When it comes to pregnancy and the postpartum period, there is an unacceptable gap in care and dialogue around the problems women face. From abdominal wall separation (diastasis recti) to pelvic organ prolapse, stress incontinence to umbilical hernia - the plethora of conditions women experience can leave them feeling far from "normal." More often than not, these symptoms are dismissed as a consequence of pregnancy and childbirth, something to live with and accept. But at Every Mother, we firmly believe in advocating for our health and kicking dysfunction to the curb. Knowledge is power, so we go straight to the source, speaking with doctors and experts in their field so that you have the insights and tools to get the healthcare experience you deserve at every stage of motherhood.
This week, we interviewed urologist Dr. Angelish Kumar to learn everything we can about the urinary system during pregnancy and postpartum, common urology problems, and the treatments to resolve them.
EM: Can you explain what a urologist is and what you do?
Dr. Angelish Kumar: A urologist is a doctor who takes care of the urinary tract. When you think about the urinary tract, we have our kidneys that make urine, the ureters which carry the urine from the kidneys down to the bladder, and the bladder, which is the organ that stores the urine. Urologists are kind of like plumbers; we fix problems like blockages from kidney stones, leaks caused by overactive bladders or stress incontinence, and inflammation in the urinary tract caused by urinary tract infections (UTIs). We also manage cancers and stones in the urinary tract.
EM: How is a urologist different from a gynecologist, and do we need both?
Dr. Angelish Kumar: There are definitely times when women need both a urologist and a gynecologist.
A gynecologist takes care of the female reproductive organs, including the ovaries, fallopian tubes, uterus, cervix, and the vagina. A urologist deals more with the bladder, urethra, and the upper tracts, which include the kidneys and ureters. The bladder, urethra, uterus, and vagina are very close together, so there is considerable overlap.
Women typically see their gynecologist yearly (like a primary care doctor) to have an annual check-up and a pap smear. If a woman is having urinary issues such as:
- Urinary leakage that is persistent after working with a pelvic floor physical therapist
- Recurrent urinary tract infections
- Urinary frequency that is affecting quality of life
- Kidney stones or blood in urine
- Irritative symptoms in the bladder with no infection
- Problems with the integrity of the pelvic floor muscles or vaginal tissue
a referral to a urologist is warranted.
It's important to note that there are gynecologists trained to treat urological issues (urogynecologists), and urologists trained in more complex female pelvic problems. These physicians complete a fellowship in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) and specialize in pelvic floor disorders as well as urological and gynecological issues.
EM: What are the common urology problems you see during pregnancy?
Dr. Angelish Kumar: Urinary frequency is common during pregnancy because the baby puts mechanical pressure on the bladder while in the uterus.
Hormones like progesterone and relaxin, which allow the uterus to stretch and expand to accommodate a baby, can also affect muscles in the urinary tract and pelvic floor. This can lead to urinary leakage when you cough, laugh or sneeze, which we call, “stress incontinence.” It can also lead to the dilation of tubes that drain the urine from the kidneys down to the bladder. Relaxation of the smooth muscle in the ureters, as well as the presence of the baby in the uterus, can also cause a condition called hydronephrosis, "the swelling of the kidney due to a build-up of urine," (National Kidney Foundation, 2015). Hydronephrosis can be asymptomatic or extremely painful; when detected on ultrasound, women are typically referred to a urologist. Urologists will also check to make sure it resolves after giving birth, and that there is no other reason for the hydronephrosis, such as a kidney stone.
The other reason pregnant women see urologists is if they are getting bladder or kidney infections. It's customary for women to have their urine checked for the presence of bacteria during routine visits with their obstetrician. Even though the incidence of UTIs is similar for a pregnant and non-pregnant woman, if a pregnant woman has a UTI, there is a higher chance it will progress to a kidney infection (pyelonephritis), which causes fevers and inflammation in the body. This is important to know because it can be a risk factor for preterm birth.
If a woman is prone to getting urinary tract infections while pregnant, it's a good idea to see a urologist to check that there is no abnormality in the urinary tract and to make a plan to limit her risk of infection, for example, by taking an antibiotic after intercourse.
EM: What are the common urological problems you see postpartum?
Dr. Angelish Kumar: First off, I think it is so important for people in the medical community to listen to the problems postpartum women face and take responsibility to help them after they've had a baby. There's this mentality that once you've given birth and your baby is healthy, you are supposed to blindly accept a whole array of physical changes.
Diastasis recti is an excellent example of that. Why should we accept a weakness in our core that is affecting our ability to perform activities of daily living when there are ways to improve and completely fix it? When men have these issues, like with erectile dysfunction, they don't get told that this is their new reality, they expect the doctor to do their best to get them back to full function. And as women, we need to demand this for ourselves!
The common problems I see postpartum:
- Overactive bladder
- Pain during intercourse and vaginal dryness
- Urinary tract infections
- Stress incontinence (leakage when you cough, laugh or sneeze)
Pregnancy is a high estrogen state. After birth, your estrogen levels decline, and you continue to lose it in your breast milk. This can lead to vaginal dryness and pain with intercourse, which can cause irritation in the vaginal area and make you more prone to urinary tract infections.
When postpartum women experience stress incontinence, they should be referred to a pelvic floor physical therapist. A lot of women are sent home and told to perform Kegel exercises, but doing Kegels on your own without guidance is typically not successful. When you do Kegels with the help of a pelvic floor physical therapist, it's shown to be effective in nearly 70% of women.
If you are experiencing stress incontinence and have gone through (about) 6 weeks of healing after delivery, begin pelvic floor physical therapy. If pelvic floor physical therapy isn't effective, you should see a urologist or urogynecologist who can offer other treatment options.
EM: Do you see a difference in urological issues between vaginal and cesarean deliveries?
Dr. Angelish Kumar: There is so much variability in the way every vaginal and cesarean delivery happens, so it's difficult to quantify the differences. The urological issues I encounter relate to the delivery method but also pregnancy itself.
EM: Can you explain some of the different methods of intervention for female urology problems, pre and postpartum?
Dr. Angelish Kumar: With pregnant women, we are very conservative with treatment.
For example, with stress incontinence, there would be no surgical procedure. I would recommend exercises that help to improve pelvic floor strength and prevent leaking. Every Mother is an excellent program for this because core strength is very protective, and by developing good core strength, you place less pressure on your pelvic floor. If you practice doing exercises during pregnancy that help to maintain a strong pelvic floor, you have a better chance of maintaining strength postpartum, and if you are used to engaging those muscles, I think it's easier after having a baby to utilize them to keep you continent.
After giving birth, you can do pelvic floor physical therapy, and if you are still having problems, then we can explore procedures such as:
- Bulking agent injections - injecting material into the urethra to plump up the urethra and create a tighter seal.
- Sling surgery - placing a strip of mesh under the urethra to stabilize the urethra to prevent leaking.
- Laser and radiofrequency treatments - in-office procedures to help restore the integrity of the vaginal walls by stimulating the growth of high-quality collagen. It is important to recognize that while there is promising data to show that these procedures can help with vaginal tightening and stress incontinence in appropriately selected patients, none are FDA cleared yet for these indications in the US. Several companies are performing the necessary clinical studies to obtain regulatory clearance that would formally allow their devices to be used for these indications.
For overactive bladder, I would start by recommending pelvic floor physical therapy. If that wasn't effective, we have medications that help the body store urine more easily, botox, and minimally invasive procedures similar to acupuncture that can calm down excessive nerve signaling, such as percutaneous tibial nerve stimulation or sacral neuromodulation.
EM: What should a woman expect from a urology exam?
Dr. Angelish Kumar: We typically talk through the issues you're experiencing and take a thorough medical history. I look at lab or imaging results that may be relevant to the problem and perform a physical exam, including a vaginal exam similar to the gynecologist, but without a pap smear. We will often perform a test while examining the urethra where you cough and bear down to see if there is any leakage of urine or laxity of the vaginal wall. If the patient has complaints of pelvic pain or is having trouble releasing the bladder, we will do an exam of the pelvic floor muscles. Generally speaking, we don't do anything painful.
Other tests include:
- Urine test
- Ultrasound imaging
- X-ray of the urinary tract
EM: What can women do to maintain or improve urological health pre and postpartum?
Dr. Angelish Kumar: During pregnancy, it's essential to drink a lot of water. That's because when you are pregnant, your kidneys are filtering everything at a faster rate. If you are not drinking enough water and your kidneys are filtering other electrolytes at a higher rate, that can put you at risk for kidney stones - so stay aggressively hydrated while pregnant. I also recommend doing some form of exercise, whether it's a home-based app like Every Mother or a class that helps you maintain core and pelvic floor strength.
I would say the same postpartum, and hydration is especially important if you are breastfeeding!
It's important to advocate for your health, get exercise, and when you see your healthcare provider, voice your concerns. Everyone says to postpartum women, no matter what they are going through, whether it is depression, body image issues, urinary leakage, or sexual problems, "well you just had a baby, of course, things are different." That's unacceptable. If you look at an athlete who tears a ligament, no one says, "just wait six months," so the same should happen for postpartum women. If your health care provider isn't listening to you or brushes you off, get a second opinion, or do research into it yourself.
EM: How does one find a urologist?
Dr. Angelish Kumar: The first way would be to get a referral through your primary care doctor or gynecologist. If that doesn't happen, and you are experiencing urological issues, visit the "Find a provider" section on the National Association for Continence, American Urological Society, or International Urogynecological Association websites. You can also check the urology and urogynecology departments at your nearby hospitals. Once you find a provider, you can visit their website to make sure they focus on the problem you are experiencing.
If you have any questions about the contents of this interview, Dr. Kumar welcomes you to email her at firstname.lastname@example.org. Please note that such email correspondence does not represent medical advice or care. Anyone seeking medical advice should consult directly with a healthcare professional. By sending an email, you also acknowledge that the email communication is not encrypted, and there is no guarantee of privacy.
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.