Our knowledge regarding the effect of local estrogen on urethral function and continence is limited and somewhat unclear. It is assumed that urethral mucosal changes mimic those occurring in the vagina during local estrogen therapy. Atrophic women with urinary urgency, frequency, and particularly nocturia - in the absence of cystitis or detrusor instability - will typically benefit from local estrogen therapy. Presumably, this is attributable to thickening of the urethral mucosa with resultant improved mucosal coaptation and thus improved sphincteric function. It has been demonstrated in vivo and in vitro that there is increased contraction of the periurethral smooth muscles with estrogen therapy. This is thought to be mediated through alpha-2-adrenoceptors. Both of these effects should positively impact continence. Some studies have shown improvement in urethral function on dynamic ure-thral profilometry during multichannel urodynamics, whereas others have not.6,7 The overall consensus regarding the effects of local estrogen therapy on urethral function is that there is a neovascularization and increased sensitivity to alpha-adrenergic medications. Therefore, local estrogen replacement is an important cofactor in the treatment of a patient with stress urinary incontinence, especially when used in combination with an alpha-agonist medication, such as phenylpropanolamine or imipramine. In our practice, we routinely use local estrogen therapy in patients with any form of pelvic floor dysfunction who are atrophic. However, we rely on other pharmacologic, physiotherapeutic, or surgical therapies as our primary means of addressing underlying continence and anatomic support problems.
We do not believe systemic estrogen replacement therapy has a significant impact on continence status, as seen in multiple previously published studies.
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