Pelvic Discomfort, UTIs and Nocturia

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By Mary Carpenter

WHEN Hilary Mantel died last week, stroke was the immediate cause, but obituaries noted her long, painful history of endometriosis from about age 11 until a hysterectomy in her late 20s. “Endometriosis is what used to be called a female complaint…menstruation run amok,” writes Judith Shulevitz in the Atlantic. “The cells in the lining of the womb that usually bleed out during a period instead grow in other parts of the body.”

Endometriosis arises rarely in postmenopausal women—occurring in only 2 to 5% of those with the condition. Symptoms —digestive complaints, such as constipation, as well as pelvic discomfort—can indicate a 2-3% likelihood of cancer, usually ovarian. But many women have signs of endometriosis without symptoms, and even the cause of the condition is uncertain. Other than as an ongoing condition, endometriosis in those over 65 is most often associated with excessive production of estrogen and with obesity.

Postmenopausal women still, however, need regular gynecological exams —which focus on the entire pelvis: the bladder and rectum, as well as the genital organs. Associated with decreased production of estrogen after menopause, GSM (genitourinary syndrome of menopause) includes recurrent UTIs (urinary tract infections) and UI (urinary incontinence), as well as genital dryness, burning and irritation.

The incidence of UTIs rises “dramatically” with age—occurring in from 15-20% of women aged 65-70. According to British and Polish researchers, “Lack of awareness of the association between recurrent UTIs and GSM may result in multiple unnecessary courses of antibiotic therapy…and altered patterns of antimicrobial drug resistance.”

“Wake to pee” (getting up during the night more than once or twice to pee), or nocturia, is one form of urinary incontinence, which is linked to overactive bladder syndrome (OAB). Another is “urge incontinence,” in which the sensation of needing badly to pee comes on suddenly and strongly. Both conditions have responded well to drug treatment that includes hormone therapy, such as topical vaginal estrogen.

Hormone replacement therapy (HRT) using systemic estrogen as well as estrogen plus progesterone have led to a “significant reduction in prevalence [of nocturia] and its associated bother,” according to Belgian researcher Kim Pauwaert. But Pauwaert believes the effects can “mainly be explained by an impact on sleep disorders and sleep quality” associated with menopause. HRT has also helped counter recurrent UTIs.

Stress incontinence (SUI), the most common type of UI, refers to involuntary loss of urine due to increased intra-abdominal pressure—notoriously in response to coughing, sneezing or laughing. But causes of SUI can include any upright movement, like walking—due to the impact and to weight bearing down on the abdomen—as opposed, for example, to swimming where there is no impact and no weight bearing down. Treatments include Botox injections into the bladder; medications that calm an overactive bladder; and a surgically implanted mesh sling.

But the simplest and usually first-line treatment is usually Kegel exercises that, by strengthening the pelvic floor, can relieve OAB symptoms associated with both kinds of incontinence. Kegel exercises involve squeezing and holding pelvic muscles in a way that both contracts and lifts for several seconds, followed by relaxing for several seconds and then repeating. For women, one suggestion is to picture a straw going into your vagina and contract muscles as if to draw something up the straw.

Alternatively, devices that simulate the exercises can help people who tend to do Kegels incorrectly or insufficiently. Vaginal electrical stimulation (VES), which involves placing thin wires inside the vagina—or in the rear for men—can work better than Kegels to both strengthen pelvic muscles and encourage growth of nerve cells that signal muscle contraction.

The EmSella Chair —sometimes called a “Kegel Throne” – is a vibrating chair “that essentially does Kegel exercises for you — 20,000 reps in a single 30-minute treatment, to be exact,” according to SHAPE. Using the chair in a doctor’s office or clinic costs around $300 per session, usually for six sessions. A similar, older and less costly method uses shots to deliver electrical stimulation—a recommended 30 minutes a day over the course of 12 weeks—that can build stronger pelvic floor muscles, although many patients report unsatisfactory results. Most stimulation methods are not covered by insurance.

Gynecological exams after menopause also check genital organs for cancer. Pap smear screening for cervical cancer, however, is no longer recommended for those over 65 who have had at least three consecutive negative Pap results and no history of advanced precancer diagnosis, according to the U.S. Preventive Services Task Force.

For my part, I haven’t visited a gynecologist since before the pandemic, believing I did not need ongoing checkups. I just made an appointment, both to have a pelvic exam and to discuss nocturia and possibilities for relief. I have tried practical suggestions like restricting liquids for hours before bedtime, however, and am aware that most drug treatments, including estrogen suppositories and sleep aids, have unwanted side effects.

But I should take inspiration from Hilary Mantel, who spent her life ravaged by endometriosis—first from the surgery that removed her womb and ovaries, along with parts of her bladder and bowel; then from unrelenting, debilitating pain due to migraines associated with the condition; and finally from the excessive weight gained as a result of ongoing hormone treatments.

But, writes Shulevitz, Hilary Mantel “worked her experience until it became the corporeal substrate of her fiction. Her magnum opus is made of blood and female bodies.”

—Mary Carpenter regularly reports on need-to-know topics in health and medicine.