What is a urologist? What do urologists do?

A urologist is a physician who specializes in diseases of the urinary tract and the male reproductive system. This can include diseases affecting the bladder, urethra, ureters, kidneys, and adrenal glands, along with the epididymis, penis, prostate, seminal vesicles and testes specifically in men.¹

Urology is commonly regarded as a surgical specialty. There are a wide variety of different procedures that urologists carry out, such is the scope of urology as a field.

In 2013, there were an estimated 9,500 urologists in the USA. This number has been projected to fall to 7,500 by 2020. It is considered to be an aging specialty; in 2012, 44% of urologists were aged above 55, 18% were aged above 65, and 8% were aged above 70.²

In a 2012 survey of 29,025 physicians representing 25 different medical specialties, however, urologists were found to be the third happiest with their lives outside of work, behind physicians practicing rheumatology and dermatology. Urologists reported an average happiness rating of 4.04 on a scale of 1-5, with 1 meaning "very unhappy" and 5 meaning "very happy."³

What is urology?^4,5

Urology, the study of conditions of the urinary tract and male reproductive system, is a broad field. Although it is generally classified as a surgical specialty, urologists require knowledge of other specialties such as gynecology and internal medicine due to the wide variety of clinical problems that they have to deal with.

The American Urological Association (AUA) have identified seven subspecialties that comprise the field of urology:

Urologists treat conditions that affect the urinary tract in men and women, as well as the male reproductive system.

• Calculi: the management of stones that form within the kidneys and move into the ureters.
• Female urology: pelvic outlet relaxation disorders and urinary incontinence.
• Male infertility: primarily surgical correction of acquired and congenital obstructions within the male genitals.
• Neurourology: includes erectile dysfunction and impotence, urodynamic evaluation of patients and voiding disorders.
• Pediatric urology: treatment of urological problems within children that are too complex for non-specialized pediatricians or urologists.
• Renal transplantation: kidney transplants may be required following kidney failure.
• Urologic oncology: treatment of cancers such as bladder cancer and prostate cancer.

Urology is a constantly changing specialty, primarily due to advances made to technology. Refinements to endoscopic procedures and the utilization of the surgical microscope have greatly increased urologists' options. Laparoscopic surgery and chemotherapy are altering how treatment is administered, and laser therapy promises to become an important part of future urologic practice.

Urologist qualifications¹

To become a urologist in the USA, candidates will graduate from an approved medical school and complete a urology residency program that takes a minimum of 5 years to complete, accredited by the Accreditation Council for Graduate Medical Education (ACGME).

During this residency program, 1 year must be spent in general surgery and 3 years must be spent in clinical urology. A minimum of 6 months can be allocated to general surgery, urology or another discipline that is relevant to the study of urology. During the final year of training, candidates will be posted as a senior/chief resident in urology, being given supervised clinical responsibility.

Surgeons may apply for certification from the American Board of Urology (ABU) following the completion of their graduation. In order to attain certification, they must complete and pass a qualifying examination and a certifying examination.

Common conditions treated⁶

The following list of conditions are commonly treated by urologists. Please note that this list is by no means exhaustive:

Kidney stones are hard deposits found in the kidneys and ureters, comprised of mineral and acid salt deposits.

• Bladder prolapse: when the tissues and muscles of the pelvic floor are no longer able to support the organs in the pelvis, the organs can drop from their usual position. As well as the bladder, this can affect the urethra, rectum, cervix, vagina and uterus. This condition is more common in women than men, and crosses over into the field of gynecology and a further subspecialty called urogynecology.⁷
• Cancer (bladder, kidney, prostate, testicular):prostate cancer is the second most common cancer in the US, with 233,000 new cases and 29,480 deaths estimated for 2014. Bladder cancer is the sixth most common cancer in the US, with 74,690 new cases and 15,580 deaths estimated for 2014. Urologists also treat cancers of other organs that fall under the scope of urology.⁸
• Enlarged prostate: also referred to as benign prostatic hyperplasia (BPH). BPH affects around one-third of men over 50.⁹ The prostate is a male gland located just below the bladder, surrounding the urethra. In BPH, an overgrowth of cells in the central portion of the gland causes the urethra to constrict, hindering urination and making it difficult for the bladder to be emptied.¹⁰
• Erectile dysfunction: when the penis is unable to attain sufficient rigidity to fully participate in sexual intercourse. Frequently, erectile dysfunction is a symptom of a further underlying problem. Between 15 million and 30 million Americans are estimated to have erectile dysfunction.¹¹
• Incontinence: an involuntary loss of bladder control caused by part of the urinary system malfunctioning. Close to 20 million Americans are believed to experience urinary incontinence - 85% of whom are women.¹²
• Infertility: while infertility in women is normally treated by gynecologists, male infertility is treated by urologists. Male partners are estimated to contribute to 40% of cases of infertility within couples. The condition can be caused by damage to the male reproductive tract and a variety of sperm disorders. A third of cases are caused by varicoceles - an enlarged vein in the sac beneath the penis.¹³
• Interstitial cystitis/Painful bladder syndrome: a chronic inflammatory bladder condition producing discomfort at varying levels and frequencies. Although the cause is unknown, it is believed that a breakdown in the bladder's lining could be related to the disease.¹⁴
• Kidney and ureteral stones: small, hard deposits made from mineral and acid salts form in the kidneys but can pass through into the ureters.¹⁴ Stones can affect urination and cause pain, nausea and vomiting.¹⁶
• Peyronie's disease: a disorder whereby a fibrous layer of scar tissue develops beneath the skin of the penis. This growth affects the erectile tissue, leading to bending or curving in the penis during erection that can cause pain and lead to difficulties with sexual intercourse.¹⁷
• Prostatitis: infection or inflammation of the prostate (as opposed to overgrowth as in BPH) can cause painful urination or ejaculation. Prostatitis is the most common urologic condition in men under 50. Cases can be acute or chronic.¹⁸
• Undescended testes: also referred to as cryptorchidism, undescended testicle is the most common genital abnormality in men. Around 4% of males are born with the condition. In normal development, testicles form inside the abdomen and descend into the scrotum before birth. If one or both do not descend, sperm production can be impaired and the risk of injury is much higher.¹⁹
• Urethral stricture: whereby scarring of the urethra can narrow or block the path of urine flowing from the bladder. Urethral stricture can be caused by infection, inflammation or injury, leading to urinary symptoms such as painful urination and reduced output. Complications include other urologic conditions such as prostatitis and urinary tract infections.²⁰
• Urinary tract infections (UTIs): a common complaint in women, whose lifetime risk is more than 50%. UTIs are frequently caused by the migration of bacteria from the digestive tract to the urethra. Common symptoms include abnormal urination, pain, incontinence, nausea, vomiting, fevers and chills.²¹

Common procedures performed²²

Urologists treat conditions with medical management or surgery, depending on the nature of the condition that is presented to them. As urology is generally classed as a surgical specialty, there are an unsurprisingly large number of different procedures that most urologists can perform if required.

Below is a list that includes some of the most common procedures that urologists perform, either in an outpatient or inpatient settings:

Erectile dysfunction is a urological condition that affects somewhere between an estimated 15-30 million Americans.

• Circumcision: removal of the skin from the tip of the penis. This procedure can be carried out for cultural and religious reasons, but also for medical reasons if the male experiences problems with retracting the skin over the glans.²³
• Cystectomy: partial or complete removal of the bladder. Most frequently used to treat bladder cancer, cystectomies can also be performed to treat traumatic injuries or defects and neurological disorders affecting the urinary system.²⁴
• Cystoscopy: a diagnostic test whereby a urologist examines the inside of the bladder and urethra using a tube with a lens called a cystoscope. Cystoscopes can also be used to take tissue samples and perform simple procedures. A cystoscopy can be performed as a simple outpatient procedure or as an inpatient procedure with general anesthetic.^25,26
• Excision and biopsies: the removal of a tissue sample or lesions as part of the diagnostic process. Depending on the size and location of the area the sample is being taken from, biopsies can be conducted under local or general anesthetic, as an outpatient or an inpatient procedure.²⁷
• Kidney transplantation: a surgical procedure conducted to replace kidneys that do not function properly with a donated one that does. Only a single working kidney is required to replace two failed kidneys, meaning that kidneys can be provided by living donors.²⁸
• Nephrectomy: a surgical procedure conducted to remove all or part of a kidney, typically carried out in order to treat kidney cancer or to remove kidneys that are seriously damaged. This procedure can be performed through open or laparoscopic (keyhole) surgery.²⁹
• Penile prosthesis: used to treat erectile dysfunction, implants can be placed inside the penis by a urologist to enable the patient to achieve an erection. This procedure is generally recommended once other treatment options have failed.³⁰
• Prostate surgery: the symptoms of BPH can be relieved through various forms of surgery. Prostatectomy, laser surgery and transurethral resection of the prostate (TURP) can all be performed, depending on the patient's health, the severity of the symptoms, and the size and shape of the prostate.^31-33
• Stress incontinence surgery: the majority of procedures performed to treat stress incontinence are either sling procedures or bladder neck suspension procedures. Slings are used to support the urethra and keep it closed, and suspensions strengthen the urethra and bladder neck to prevent them from sagging.^34,35
• Testicular surgery: there are several procedures involving the testicles that are commonly performed. Hydrocele repairs involve the draining of built-up fluid from around the testicles. Varicocele surgery involves the tying off of affected veins to redirect blood flow to healthier veins. Orchiectomy is the removal of one or both testicles, often as part of cancer treatment.^36-38
• Transurethral bladder tumor resection (TURBT): a surgical procedure used for cancer diagnosis, staging and treatment. Using a cystoscope, a urologist can remove bladder tumors using high-energy electricity, a laser or a small wire loop.³⁹
• Stones treatment: stones in the kidney and ureters can be dealt with in several different ways. Sound waves can be utilized in a procedure called extracorporeal shock wave lithotripsy. Large stones can be removed directly from the kidney with open surgery called percutaneous nephrolithotomy. Small stones can be removed using a scope called a ureteroscope.⁴⁰
• Urethral dilation: urethral stricture can be treated by stretching the stricture using dilators to widen the urethra. This can also be achieved using a catheter and a special balloon. This procedure needs to be repeated each time a stricture reappears.⁴¹
• Vasectomy: a form of male birth control whereby a urologist cuts and seals the sperm-carrying tubes in the genitals. It is a simple procedure that can be carried out in a clinic under local anesthetic. Vasectomy is considered to be a permanent form of birth control, although in some cases a urologist may be able to reverse the procedure.⁴²

When to see a urologist

Patients are advised to seek the advice of a urologist if they experience any problems affecting their urinary system. Male patients should also contact a urologist regarding problems with their reproductive system, annual prostate health checks or if they wish to have a vasectomy.⁴³

Due to the wide scope that urology encompasses, patients seeing urologists could be referred on to experts within other specialties. Likewise, a patient referred to one specialist may find themselves referred on to a urologist if it the condition being treated is deemed urological.

References:

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4.        AUA What is urology?, accessed 26 November 2014.

5.        Urology Care Foundation Kidney (renal) transplantation, accessed 26 November 2014.

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8.        National Cancer Institute Common cancer types, accessed 27 November 2014.

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41.     Urology Care Foundation Urethral stricture disease, accessed 1 December 2014.

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