Urgency Urinary Incontinence is a Consequence of the Decline in Estrogen Levels after Menopause

Background: Urinary incontinence is a chronically progredient condition that usually begins around in the early forties of life with urine leakage through coughing or sneezing (stress urinary incontinence, SUI). Several years later the patients realize that after the feeling of urge to void they may lose urine when waiting too long (urgency incontinence, UUI). In the beginning of UUI patients can still reach the toilet “dry” if they go immediately after the urge to void, however, within few years the time intervals shorten until loss of urine becomes uncontrollable. That has significant impact on the quality of private and social life. The etiology of UUI is unknown. Therefore, there is no specific therapy for UUI and current treatments are aimed to reduce symptoms. However, previous studies have shown that these patients with UUI could regain continence by the surgical tensioning and elevation of the vagina and the attached trigone of the bladder. That effect was achieved by the replacement of the uterosacral ligaments (USL) by laCESA or laVASA. An additional suburethral tape led to overall continence rates (CR) between 67% and 87% in these patients. Multivariate analyses revealed that the difference in the continence rates (CR) after laCESA and laVASA was dependent on the age of patients at surgery. Patients younger than 60 years had significantly higher CR than the older patients. The CR after a TOT; however, was independent of the age at surgery. It has been hypothesized that this development of incontinence is caused by declining estrogen levels already before and after menopause. Therefore, this study was aimed to test the hypothesis that the increasing urinary incontinence from SUI to UUI was associated with menopause and the time interval after menopause. Material and Methods: All patients were suffering from UUI. The diagnosis and the age at menopause were evaluated in the context of personal interviews. In all patients with UUI, the vagina was elevated and tightened in the longitudinal axis laparoscopically by substituting the uterosacral ligaments (USL) with PVDF-structures of defined length (laCESA, laVASA). If that did not lead to continence, a suburethral tape (TOT 8/4) was inserted some months later. Results: Between 2010 and 2022, 326 patients with UUI underwent the surgical treatment. After previous SUI they had developed UUI after menopause. Patients who got estrogen or estrogen/gestagen combinations before menopause became incontinent after they had discontinued their hormonal treatment. In total, between 56% and 87% of the patients became continent after surgery. The CR after tensioning the vagina by laCESA/laVASA were between 46% and 58% in 50-year-old patients decreasing to 16% and 20% in patients older than 70years. An additional TOT 8/4 led to continence in between 43% and 40% of the still incontinent patients irrespective of their age. Conclusions: In all patients’ urinary incontinence started premenopausally as SUI and continued to UUI after estrogen deprivation, usually after menopause. This continuous worsening of UUI during the years after menopause was probably caused by the estrogen deficiency.