The Impact of Genitourinary Syndrome of Menopause on Continence

FOCUS

The impact of genitourinary syndrome of menopause on continence

Sarah Hillery, Urology Advanced Nurse Practitioner, Directorate of Urology and General Surgery, York Hospitals NHS Foundation Trust, and BAUN Trustee ([email protected])

ost women approaching the majora/minora, clitoris, vestibule/ (UTI) from the resultant post-void residual. menopause are only too aware introitus, vagina, urethra and bladder. The aetiology of recurrent urinary tract of the possibility that they can The syndrome may include but is infection in postmenopausal women is, look forward to mood swings, not limited to genital symptoms of of course, multifactorial. Not only does Mhot flushes, night sweats and reduced libido dryness, burning, and irritation; sexual the presence of retained stale urine provide (Sassarini and Lumsden, 2015). What is not symptoms of lack of lubrication, a reservoir for infection, but the protective always so commonly appreciated is the effect discomfort or pain, and impaired effects of vulvovaginal oestrogenisation of the hormonal changes on the woman’s function; and urinary symptoms of are lost. urogenital tract. urgency, dysuria and recurrent urinary These effects include a reduction in Oestrogen receptors are found in tract infections.’ the acidity of vaginal fluid and with it the abundance in the urethra and urinary population of healthy Lactobacillus bacteria. bladder, vagina and structures of the pelvic Evidence has shown that about 7 in 10 As the environment increases in pH, the floor (Alperin et al, 2019). As the woman’s women have symptoms of GSM, but only 7 bacteria that are are usually kept in check oestrogen levels decline, the epithelial cells in 100 women will attain effective treatment by competition with Lactobacillus are of the vagina also degenerate, with the loss (Nappi and Kokot-Kierepa, 2012). allowed to proliferate, causing infection and of elastin, collagen and subcutaneous fat, all irritation (Ghandi et al, 2016). Furthermore, of which affect the integrity and robustness Effects on continence devascularisation of the area further inhibits of the vulvovaginal tissues. Objectively, the Urological complications of GSM (Box 1) the woman’s innate immunological response woman may experience dryness, irritation may include reduced blood supply to to infections, making them much harder to and skin tightness in and around the vagina. the bladder trigone, leading to irritative clear up without intervention. Interestingly, In years gone by this phenomenon was bladder symptoms (Ghandi et al, 2016). The cigarette smokers are more likely to develop known as ‘atrophic vaginitis’. The term correlation of overactive bladder symptoms GSM, possibly due to microvascular changes described the external physiological signs with increasing age in women evidences this of the urogenital structures (Sousa, 2017). of oestrogen deficit, but failed to effectively effect well (Ellsworth et al, 2013). Similarly, articulate the full spectrum of genitourinary decreased vitality, plumpness and plasticity of Identifying GSM in practice symptoms that evidence now shows are the urogenital tissues increase the risk of stress Understandably, many women feel concomitant with menopause. incontinence by affecting urethral support. embarrassed to discuss their vulval and In order to reflect the greater Urinary frequency, urgency and nocturia genitourinary symptoms with healthcare understanding of the effects of oestrogen can have a huge impact on quality of life for providers and, consequently, to seek help. This withdrawal on the urogenital tract, the many women. is compounded by the fact that menopause is Vulvovaginal Atrophy Terminology Consensus Another significantly troublesome effect universally viewed as a natural and inevitable Conference Panel agreed in 2014 to adopt of GSM on continence is the increased event. However, the fact that it is inevitable the term genitourinary syndrome of likelihood of urethral and vaginal prolapse. does not mean it is OK for a women to suffer menopause (GSM) (Portman et al, 2014): As the vulvovaginal skin tightens and retracts, the secondary effects. the urethral meatus may begin to expose Careful questioning and examination can ‘Members of the consensus conference the delicate inner urethral lining, which help identify women who have symptoms of agreed that the term genitourinary then becomes highly irritated causing pain GSM in many clinical settings. Continence syndrome of menopause (GSM) and bleeding as a urethral caruncle develops nurses have a particularly important role in is a medically more accurate, all- (Hum and Dytoc, 2017). Urethral prolapse facilitating discussions about vulvovaginal encompassing, and publicly acceptable is a risk factor for voiding difficulties, as is symptoms in relation to continence, but term than vulvovaginal atrophy. the converse presentation where the urethral any nurse caring for a woman who is post- GSM is defined as a collection of meatus retracts into the anterior vaginal wall. menopause with continence problems can symptoms and signs associated with Cystocele, urethrocele and rectocele again help her patient to overcome the barriers of a decrease in estrogen and other sex increase the risk of voiding difficulty, along embarrassment and shame in order to seek

342 British Journal of Nursing, 2020, Vol 29, No 6 FOCUS

Useful screening questions may include asking the patient if she experiences any Box 1. Urological signs, symptoms and complications of genitourinary syndrome of menopause problems of the vulval or vaginal skin. Dryness or soreness, itching, burning or ■■ Frequency ■■ Meatal stenosis irritation may all indicate that GSM is a ■■ Urgency ■■ Cysticele and recticele ■■ Post-void dribbling ■■ Urethral prolapse feature of the patient’s presentation. Women ■■ Nocturia ■■ Urethral atrophy undergoing aromatase inhibitor therapy, ■■ Stress/urgency incontinence ■■ Retraction of urethral meatus inside vagina chemotherapy, radiation or some surgical ■■ Dysuria associated with vaginal voiding treatments for breast cancer, or gynaecological ■■ Haematuria ■■ Uterine prolapse cancers, are particularly vulnerable to ■■ Recurrent urinary tract infections ■■ Urethral polyp or caruncle ■■ Ischaemia of vesical trigone developing vulvovaginal symptoms relating to GSM (Lester et al, 2015). Source: Gandhi et al, 2016 Physical examination findings include pale vaginal mucosa, shrinking of labia or Box 2. Case study tightened and shortened vaginal introitus, A 67-year-old woman was referred to the hospital found to have fused almost completely, sparing making internal examination difficult or continence clinic for assessment and investigation only an 8 mm aperture that allowed for urine impossible (Box 2). Some cases of GSM of recurrent urinary tract infections (UTI) and drainage. The tissue was so tightly adhered that may be so severe that labial fusion makes incomplete voiding. She had previously been no visualisation of the inner vulval structures full examination impossible. Cases such as diagnosed with a persistent post-void residual was possible. these should be screened carefully for lichen volume of 200 ml, but had not been examined. The patient was immediately referred to The refferal requested that the patient be taught gynaecology where division of adhesions, sclerosus and malignancy. intermittent self-cathterisation in order to manage cystoscopy and full examination under anaesthetic post-void residuals and therefore mitigate were undertaken. Biopsy was taken for histological Treatments for GSM further infections. analysis and the patient was prescribed topical The benefits of topical oestrogen therapy, The patient herself was unaware of being oestrogen therapy. including creams, rings and pessaries, are unable to void to completion, but did describe She eventually made a full recovery, where some minor itchiness of the vulval skin tissues. her voiding difficulties and recurrent UTI were well documented and can offer reliable On examination, the patient’s labia majora were completely resolved. symptomatic relief for women. Their use in mitigating recurrent UTI has increased in popularity, in addition to aiming to reduce risk of, or who have had, breast cancer. Ellsworth P, Marschall-Kehrel D, King S, Lukacz E. bladder and pelvic pain. It is an incorrect A range of other non-hormonal topical Bladder health across the life course. Int J Clin Pract. 2013;67(5):397–406. https://doi.org/10.1111/ assumption that women taking systemic treatments such as lubricants and lidocaine- ijcp.12127 oestrogen therapy (hormone replacement containing preparations may also provide Gandhi J, Chen A, Dagur G et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, therpay (HRT)) cannot have topical symptomatic relief. Laser vaginal treatments pathophysiology, etiology, evaluation, and management. oestrogens concurrently. that promise restoration of healthy vaginal Am J Obstet Gynecol. 2016; 215(6): 704-711. https:// doi.org/10.1016/j.ajog.2016.07.045 These women may safely be prescribed tissues by promoting collagen growth may Hum M, Dytoc M. A dermatologist’s approach topical oestrogen therapy. Historically, there prove useful in time, but these are not yet to genitourinary syndrome of menopause. J has also been concern surrounding the safety available in NHS care settings. Cutan Med Surg. 2017;21(5):418-424. https:doi. org/10.1177/1203475417708165 of topical oestrogens in women who have Lester J, Pahouja G, Andersen B, Lustberg M. Atrophic had breast cancer. Currently, the only explicit Conclusion vaginitis in breast cancer survivors: a difficult survivorship issue. J Pers Med 2015;5 (2): 50–66. situations in which topical oestrogens should Much progress has been made in recent https://doi.org/10.3390/jpm5020050 be avoided are ‘… active breast cancer and years in the overall understanding of the Nappi RE, Kokot-Kierepa M. Vaginal Health: Insights, Views & Attitudes (VIVA)—results from an also undiagnosed vaginal or uterine bleeding’ menopause and its broad-reaching effects international survey. Climacteric. 2012; 15(1):36-44. (Williams and Lustberg, 2019). Because on women. By, essentially, rebranding the https://doi.org/10.3109/13697137.2011.647840 the amount of active ingredient absorbed urogenital effects as ‘genitourinary syndrome Portman DJ, Gass ML; Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary systemically is so tiny, the absolute risk of of menopause’ the aim is to enable health syndrome of menopause: new terminology for increased circulating oestrogen remains professionals to more readily identify vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the very small. reversible bothersome symptoms and offer North American Menopause Society. Menopause. Although topical oestrogens continue treatment, where possible. 2014; 21(10);1063-1068. https://doi.org/ 10.1097/ GME.0000000000000329 to provide the mainstay of treatments for It is hoped that, in so doing, health Sassarini J, Lumsden MA. Oestrogen replacement in GSM, other treatments may prove useful in professionals may also convey to all postmenopausal women. Age Ageing. 2015;44(4): 551– 558. https://doi.org/10.1093/ageing/afv069 combating GSM. These include prasterone, women that they no longer need suffer in Sousa M, Peate M, Jarvis S, Hickey M, Friedlander M. which applied to the vagina assists in the silence with embarrassing and debilitating A clinical guide to the management of genitourinary synthesis of oestrogen to relieve vaginal menopause-related continence problems. BJN symptoms in breast cancer survivors on endocrine therapy. Ther Adv Med Oncol. 2017;9(4):269-285. tightness and shrinkage. Ospemifene is an oral https://doi.org/10.1177/1758834016687260 medication that has found some success in Alperin M, Burnett L, Lukacz E, Brubaker L. The mysteries Williams NO, Lustberg MB. Time for action: managing of menopause and urogynecologic health: clinical genitourinary syndrome of menopause. J Oncol Pract. treating some symptoms of GSM, but this is and scientific gaps. Menopause 2019; 26(1): 103–111. 2019;15(7):7:371-372. https://doi.org/ 10.1200/

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