Applying to Urogynecology / FPMRS, with Dr. Edward Kim

We welcome back Dr. Edward Kim, an FPMRS fellow at the University of Pennsylvania, who’s talking with us today about how to apply for urogynecology fellowship!

Disclosures: We’re from a large academic institution. What we say may not apply to those from smaller programs or those from community programs! Please feel free to reach out to us though for other specifics or connections on advice.

1. What is Urogynecology or FPMRS?

1. Female pelvic medicine and reconstructive surgery

2. We are a subspecialty of either Ob/Gyn or Urology that focuses on medical management, surgical management and research of women’s pelvic floor conditions. Vast majority of our surgeries are elective and outpatient or at the most overnight stays. Compared to other gyn surgical subspecialties like gyn onc or MIGS, there is very little inpatient care needs or consults. Our patient population is predominantly older patients with exceptions at institutions that do gender affirming surgeries, peripartum pelvic floor care, etc. Our research areas range from basic science to NIH-funded research network.

3. Historically, the name FPMRS was created to replace or supplement the name urogynecology in order to relay that our scope of practice can go beyond urologic and gynecologic conditions. However, more recently, the name FPMRS is being re-discussed as the word female is not inclusive especially given that more of us are seeing gender diverse patients and perform gender affirming surgeries.

4. Long story short, urogynecology and FPMRS are synonymous for the time being but it may evolve.

5. In terms of the duration of training: For Ob/Gyns it’s a 3 year fellowship and for Urologists it’s a 2 year fellowship. For Ob/Gyns, these 3 years include 12 months of research, as it is for all ABOG certified subspecialties.

6. Your training will cover a variety of pelvic floor conditions as defined by American Urogynecologic Society’s (AUGS) scope of practice:

1. Urinary Incontinence

2. Pelvic organ prolapse

3. Voiding dysfunction

4. Neurogenic bladder

5. Urethral diverticula

6. Vesico-vaginal and recto-vaginal fistulae

7. Congenital anomalies of the pelvic floor

8. Fecal incontinence

9. Recurrent UTI

10. IC/BPS

11. Managing pelvic floor surgery complications and mesh complications

12. And at some programs:

a)    Transgender care and gender affirming surgeries

b)    Peripartum pelvic floor care

c)     Pelvic pain

d)    Etc.

1. Years I - II

1. NOTE: Urogyn is EARLY application and EARLY match just like Urology. Urogyn timeline is thus a few months earlier than other Ob/Gyn subspecialties. Applications OPEN in NOVEMBER/DECEMBER and CLOSE by January of PGY3 year, interview in SPRING of PGY3 year and match by AUGUST of PGY4 year. So solidifying your interest in urogyn earlier in residency is beneficial.

2. If you are at a residency with big urogyn presence and have fellowship. Typically you will rotate through or be exposed to urogyn as junior residents. If so,

1. See what your attendings and fellows do. Talk to them about why they went into it. Do you like major and minor urogyn surgeries? How about the predominantly older patient population?

2. See what kind of scholarly activities are happening in the division. Ask if you can be more involved with research. This will help you get “plugged in” with the division.

3. Do well on CREOGs but not a huge deal until your third year. Show an upward trend if you can.

3. If you are not at a residency with big urogyn presence

1. Identify a local urogyn faculty or urogyn division.

2. If your residency and host institution allow, do an away rotation. Try to impress them and get a great letter. Ideally, you should have at least one urogyn write a letter of recommendaiton for you.

3. At the least, do scholarly work like a book chapter or full on research project.

4. PGY2s should consider either:

1. AUGS Resident Scholars Program that gives funding to attend AUGS meeting to network and be exposed to the greater urogyn world

2. ABLE Scholar Travel Award that is similar to the resident scholars program but focused on residents from diverse backgrounds

3. You can apply as a PGY3, but by the time you attend AUGS, your fellowship application process will already be in full swing. So try to go in PGY2 year to network if you can.

2. Third Year

1. Identify people that can write your letter of recommendation.

2. Continue your research projects and other scholarly activities

3. If you haven’t already, apply for either resident scholar programs that I mentioned

4. Applications open in November/December!

1. So in the summer/early fall time, look at AUGS’ listing of fellowship programs. Look at each program’s information. Make a list of programs you’d be interested in

2. Sit down with your mentor/fellows and edit or add to the list

a)    Talk about: research heavy? Academic versus private after graduation? Specific niches like gender affirming care, basic science research, dual degree opportunities?

1. Applications

1. Overview: Applications open in November/December and close in January typically. Interview invitations will be sent out around February. Interviews are from March to June. With the match in August.

2. In early fall of PGY3 year, update your CV and get the application material together.

3. Write your personal statement and have your mentors review it. Help the readers understand why urogyn and what you want to accomplish in your career.

4. Most programs will not review the application as soon as the application opens in Nov/Dec. Do submit on the earlier side because you don’t know what the process is like at your top choice programs. But don’t rush at the cost of making mistakes in your application.

5. All programs will send out interview invites on a single designated day typically in February.

1. Just like in residency, be prompt about responding to interview invites as to not end up on the waitlist.

2. Interviews

1. Back in our day for Nick Fei and I, we spent a lot of money on in-person interviews! Virtual interviews are wallet-friendly and schedule-friendly, but they are also exhausting! Allow yourself some breaks and downtime between interviews if you can and try to optimize the number of interviews you do.

2. You all know this by this point in your career but:

1. Do your homework on the program! Some programs have good information about their programs on their websites or on their AUGS program listing. Try not to ask questions that is reasonably evident lest you want to be seen as not interested in the program. Ask people you know about the programs. Networking at AUGS will come in handy.

2. Know the program faculty and what their interests are

3. Have a list of questions:

a)    Surgical modality breakdown: robotic, vaginal, laparoscopic, etc.

b)    What kinds of non-bread and butter urogyn things do they do? Gender affirming care, peripartum pelvic floor issues, etc.?

c)     What is their research year structure? One full year? Or 12 months broken up throughout?

d)    What kinds of research do their fellows do? Basic science? Clinical?

1. For logistical questions like calls, transportations, try to save those for the fellows or perhaps the PD

1. It’s hard to get a sense on virtual interview days but try to see if the division members seem friendly and collegial with one another.

2. See if everyone in the division makes it to the interview. Programs that are vested in their fellowship will try very hard to pick a time and day that works for everyone, block out their ORs and clinics, etc.

1. Rank Lists

1. Make your rank list and seek feedback from your mentors. Think about geography and what you want in a program. 3 years is a long time and you will have a lot more free time in urogyn fellowship compared to residency or even other ob/gyn subspecialties! So being at a place that you can be with family, friends, or things you like doing are also something to consider.

2. Be sure to reach out to a few programs that you really loved. You voluntarily telling your top choices that they are your top choices is not against the NRMP rules.

1. Some programs do not write back at all.

2. To really support your emails of interest; Ask your mentors to reach out on your behalf.

3. It’s hard to know which programs want thank you emails or not. Try to lean on the side of doing them. Again, some program and interviewers will not write back. That’s okay!

Microscopic Hematuria

Committee Opinion 703 serves for additional reading today!

Defining Microscopic Hematuria

• 2012 American Urologic Association (AUA) criteria - 3+ RBC/high power field

• The AUA guidelines also noted that if found, recommendation for evaluation for all patients older than age 35 years

  • This evaluation includes cystoscopy and upper urinary tract imaging with CT, with the primary concern being urothelial malignancy

• The data supporting this approach was largely based on male patients - so ACOG and AUGS put together this series of recommendations thinking about the female patient 

  • As an example of how this can be so different: the CO points to a large study where 20% of urinalyses performed had microscopic hematuria, and other studies pointing to incidences between 2% and 31% – that would be a lot of studies!

• These studies do carry risks – radiation and malignancy risk, particularly for young patients.

Differential Diagnosis and Risk Factors

• ACOG points to specimen collection being potentially more challenging in women:

  • Hematuria might result from true hematuria, but also from

    • Menstruation

    • Urogenital tract atrophy

    • Pelvic organ prolapse

    • Other non-threatening urogenital diagnosis (prostatic hypertrophy in men, urethral stricture, etc). – these are much less common in women as well.

  • The primary concern with microscopic hematuria: urothelial malignancy.

    • Risk factors:

      • Male sex

      • Age over 50

      • Previous or current smoker

      • Gross hematuria

      • HIstory of pelvic radiation

    • Male sex specifically has 3.3x more new cases of bladder cancer than female sex

      • 4th most common cancer in men, while not in the top 10 cancers for women

    • Renal cancer is also 1.7x more likely in men.

When is reasonable to consider screening in women?

• Studies looking at women have found:

  • Urologic malignancy rate in women under 40 years with any microscopic hematuria was 0.02%, and older than 40 years was 0.4%

  • Urologic malignancy rate is higher in women with 25 RBCs / hpf or greater

  • Smoking also increases risk.

• Bottom line: women older than 60, with gross hematuria, and history of smoking have highest risk of urologic cancer.

  • Low risk, never smoking women, younger than 50 and fewer than 25 RBC/hpf - risk of urologic malignancy is less than 0.5%. 

• In 2020, the AUA updated their guidelines to incorporate these gender-specific screening pathways, which are helpful to recognize and be  aware of:

  • Low risk women can undergo repeat urinalysis within 6 months, or cystoscopy/renal ultrasound

  • Intermediate risk women should undergo cystoscopy and renal ultrasound

  • High risk should undergo cystoscopy and CT urogram

• Of course, keep your local urogyn / urologist aware of any patient for whom you have concern based on risk factors to discuss evaluation for urothelial cancers.

View fullsize

AUA/SUFU 2020 Microhematuria Algorithm

Uterovaginal Prolapse

Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!

The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.

One common quiz question are the levels of support. These are:

• Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.

• Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP. 

• Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter.  Loss of level 3 support can result in a distal rectocele or perineal descent.  

Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.

Urinary Incontinence

On today’s episode, we visit with Dr. Kyle Wohlrab, who is an associate professor and urogynecologist at Brown University / Women and Infants Hospital of Rhode Island. He takes us through the basics of urinary incontinence.

Urinary incontinence is quite common: almost 1/3 of women in their lifetime. The Women’s Preventive Services Initiative even recommends annual standardized incontinence screening for women annually.

The mechanisms of incontinence include:
Stress - leakage with Valsalva (sneeze/laugh/cough/activity). Generally in small volumes.
Urge - aka overactive bladder; spasms or overactivity of bladder detrusor muscle that can prompt large volume leakage.
Mixed - a combination of the above; often one of the above types is “predominant.”

We review in the podcast many of the most important parts of a history and workup, but the most important aspect are the patient’s goals with respect to incontinence. This also will guide our therapy. Childbirth, obesity, and activities involving heavy weight bearing are some common risk factors.

One of the tests that can easily be performed, but many have limited experience with, is a simple cystometrogram. Essentially, one backfills the bladder. If during filling, one sees a rise in the meniscus, this is suggestive of detrusor overactivity. After filling with 200-300cc,, one can do a filled cough stress test to evaluate for stress incontinence.

Treatments vary by type of incontinence, but can be broken down into three categories for each type:
Stress - pelvic floor PT, vaginal inserts, and surgical therapy — midurethral sling, Burch urethropexy, urethral bulking.
Urge - pelvic floor PT and behavioral modification, medial therapies, and surgical therapies — neurostimulators.

For medical therapies for urge incontinence, antimuscarinic therapy is generally first line. Oxybutynin and trospium are the most commonly used medications in this class. Recall that antimuscarinic drugs have the “slow down” side effects of dry mouth/dry eyes, constipation, abdominal pain, and sedation. Newer medications in this class can have fewer side effects but can have difficulty with insurance coverage. Trospium is the newest medication that also doesn’t cross the blood-brain barrier, limiting neurologic side effects — especially useful in the elderly!

Beta agonists are another option for medical therapy with mirabegron. Rather than acting on muscarinic receptors, these act on beta agonists. These thus should be avoided in patients with uncontrolled hypertension.

When should someone refer to urogynecology? Dr. Wohlrab’s advice is to refer once someone has failed a line of therapy, or when patients begin looking for surgical therapy. Especially after listening today, we hope you’re comfortable with this workup and treatment!

Further reading from the OBG Project:
Urinary Incontinence – How to Make the Diagnosis in Your Office and When to Refer
Treating Urinary Incontinence Without Surgery: Options and Pearls
Prolapse and Stress Incontinence: Burch Procedure vs Midurethral Sling
Surgery for Urinary Incontinence – When the Sling’s the Thing