In this episode of The Expert APProach: Conversations in Uro-Oncology, host Joy Maulik, CRNP, sits down with Michael Ritmiller, PA-C, MPAS, a neuro-urology physician assistant whose career has been defined by deep clinical expertise, procedural skill, and a commitment to comprehensive, patient-centered care. Ritmiller shares his background as a Navy veteran and surgical corpsman and describes his transition into physician assistant practice, where he has spent more than 2 decades caring for patients with complex neurogenic bladder conditions. His work spans spinal cord injury, stroke, traumatic brain injury, and other neurologic disorders that profoundly affect bladder function. A major focus of the discussion is the role of video urodynamics in evaluating voiding dysfunction. Ritmiller explains how advanced urodynamic testing allows clinicians to assess not only bladder pressures and flow, but also bladder anatomy, sphincter coordination, reflux, and long-term risk to the upper urinary tract. He emphasizes that voiding dysfunction is often neurologic in origin and reflects impaired communication between the brain, spinal cord, and bladder rather than a purely urologic problem. The conversation explores how he formulates individualized treatment plans by evaluating the patient as a whole—incorporating neurologic exam findings, caregiver input, functional status, cognition, and risk factors. Management strategies may include medications, intermittent catheterization, Botox injections, urethral bulking agents, suprapubic tube placement, or staged procedural interventions, with careful attention to safety, bleeding risk, autonomic dysreflexia, and patient education. Ritmiller also provides a nuanced discussion of urinary tract infections in neurogenic patients, highlighting the importance of symptom-based treatment rather than relying solely on urine cultures. He outlines his approach to recurrent infections, reflux-associated risk, and advanced management options such as intravesical gentamicin instillations for select patients. Beyond clinical care, the episode highlights the evolving role of advanced practice providers in urology. Ritmiller advocates for APPs practicing at the top of their license to address workforce shortages, reduce burnout, and improve access to high-quality care. He reflects on the importance of mentorship, humility, lifelong learning, and institutional support in developing procedural confidence and subspecialty expertise. The conversation concludes with a shared emphasis on team-based care, professional growth, and the impact that empowered APPs can have on patients, practices, and communities.
