to urinate with little warning; may not make it to the bathroom in time
• Cause: Bladder muscle spasms, often worsened by estrogen loss and bladder irritation
• Associated symptoms: Frequent urination (8+ times/day), nocturia (waking at night to urinate)

3. Mixed Incontinence

Combination of stress and urge incontinence—experiencing symptoms of both types.

4. Overflow Incontinence

• Symptoms: Frequent or constant dribbling, feeling like the bladder never fully empties
• Cause: Weak bladder muscle, blockage, or nerve damage (less common in women)

Treatment Options for Incontinence

First-Line: Pelvic Floor Physical Therapy

• Kegel exercises: Strengthen pelvic floor muscles; most effective when taught by a physical therapist to ensure correct technique
• Frequency: 3 sets of 10 contractions daily, holding for 5-10 seconds each
• Success rate: 50-70% improvement in stress incontinence with consistent practice
• Biofeedback: Pelvic PT may use biofeedback or internal devices to help identify and isolate the correct muscles

Behavioral Modifications

• Bladder training: Gradually increase time between bathroom visits to retrain the bladder
• Scheduled voiding: Urinate on a set schedule (every 2-3 hours) to prevent urgency
• Fluid management: Avoid excessive caffeine, alcohol, and carbonated drinks (bladder irritants); don't restrict fluids excessively
• Weight loss: If overweight, losing even 5-10% of body weight can significantly reduce incontinence

Vaginal Estrogen

• How it helps: Thickens and strengthens urethral and bladder tissues, reduces urgency and frequency
• Forms: Cream, tablet, or ring inserted vaginally
• Safety: Minimal systemic absorption; considered very safe even for women who can't take systemic HRT
• Effectiveness: Often improves urge symptoms and recurrent UTIs; less effect on stress incontinence alone

Medications

• For urge incontinence: Anticholinergics (oxybutynin, tolterodine) or beta-3 agonists (mirabegron) relax bladder muscle
• Side effects: Dry mouth, constipation, cognitive effects (especially in older women)
• When to use: If behavioral changes and vaginal estrogen aren't sufficient

Pessaries

A silicone device inserted into the vagina to support the bladder and reduce stress incontinence. Fitted by a gynecologist or urogynecologist; requires regular removal and cleaning.

Surgical Options

• Midurethral sling: Most common surgery for stress incontinence; success rate 80-90%
• Botox injections: For overactive bladder refractory to medications; temporarily paralyzes bladder muscle
• Sacral nerve stimulation: Implanted device for severe urge incontinence not responsive to other treatments

Recurrent UTIs After Menopause

Why Risk Increases

• Vaginal pH changes: Estrogen loss increases pH, reducing protective lactobacilli and allowing harmful bacteria to proliferate
• Tissue thinning: Thinner urethral and bladder lining is more susceptible to infection
• Incomplete bladder emptying: Pelvic floor weakness or prolapse can lead to residual urine, promoting bacterial growth

Symptoms

• Burning or pain with urination
• Frequent, urgent need to urinate
• Cloudy, strong-smelling, or bloody urine
• Pelvic or lower back pain

Prevention Strategies

• Vaginal estrogen: Restores healthy vaginal flora and pH; reduces UTI recurrence by 50%+
• Adequate hydration: Drink 6-8 glasses of water daily to flush bacteria
• Urinate after sex: Helps flush out bacteria introduced during intercourse
• Proper wiping technique: Always wipe front to back
• D-mannose supplement: Some evidence for preventing E. coli UTIs (1-2 grams daily)
• Cranberry products: May help prevent UTIs, but evidence is mixed; choose unsweetened juice or supplements

When to See a Doctor

Treatment

• Antibiotics: Short course (3-7 days) for acute infection; choice based on local resistance patterns
• Preventive antibiotics: Low-dose daily or post-coital antibiotics for recurrent UTIs if other measures fail
• Vaginal estrogen: First-line preventive therapy for postmenopausal women with recurrent UTIs

Pelvic Organ Prolapse

What It Is

Descent of pelvic organs (bladder, uterus, rectum) into or beyond the vaginal opening due to weakened pelvic floor muscles and connective tissue.

Symptoms

• Feeling of pressure or "something falling out" in the vagina
• Seeing or feeling a bulge at the vaginal opening
• Difficulty emptying bladder or bowels
• Urinary incontinence
• Lower back pain

Management

• Pelvic floor PT: Can improve symptoms and prevent worsening
• Pessary: Supports prolapsed organs; effective for many women
• Surgery: For severe cases or if conservative measures fail; multiple surgical options depending on type and severity

Pelvic Floor Physical Therapy: What to Expect

Pelvic floor PT is specialized physical therapy focused on the muscles, ligaments, and connective tissue of the pelvic floor. It's highly effective for incontinence, pelvic pain, and prolapse.

What Happens in a Session

• Assessment: Detailed history, external and often internal vaginal or rectal exam to assess muscle strength, tone, and coordination
• Exercises: Customized strengthening (Kegels), relaxation techniques, and coordination training
• Education: Proper body mechanics, breathing, and strategies for daily activities
• Biofeedback: Visual or auditory feedback to help you engage the correct muscles

How to Find a Pelvic Floor PT

Ask your gynecologist or search the American Physical Therapy Association's directory for certified pelvic floor physical therapists.

The Bottom Line

Urinary and pelvic health issues are common during perimenopause and menopause but are not "just part of aging." Effective treatments exist, from pelvic floor PT and vaginal estrogen to medications and surgery. Don't suffer in silence—talk to your doctor and consider seeing a urogynecologist or pelvic floor PT for specialized care.