Nonhormonal therapy for urinary symptoms in menopause

Urinary symptoms such as urinary frequency, nocturia and urgency, are common in postmenopausal individuals but are under-reported and undertreated. Urinary incontinence becomes more common with age after menopause. For guidance on the assessment of urinary incontinence, including referral indications, see the National Institute of Clinical Excellence Guideline on Urinary Incontinence. This includes determining whether the problem is stress incontinence, urge incontinence or a mixture.

Key factors for achieving continence are lifestyle change and nonhormonal therapies. While intravaginal estrogen can improve urinary symptoms by treating underlying vulvovaginal atrophy and reducing the frequency of recurrent urinary tract infections, it has a limited role in treating incontinence. It may reduce urge incontinence but does not resolve it fully; there is limited evidence for objective benefit in stress incontinence, although some improvement in quality of life is reported.

Weight loss and bladder retraining are first-line therapy for overactive bladder symptoms, including urge incontinence, followed by pharmacotherapy. Oxybutynin is available on the Pharmaceutical Benefits Scheme (PBS) and low doses are usually well tolerated. Transdermal oxybutynin and some drugs that are more selective for receptors in the bladder than other sites (eg darifenacin, solifenacin) are less likely than oral oxybutynin to cause dry mouth, constipation, dry eyes or gastrointestinal symptoms. Mirabegron, a beta-3-agonist, is well tolerated as it avoids anticholinergic effects, but blood pressure must be stabilised before treatment is started and review a week afterwards is advised.

First-line management for stress incontinence is weight loss (in overweight or obese people), fluid management and pelvic floor muscle training. See the Continence Foundation website for general advice on managing incontinence. If symptoms do not respond to pelvic floor exercises and advice on fluid management, surgery may be considered. See also the Care Pathway for the Management and Referral of Urinary Incontinence in Women.

For more information on the management of incontinence, see the Royal Australian College of General Practitioners (RACGP) aged care guideline on urinary incontinence. See the Continence Foundation of Australia for information on resources including a search service for clinics and physiotherapists with expertise in bladder management.