A urogynecologist is a physician who specializes in pelvic floor disorders such as pelvic organ prolapse, urinary incontinence, recurrent urinary tract infections, fistulas, and other complex pelvic conditions. Yet many women do not know the specialty exists. Dr. Tanaz Ferzandi believes that is one of urogynecology’s biggest challenges.
Key Takeaways From Dr. Ferzandi
- The specialty has a recognition problem that reaches patients and referring physicians
- Surgeons trained in one technique can’t offer patients a full range of options
- Minimum case numbers in residency don’t equal competency
- No subspecialty code exists for urogynecology, so the workforce can’t be measured
- CMS data showed hospital payment roughly 2.5x higher under urology than gynecology for a comparable sling
- Patients should ask surgeons how many different ways they perform a given procedure
- Good outcomes create access, because correctly treated patients stop returning
What Is a Urogynecologist?
A urogynecologist is a doctor who treats pelvic floor disorders in women. The subspecialty is also known as female pelvic medicine and reconstructive surgery. Dr. Ferzandi indicates the major areas include female incontinence, prolapse, recurrent UTIs, hematuria, fistulas, and gynecologic surgical care.
The term pelvic floor disorders covers a lot more than just incontinence and prolapse, such as vaginal masses and cysts, obstetrical injuries and endometriosis. Ferzandi notes that her patients have often been diagnosed with one of these, but not given any clear next steps.
Dr. Ferzandi is also working on improving awareness through public service announcements and patient advocacy partnerships.
“It’s a branding problem and we’re working on it” – Dr. Tanaz Ferzandi
Urogynecologist vs. Gynecologist: What’s the Difference?
Training and scope are the main differences, according to Dr. Ferzandi. Most urogynecologists complete a four-year OB-GYN residency and then a three-year board-accredited fellowship in urogynecology and reconstructive pelvic surgery, formally titled female pelvic medicine and reconstructive surgery. Some others start with a urology residency instead. Dr. Ferzandi pinpoints the additional three years as where the specialty has the most room for growth. This is the period where the doctors learn advanced gynecologic surgery. She advocates for trainees to graduate versed in laparoscopic, vaginal, open, and robotic approaches rather than a single one.
The range is the practical difference for patients. A general gynecologist may manage some pelvic floor conditions and refer others out. A urogynecologist handles the full spectrum, from non-surgical management through complex reconstruction.
What Women Should Ask Before Pelvic Floor Surgery
Dr. Ferzandi highlights the two questions a woman should ask to advocate for herself:
Before pelvic floor surgery, ask your surgeon:
Where did you train?
How many different ways do you perform this procedure for this condition?
The goal is not to find a surgeon who performs every technique. It is to understand whether the recommended approach reflects your anatomy and needs, rather than simply being the only approach available.
She compares the process to buying a shirt in a store. You wouldn’t buy the first one you see, you look at the options and see what fits. A decision regarding surgery deserves at least that much consideration. She advises to find a different surgeon if they don’t answer or won’t explain why there isn’t an alternative being offered.
She also advocates for trainees to ask their program director why they are only learning one approach. While program directors don’t control hiring, they have a direct line to the people who do.
Living with prolapse, incontinence, or another pelvic floor condition? You have options. Find a Pelvic Floor Specialist experienced in pelvic floor reconstruction and begin the conversation.
When Should I See a Urogynecologist?
Consider seeing a urogynecologist if you experience vaginal pressure or bulging, urinary leakage, difficulty emptying your bladder, recurrent urinary infections, accidental bowel leakage, pelvic floor injury after childbirth, or symptoms of pelvic organ prolapse.
A Call to Action
Dr. Ferzandi’s AUGS Presidential Address was titled A Call to Action and is published in Urogynecology. She intentionally covered many items rather than focusing on a single issue. She covered payment reform, advocacy at the CMS level, billing and coding literacy, surgical training, the skill set of the current workforce, the pipeline feeding it, and the fact that the specialty lacks reliable data on any of it.
Why Surgeons Get Trained Too Narrowly
Dr. Ferzandi discusses her central concern that training programs are producing surgeons who only know one way to do things. For instance, when she arrived at USC, she found essentially everyone was only performing retropubic slings. She responded by building a deliberate paradigm across the institutions where she works, so trainees see obturator slings, outside-in and inside-out approaches, and single-incision techniques rather than one method. She doesn’t say fellows need to master every technique, but that they shouldn’t graduate having only seen one.
Dr. Ferzandi also questions the training standards themselves. She notes that minimum case numbers were set low even when written, and that a trainee can count a case at just over 50% participation. Speaking as a board examiner, she says she is not confident case lists are being meaningfully reviewed. Her position on proposals to extend residency is that the problem is not the number of years but what happens inside them.
The Reimbursement Gap Between Male and Female Slings
Dr. Ferzandi reviewed the obturator sling procedure as performed in men and in women and found the surgical steps were essentially the same, just with more dissection and a larger incision for males because of the anatomy.
Work RVUs were slightly higher for the male procedure. She describes that as fair, since work RVUs are meant to reflect exactly that kind of difference. She then pulled CMS data for the same procedures under urology versus gynecology. Hospital payment, she found, was close to two and a half times higher for urology.
As Dr. Ferzandi describes it, gynecology is often financially disadvantaged within hospital systems; it lacks the high-margin implant revenue of specialties like orthopedics but is held to the same strict productivity metrics. To address this systemic issue, AUGS is advocating for a dedicated urogynecology subspecialty code. Dr. Ferzandi says that without a code, urogynecologists cannot be separated from the broader pool, which means no quality data, no workforce data, and no basis for a payment reform conversation with CMS.
The Business Skills Nobody Teaches
Dr. Ferzandi directly addresses a gap in medical training. She says very smart people are often bad at business, and health systems are structured in a way that can take advantage of that. She advises junior faculty to:
- Wait three to six months before taking a billing and coding course to ensure enough practice history
- Self audit the sheets you are given and compare them to your own calendar and case log
- Build a relationship with your billing and coding team
Dr. Ferzandi applied this mindset within her own practice by shifting initial consultations to telemedicine. This allows her to take a full history, order imaging, and get a bladder diary started before a patient ever comes in. This condenses work that took three or four visits into just two, and saves the patient time as well.
The larger message from Dr. Ferzandi is simple: women deserve to know that this specialty exists, understand the choices available to them, and feel empowered to ask why a particular treatment is being recommended. Better awareness of urogynecology is not simply a branding exercise. It can influence whether women reach the right specialist and receive care matched to their individual condition.
I would also keep VNEW out of this article. The educational approach gives ARMS more credibility and makes the piece stronger long term.
Episode Timestamps
| Time | Topic |
| 00:24 | Introduction: leaking is not a lifestyle |
| 02:12 | Working with industry, and being a tinkerer |
| 03:02 | The concern behind the presidential address |
| 04:33 | Arriving at USC to find everyone doing one sling |
| 05:08 | Building a deliberate multi-technique paradigm |
| 07:51 | One-trick ponies and why they are a risk |
| 08:38 | What narrow training does to market access |
| 11:42 | Her own training, and why it protected her |
| 12:54 | Residents more comfortable with C-sections than hysterectomies |
| 16:47 | Minimum case numbers versus competency |
| 18:03 | Why extending residency is the wrong fix |
| 18:47 | Should OB and GYN be split |
| 21:58 | The chief resident who stopped operating |
| 23:36 | Redesigning clinic workflow around telemedicine |
| 28:42 | The business skills medical training leaves out |
| 30:15 | Why you have to self-audit |
| 34:52 | Minnows in a sea of sharks: women’s health inside hospital systems |
| 37:16 | The case for a urogynecology subspecialty code |
| 37:49 | Comparing male and female sling reimbursement |
| 40:39 | Wait times, and why the numbers are unreliable |
| 42:47 | Insurance denials and comparable providers |
| 45:30 | What women should ask their surgeon |
| 47:00 | A challenge to trainees and program directors |
| 51:41 | Ten minutes in sterile processing |
FAQS
A urogynecologist is a subspecialist who treats pelvic floor disorders in women. Dr. Ferzandi describes the practice as covering the major buckets of female incontinence, prolapse, recurrent urinary tract infections, hematuria, and fistulas, alongside advanced gynecologic surgical care. Most complete OB-GYN residency first, though a small number train through urology.
Training and scope. A urogynecologist treats women exclusively and completes a three-year board-accredited fellowship in urogynecology and reconstructive pelvic surgery after OB-GYN residency. Dr. Ferzandi describes that fellowship as focused on becoming an advanced gynecologic surgeon, covering the full range of pelvic floor conditions from non-surgical management through complex reconstruction.
Pelvic organ prolapse, urinary incontinence, recurrent urinary tract infections, blood in the urine, fistulas, vaginal masses and cysts, obstetrical injuries, and endometriosis. Dr. Ferzandi notes that many patients have overlapping conditions and often arrive already diagnosed but without a clear next step.
Seven years after medical school for the OB-GYN pathway: a four-year residency followed by a three-year board-accredited fellowship. Dr. Ferzandi notes the fellowship has been board accredited for more than ten years and includes a research component alongside surgical training.
Dr. Ferzandi’s advice is to be curious. Ask where the surgeon trained, and ask how many different ways they perform the procedure being recommended. If a surgeon is unwilling to explain the options available to you, or why an alternative is not being offered, she suggests seeking another opinion.
Dr. Ferzandi calls it a branding problem and notes that it extends beyond patients, since many primary care physicians are also unfamiliar with the subspecialty. She says AUGS is running public service announcements and working with patient advocacy groups to improve recognition.
Dr. Ferzandi compared the obturator sling performed in men and in women, procedures she describes as nearly identical in surgical steps. Work RVUs were slightly higher for the male procedure, which she considered a reasonable reflection of the additional dissection involved. Reviewing CMS data for the same procedures under urology versus gynecology, she found hospital payment was close to two and a half times higher on the urology side.
