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Nina Collins
August 2, 2021

The 411 on Female Urology

An Interview with Dr. Angelish Kumar, Founder / MD, NCMP of Women’s Urology New York

Pelvic floor physical therapy is when you go to a physical therapist who has special training in the anatomy and function of the pelvic floor muscles.

Dr. Kumar is a board-certified urologist in New York City. After graduating from the Tufts University School of Medicine with honors, she completed her residency in urology at New York University Langone Medical Center. She founded Women’s Urology New York, with the goal of redesigning the urology experience for women. Dr. Kumar is a member of the Alpha Omega Alpha Honor Society, American Urologic Society, American and International Urogynecologic Societies, North American Menopause Society, and Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction. She is also a Diplomate of the American Board of Urology. You can visit her website here.

The word urology has always made me think of old men and prostate issues. But now that I’m menopausal, a whole new world of urinary issues have come to light. Can you please tell us, what is a Uro-gynecologist, and are you one?

People generally use the term uro-gynecologist to describe a doctor who specializes in women’s pelvic floor and urinary issues, such as urinary incontinence and pelvic organ prolapse. To get technical, a urogynecologist is actually a doctor who has done his or her residency training in either urology or obstetrics and gynecology, and then gone on to do a fellowship in “Female Pelvic Medicine and Reconstructive Surgery,” or,”FPMRS.” The fellowship allows both urologists and gynecologists to gain more experience with advanced surgical procedures for incontinence and prolapse.

I am a urologist who specializes in women’s genitourinary health, but I have not done an FPMRS fellowship, so I am not a urogynecologist. But there are many urologists and gynecologists who deal with female genitourinary problems who have not done an “FPMRS.” What really matters is that you are seeing a doctor who specializes in the problem you are having, and that if it is not their area of specialty or interest, that they refer you to someone more appropriate.  

What are some of the most common urologic issues you see and treat in women over 40?

We start seeing some of the issues that arise with peri-menopause, like urinary tract infections and urinary leakage. When the vagina is well-estrogenized, it is very protective against getting urinary infections. As estrogen levels begin to fluctuate in perimenopause, women can be more prone to urinary infections, especially after sex. So, I’ll see women who never had a problem with UTIs in their life and then suddenly it becomes an issue. Other things around this time of life can contribute, such as stress and lack of sleep. I have seen women who gain weight in their forties, and then they notice that they can’t hold their urine as well as they used to, so they have to empty their bladder more often. I feel it’s really important to get into these kinds of issues, because it’s important to address the underlying reasons why a bladder issue is happening, than to start medication for overactive bladder.

Why do we have so many urological problems as we age?

Well, there are a few reasons. One is that the bladder, urethra, and pelvic floor are estrogen sensitive. So when we lose estrogen in menopause, the entire lower urinary tract can be affected. This can mean that you are more prone to urinary tract infections, like we talked about above, but it can also lead to problems like stress incontinence and vaginal dryness. The urethra is supported by the connective tissue and muscles around it, and as we lose estrogen, we lose the healthy collagen and blood supply around the urethra, and the muscles become weaker. This makes it much easier to leak urine. Without estrogen, the vaginal tissue loses its thickness and elasticity, and we see problems with vaginal discomfort and pain with intercourse. Collectively, we call these vaginal and urinary symptoms the “genitourinary syndrome of menopause.” What is shocking is that these symptoms were not even recognized as being related to menopause in medical parlance until 2014, when the North American Menopause Society and International Society for the Study of Women’s Sexual Health endorsed the terminology. And genitourinary syndrome of menopause is tremendously under-recognized. One study showed that up to 50% of women who are going through menopause experience these symptoms, but only 4% attributed them to menopause. Healthcare providers are not adequately addressing these issues either, with only about 13% raising the issue of genitourinary symptoms when they see women around the age of menopause. So, it’s really important that women advocate for ourselves. I also know so many women who were having mood, sleep and energy disturbances, and their doctors were putting them on antidepressants, when all they needed was a little estrogen!

When I was having my own urology crisis, my GYN kept wanting to try and treat me herself, long after I realized I probably needed a specialist. Why do our gynecologists seem reluctant to refer us out?

I don’t know if it’s a reluctance; it may just be that the person you are seeing feels they are doing their best within their scope of practice and experience. I think if you’re really asking yourself whether there are other options beyond what your existing doctor is offering you, you should be looking up and asking about other doctors, and getting a second opinion. One doctor may not know that another doctor is going to offer you something different. When I was a resident, we actually did not have much training in female sexual medicine but I learned about these issues because they tended to co-exist with the urinary problems we saw in peri-menopausal and menopausal women. I didn’t learn about genitourinary syndrome of menopause until I was in practice and it became an area of great interest to me. So even within urology, there are some urologists who are more aggressive and proactive about recognizing and treating this.

Is vaginal valium as good as it sounds? What does it do, for whom, and where do you get it?

This is an interesting question. It is typically used in women who have issues relaxing their pelvic floor muscles. When the muscles are too tight, it may cause incomplete bladder emptying or pelvic pain. We believe that the valium acts as a muscle relaxant for the pelvis. There is some systemic absorption of the valium so people will get a sedative effect from that, and it is unclear whether the patients who find it effective could just take oral valium and it would be just as effective. In studies, vaginal valium has not been shown to be more effective than placebo. but many doctors who use it have good anecdotal evidence in their own patients. I certainly have had patients who have found it very helpful, and especially when we recommend pelvic floor physical therapy for hypertonic pelvic floor muscles, the intravaginal valium can facilitate patients receiving this therapy. Pelvic floor physical therapy is very important in helping patients learn how to relax the muscles, and some women need the intravaginal valium to be able to do the physical therapy sessions. It is not commercially available so you have to have it made by a compound pharmacy that you trust.

Are you a fan of HRT?

The short answer to that question is yes! I definitely think HRT should be an option for appropriately selected women. For many women who have moderate to severe menopause symptoms, hormone therapy is indicated within 10 years of menopause and up to age 59.

It is extremely important that it is prescribed by a doctor who takes a thorough medical history with careful attention to a history for high blood pressure, migraines, stroke, heart disease, blood clots, and endometrial, ovarian or breast cancer.

The risks of breast cancer are still being assessed and may have more to do with the use of concomitant progesterone replacement. But the data shows that using HRT is most beneficial and has the least risk in women who take it within 10 years of the onset of menopause and before age 60.

In women with genitourinary syndrome of menopause, I think we need to be really proactive about using vaginal estrogen. It’s important to recognize that when we use an estrogen cream, tablet, or ring in the vagina, it’s not hormone replacement therapy. It works locally to improve the health of the vaginal tissue, maintain a healthy vaginal microbiome, and helps to prevent urinary tract infections. It is also very effective for vaginal dryness and painful intercourse. People tend to get scared when the hear the word, “estrogen,” but topical estrogen is not the same as HRT.

What is pelvic floor therapy? Do you offer it? What kind of issues does it treat best?

Pelvic floor physical therapy is when you go to a physical therapist who has special training in the anatomy and function of the pelvic floor muscles. They also assess how these muscles interact with other muscles and joints in the hips and lower back. The pelvic floor muscles surrounding the urethra, vagina, and rectum, are called the levators, and when they are contracted, the bladder and rectal sphincters are closed. In order to urinate or have a bowel movement, or to have comfortable intercourse, these muscles need to be relaxed. If you are trying to hold urine or prevent passing gas, the muscles need to contract.

For women who leak when they cough, laugh, sneeze or exercise (stress incontinence), a pelvic floor physical therapist can help them strengthen the muscles to prevent involuntary leakage of urine. For women who feel like they just can’t hold it when they get the urge to urinate, learning how to contract these muscles helps them defer the need to go until they reach the bathroom. A lot of women try to do these exercises at home, but this is not as effective as doing them with a pelvic floor physical therapist. Pelvic floor physical therapy is considered first line therapy by the American Urologic Association for both stress urinary incontinence, and overactive bladder.

The other issue that pelvic floor physical therapy treats is hypertonicity, or excessive contracture of the pelvic floor muscles. If the muscles cannot relax properly this can lead to bowel and bladder dysfunction. If the muscles are in a contracted state where lactic acid is building up, this can lead to pelvic pain. Sometimes a painful stimulus such as endometriosis, or painful intercourse, leads to tightening of the muscles, and then they fail to go back to a relaxed neutral position, and this leads to prolonged pain. Pelvic floor physical therapists can provide direct manual therapy to soothe muscle tension, help women learn how to relax these muscles, as well as do stretching exercises. In my practice, I have a list of pelvic floor physical therapists who I have vetted, that I recommend to

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