Urinary health concerns in the trans community

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Aleece Fosnight, MSPAS, PA-C, CSC-S, CSE, NCMP, IF and Medical Advisor at Aeroflow Urology has been a physician assistant for the past 10 years and has been a sexual health counselor and educator for almost 6 years. She is a provider of comprehensive sexual and reproductive health, basic urologic care, and gynecological care for Western North Carolina and the Southeast. Aleece provides all-inclusive urologic care to all generations. She is also a nationally certified sexual health counselor and educator, providing sexual health education, information and personalized counseling to patients of all ages.

Unfortunately, LGBTQ+ individuals are subject to implicit and explicit biases. This can inhibit willingness to seek medical care—and, subsequently, lead to worse health outcomes.⁠ In the trans community, there is also a probability of urinary health issues stemming from possible hormone replacement therapy and even lack of bathroom access.

Relatively little is known in the medical community of how hormone therapy changes the urinary tract with many providers unaware of who to refer trans patients to. This often results in trans patients not having their concerns taken seriously and even missing out on a proper pelvic/physical exam, leading them to experience larger medical issues and misdiagnoses.

Most trans individuals are also faced with the pressure to hold in their bowel movements and urge to urinate when in public due to uncertainty and anxiety around which restrooms they can use safely. This adversely leads transgender individuals to become more susceptible to situations of incontinence, which occur when an individual’s pelvic muscles are too tight. Results from the US Transgender Survey also reported that 8% reported having a kidney or urinary tract infection, or another kidney-related medical issue, from avoiding restrooms in the last year.

Hormone changes can occur in the genitals secondary to gender hormone transitioning therapy, especially for trans men. It is important to care for the lower urinary tract as those changes can cause urgency, frequency, dysuria, and recurrent urinary tract infections. We often forget that there are hormones located in the bladder and urethra, and those receptors are not spared by the hormone therapy. One of the best ways to improve the health of the lower urinary tract is to stay hydrated with water. This helps to dilute the urine and avoids extra irritation for waste products that are filtered into the urine. Another way is to add local hormones to those individuals that have female reproductive organs. This helps to locally add back hormones, balancing out the normal microbiome/flora, calming the urinary tract and improving those previously mentioned urinary symptoms.

Most of the time, trans individuals have hypertonic pelvic floor muscles leading to bladder overactivity, urgency, frequency, dysuria, and voiding dysfunctions. Overactive pelvic floors can be a result of holding urine secondary to no access to a restroom or not feeling safe to use the restroom in a public space. Again, there are hormone receptors on the pelvic floor muscles and this can contribute to the hypertonicity as well. Managing anxiety and performing deep breathing exercises can help to lengthen those tight muscles. Hip and lower back stretches can also be beneficial - for example, holding a deep squat, butterfly stretch, IT band stretching, prone obturator internus muscle stretch.  

I also encourage a good stretching class, such as yoga, which is also good for those pelvic floor muscles. An exercise to avoid is kegels or contraction of those pelvic floor muscles. This will compound an already tight muscle and makes the situation worse causing increased pain and tension in the pelvis. Avoiding constipation is extremely helpful as the increased bowel distention places extra tension on the muscles causing pain and hypertonicity. And please do not delay the need to void if possible - empty your bladder when your body tells you to!

WPATH (World Professional Association for Transgender Health) is a great starting point to find providers, although not all great providers are certified with WPATH. A vital clue to knowing if a provider is competent is if they have key words on their website, social media, or other web-based platforms that are trans friendly and talk about being trans informed. Also, if their staff is well versed and competent, even the front desk person, that is a sign that the provider/s took the time to make sure their staff is educated and trans aware. Word of mouth is also a great way to know who has been seen by that provider before and had a great experience. Unfortunately, trial and error may be the default if there is no access to resources in the area. Go in with an inquisitive mind - remember you are the one interviewing the provider just as much as they are interviewing you.

Unfortunately, the medical community is still struggling with getting out the information to the community and their colleagues about the importance of trans care and knowledge about what trans healthcare looks like.

It's imperative we continue to address LGBTQ+ nondiscrimination protections to ensure all people feel safe to use public bathrooms and seek medical care when needed. ⁠