Have you ever tried to put a square peg in a round hole?

No matter how hard or straight that peg is, it’s not going to fit. It won’t fit even if the peg is made by Boston Scientific or Coloplast, contains 2 pieces, 3 pieces or is semi-rigid.

Square peg. Round hole.

As urologists we have the unique privilege of being able to take care of all genders. We have proclaimed ourselves the sexual medicine experts, and our field’s encouragement of quality-of-life medicine is the exact thing that drew me in all those years ago.

As a society, the AUA has partnered with the Sexual Medicine Society of North America to publish pioneering guidelines for erectile dysfunction, disorders for ejaculation, testosterone deficiency and priapism.

When a guideline gets published the whole field listens, and a framework is developed for incorporating new standards to urology practices worldwide.

I propose a new guideline: one for Genitourinary Syndrome of Menopause (GSM).

GSM is a relatively new term that was established around 2014 to replace the diagnosis of vulvovaginal atrophy/atrophic vaginitis.¹ Not shockingly, women don’t like to be told their vagina is atrophic, and just as important, the term atrophy doesn’t describe the signs and symptoms of what actually happens to the genitals and urinary tract after hormone withdrawal.

GSM is essential for urologists to understand, diagnose and treat. In fact, I would argue it is essential for urologists to take ownership of this condition as the urinary implications of this disease are quite serious.

Unlike hot flashes and night sweats in menopause which often diminish over time, GSM is a chronic and progressive condition that has the potential to pose significant morbidity to our patients. Think about the 90-year-old nursing home patient with urosepsis. The source of the urosepsis is much more likely from her GSM than her 2 mm nonobstructing stone. And you can bet I would place her on Food and Drug Administration approved vaginal estrogen or prasterone with refills lasting forever.

Without circulating estrogens and androgens there is a loss of collagen and elastin, diminished blood supply, and a loss of an acidic environment which changes the entire ecosystem of the genital and urinary tract. Because of these changes women develop urinary frequency, urgency, dysuria, pelvic pain and recurrent urinary tract infections (UTIs). Additional symptoms include vaginal dryness, dyspareunia and difficulties with desire, arousal and orgasm.²

Approximately 50% of postmenopausal women experience GSM symptoms³ and 10%–15% of women over 60 years old have recurrent UTIs.⁴ Among women who are experiencing GSM symptoms less than 10% are prescribed therapies; this discrepancy between prevalence and treatment is due in part to lack of patient education regarding GSM and the lack of physician initiated assessment.⁵ The urological community has been slow to integrate GSM assessment into its treatment of postmenopausal patients.

A promising development is the 2019 guidance of the American Urological Association; Canadian Urological Association; and Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction to include vaginal estrogen as a prophylaxis for peri- and postmenopausal women with recurrent UTIs to reduce the future UTI risk (Moderate Recommendation; Evidence Level: Grade B).⁶ These treatment guidelines are an important initial step toward the urology community introducing the assessment and treatment of GSM in their clinical practice.

We are the leaders in managing erectile dysfunction and hormone deficiency in men, and the leaders in managing urinary problems in women. If we place penile implants and care about satisfaction outcomes with these devices, we must also start thinking about where that device is often being inserted. No matter the quality of the implant, or the high volume center where it was placed, if the partner suffers from GSM, satisfaction will not be maximized.

If we have guidelines in place for the urological community to screen and manage GSM (it’s the easiest and most rewarding thing I do in my practice) then not only will quality of life improve for both our male and female patients, but calls to your office for urgent urine cultures will dramatically decrease, as will hospital admissions for urosepsis.