A Focus on Women: AUA Best Posters Highlight Female Athletes, Prenatal Care, and Women in Urology

Three award-winning posters covered a range of topics on women’s urology, including urinary incontinence in female athletes, prenatal care utilization for fetuses with spina bifida (SB) in California, and the historical journey of women residents at the Brady Urological Institute at Johns Hopkins Medicine. These posters were just a few among the many presented at the American Urological Association (AUA) 2024 Annual Meeting, which took place May 3 to May 6, in San Antonio, Texas.

Urinary Incontinence in Female D1 Athletes

Young, nulliparous female elite athletes frequently experience urinary incontinence, yet the impact of intense exercise on pelvic floor health remains unclear, prompting an exploratory study aimed at investigating urinary symptoms alongside pelvic floor anatomy and function.

In the cross-sectional study of National Collegiate Athletic Association Division 1 nulliparous female athletes, researchers compared symptomatic athletes—those who had experienced urinary leakage during exercise—against asymptomatic athletes, evaluating pelvic floor function through pelvic exam and MRI at rest and maximal strain.¹ Researchers collected demographic data, sport characteristics, relevant medical history, and utilized validated genitourinary symptom questionnaires (Lower Urinary Tract Dysfunction Network Symptom Index-29 [LURN SI-29] and the Female Genitourinary Pain Index [GUPI]), and these data were compared between groups. A total of 29 athletes were included in the study, with 18 being symptomatic and 11 being asymptomatic, and both groups showed similar demographics, sport characteristics, and pelvic exam findings.

The study revealed that symptomatic athletes exhibited significantly worse overall urinary symptoms, with a median LURN SI-29 of 8.5 compared with 8 for asymptomatic athletes (P = .02). They also experienced significantly worse genitourinary pain, with a median GUPI of 7 compared with 3 (P = .04). Based on MRIs, symptomatic athletes also had a greater thickness of certain pelvic floor muscles, including the striated muscle of the urethral sphincter (2.5 mm vs 1.8 mm, P = .02) and pubovisceral and levator ani muscles (10.3 mm vs 8.7 mm, P = .04).

Additionally, symptomatic athletes tended to show more pelvic floor abnormalities, though these differences did not reach statistical significance. These abnormalities included:

• Hiatal enlargement
• Pelvic floor descent
• Urethral hypermobility
• Bladder neck funneling during Valsalva
• Abnormalities of the paraurethral and pubourethral ligaments
• Shorter urethral length
• Lower median Brink score on pelvic exam

Based on these findings, a longitudinal assessment is necessary for identifying modifiable risk factors and interventions for female elite athletes who have not yet given birth in their life.

Prenatal Care for Spina Bifida

Despite an initial decrease in incidence after folic acid fortification, SB remains prevalent in the US. In cases of an in utero diagnosis of SB—when it is considered a high-risk pregnancy—frequent prenatal care is recommended.

A retrospective observational case-control study presented at the AUA 2024 Annual Meeting was conducted to assess SB birth prevalence and associated risk factors, compare prenatal care utilization among women carrying fetuses with and without SB, explore factors linked to inadequate prenatal care in the SB group, and evaluate correlations between neonatal morbidities and prenatal care in the SB group.² The California Department of Health Care Access and Information Database was queried for liveborn infants between 2005 and 2012, and prenatal care utilization was assessed using the Adequacy of Prenatal Care Utilization Index, which categorized visits into sufficient and insufficient care groups.

With more than 4 million babies born between 2005 and 2012 in California, 1049 babies were born with SB, with a prevalence of 1 in 3857 births and an annual incidence of 131. Maternal race (P = .01), pre-pregnancy obesity (P < .01), diabetes (P < .01), insurance status (P < .01), and neighborhood socioeconomic status (P < .01) were all associated with SB births compared to infants without the condition.

While the proportions of sufficient and insufficient prenatal care were fairly similar between the SB and non-SB groups, there were disparities between those receiving more than adequate care and those receiving inadequate care; while 47% of mothers to babies with SB had more than the recommended number of prenatal care visits, 20% of mothers received insufficient care.

Looking into factors that may have led to these gaps, the researchers found that having non-private insurance was a major factor in receiving insufficient care, more than doubling these mothers’ risk of not receiving the care they need even after adjusting for maternal demographics. Diabetes was also a key factor, also doubling the risk of insufficient prenatal care. There was also a higher incidence of neonatal morbidities among infants born with SB in the group receiving more than adequate prenatal care compared with those in other prenatal care groups (P < .001).

Female Residents at the Brady Urological Institute

In 1985, the landscape of urology in the US was much different from today, but unfortunately similar in many ways. With only 22 female urologists in the country, women were scarce in the field. Fast forward more than 35 years later, and while women's presence in medicine has grown, they remain a minority in urology. This reality prompted a look into the experiences of women in urology, particularly those who trained at the Brady Urological Institute at Johns Hopkins University.

As the first residency program in urology in the country, the Brady Urological Institute holds a prestigious position in urology. To explore the challenges and successes of women in urology, researchers talked to 8 of the 16 women who trained at Brady from 1980 to 2022 about what it’s like to be a female urologist.³

Through interviews and archival research, it became clear that the journey of a female resident at Brady is characterized by the pursuit of greatness. With the guidance of exceptional mentors, these women are inspired to achieve their utmost potential in a traditionally male-dominated domain. However, the intersection of professional ambition with family responsibilities poses a unique set of challenges—for many, the balancing act between career aspirations and family obligations creates tension and complexity.

Despite strides in acceptance within the field, female urologists still encounter barriers from patients and colleagues alike, but the Brady Urological Institute continues to promote gender diversity and nurture the next generation of urologists. By documenting and contextualizing the experiences of women in urology, this project not only sheds light on their journey but also paves the way for future advancements in promoting gender equity and inclusion in the field.

References

1. Gan ZS, Sundaram K, Smith AL. Pathophysiologic mechanisms of urinary incontinence in nulliparous female elite athletes: a cross-sectional study using dynamic pelvic magnetic resonance imaging. Presented at: AUA 2024 Annual Meeting; May 3-6, 2024; San Antonio, TX. https://www.auajournals.org/doi/10.1097/01.JU.0001008776.99097.8a.09
2. Kyaw TS, Leva N, Goldberg D, et al. Prenatal care utilization for fetuses with spina bifida in California. Presented at: AUA 2024 Annual Meeting; May 3-6, 2024; San Antonio, TX. https://www.auajournals.org/doi/10.1097/01.JU.0001008844.84871.17.01
3. Grutman AJ, Comfort NC, Clifton MM, Walsh PC. Great expectations: a brief history of women residents at the Brady Urological Institute at Johns Hopkins Medicine, 1980-2022. Presented at: AUA 2024 Annual Meeting; May 3-6, 2024; San Antonio, TX. https://www.auajournals.org/doi/10.1097/01.JU.0001008760.25751.09.03