Difficulty in urination is very common in the elderly and is one of the most important factors affecting their health. Previous knowledge of female dyspareunia has focused on female bladder neck obstruction, with little research on the causes of dyspareunia in older menopausal women. Both the female urinary system and the reproductive system originate from the primordial genital sinus of the embryo and are estrogen-dependent organs that are influenced by estrogen during development. Experimental studies have demonstrated the presence of estrogen receptors in the female bladder triangle, bladder mucosa, urethral mucosa or nucleus, while the concentration of receptors in the urethra is significantly higher than that in the bladder. Estrogen is able to selectively act on urothelial cells and maintain the tension of urethral smooth muscle. Thus it seems that estrogen has an important role in maintaining the integrity of the bladder and urethral mucosa and the support of the pelvic tissue in women. Declining estrogen levels inevitably have an effect on the structure of the lower urinary tract, leading to dysfunction. The decline in ovarian function in postmenopausal women and the decrease in estrogen levels in the body cause a decrease in blood supply to the urethral mucosa, resulting in mucosal atrophy, thinning of the elastic fibers around the urethra, and the appearance of urethral mucosal hyperplasia (urethral meatus). In our group, three cases over 80 years of age presented with severe constriction of the urethrovagina, retreat of the urethral orifice into the posterior pubic bone, and urinary retention, which also created difficulties for catheter placement. With aging, the bladder forced urinary muscles also appear to age, and the incidence of idiopathic forced urinary muscle instability increases significantly, with diminished contractile function. At the same time, recurrent urinary tract infections often occur due to poor urinary drainage, and antibiotic treatment is often not effective when applied. This group of cases shows that the diagnosis of dyspareunia in elderly women is mainly based on medical history, physical examination, urodynamic examination, and ultrasound of the bladder. Exogenous factors such as urethral caruncle and urethral diverticulum are one of the causes of dyspareunia, moreover, urethral caruncle does not require surgical treatment when it does not obscure the external urethral opening. Bladder outlet obstruction is another cause, and transurethral surgery can be a good cure for this condition. Bladder outlet obstruction was found in only 8% of the cases in this group. While most of the cases in this group (81% of cases) were suspected obstruction and impaired contraction of the detrusor muscle. Urethral manometry revealed abnormally high mid-urethral resistance in all cases, and most of these cases were combined with age-related vaginitis. Estrogen supplementation can effectively treat postmenopausal elderly women with urethritis by reversing urethral atrophy and increasing urethral endurance, which can effectively relieve urinary symptoms and also effectively treat senile vaginitis. However, estrogen alone cannot rapidly improve the symptoms of dyspareunia. Urethral dilatation to reduce urethral resistance combined with local application of estrogen as an adjunct to treatment can be very effective. Urethral caruncles need to be surgically removed only when they significantly cover the urethral orifice. Moreover, estrogen has a very good therapeutic effect on urethral caruncle. In this group, two patients with no significant relief of urinary frequency symptoms after treatment were found to have unstable bladder by urodynamic examination. one patient had urethral pressure less than 40 cmH2O and bladder pressure at 40 cmH2O during urination, which had reached dynamic equilibrium and no further treatment was done. In conclusion, the causes of dyspareunia symptoms in middle-aged and elderly menopausal women are mainly caused by the decrease in the estrogen level of the body and histological changes in the vaginal urethra. In targeted treatment, urethral dilatation combined with estrogen topical treatment can rapidly improve the symptoms and relieve the patient’s pain. If bladder neck obstruction, urethral diverticulum or urethral meatus is found to affect urination, surgical treatment is required first.