A urologist is a doctor who specializes in helping both male and female patients with problems of the urinary tract as well as helping with problems of the male genitalia. Urologists typically specialize in helping patients who are having problems of the kidneys, adrenal glands, ureters, urinary bladder, urethra, and male reproductive organs. Since problems of the reproductive organs and urinary tract are often linked and related, many problems fall under the more general term of “genitourinary disorders.”
In the United States, urology is currently one of the most competitive medical fields. Every year, fewer than 1.5% of medical school graduates graduate with a degree in urology. In Canada, medical professionals working in the urological field are even rarer, comprising roughly .1% of the total population of doctors. In the United States, urologists must complete a mandatory period of at least five years of post-medical school training in order to become fully licensed. 12 months of that post-graduate study must be completed in the general surgery field, and 36 months must be completed specifically within clinical urology. After both of these specific time periods, another 12 months must be spent doing a student’s choice of work within general surgery, urology, or any other field that can relate to urologic surgery. After this minimum amount of training, many students decide to continue their training by doing a 12-36 month fellowship on a more specific field within urology. Typically these fields include (but are not limited to) pediatric urology, urogynecology, reconstructive urological surgery, urologic oncology, and many others.
Since urologic science can frequently merit special knowledge, there are eight officially-recognized sub-disciplines of urology. They are listed and described below:
Endourology
Endourology involves a special form of urologic surgery that is particularly non-invasive. This is typically reserved for kidney stone surgeries, urothelium surgery, and prostate surgery. Using this method of surgery, urologists can perform procedures using very small cameras and instruments that can be operated remotely. Thanks to the non-invasive nature of this particular specialty, these procedures provide a significant increase to patient comfort.
Urologic oncology
This sub-discipline revolves around issues of cancer within urinary tracts and reproductive organs. Common forms of cancer that this specialty typically helps are cancers of the penis, testicles, kidneys, bladder, or prostate. Similarly to endourology, the sensitive nature of many instances of these types of cancer have encouraged doctors to explore the use of robots and other remotely operated tools that help urologic oncologists to be especially sensitive and non-invasive.
Laparoscopy
This sub-discipline is primarily focused on the use of robots within urologic surgery. So, while this sub-discipline shares some aspects with the previous two disciplines, it is differentiated by the defining characteristic being the method of surgery and not the specific problem meriting treatment. While the use of such advanced technology has helped there to be a decrease in invasive urologic procedures in recent years, the price of the technology and relative newness of these methods can cause them to be quite expensive when compared to more traditional methods.
Neurourology
This specialty primarily revolves around helping patients who have urological problems that are caused by other neurological problems. Problems within the urinary tract can be caused by physical trauma (such as spinal injuries) as well as neurological conditions such as M. S. and Parkinson’s disease.
Andrology
Andrology is a sub-discipline concerning male urologic disorders. Disorders in this category are typically those surrounding ejaculatory issues, erectile dysfunction, and even problems between sexual partners. Frequently, patients will need to visit both an andrologist and endocrinologist since male urologic and sexual disorders are frequently linked to hormonal imbalances. Common procedures performed under the umbrella of andrology include the installation penile prostheses, reversing vasectomies, and aiding in fertilization.
Female urology
This specialty focuses on helping women with urologic disorders. Problems that might merit a visit to a urologist specializing in specifically female problems include overactive bladder issues, bladder control problems, and even pelvic organ prolapse. Since these problems both affect women more frequently than men and since treating them in women requires a more nuanced understanding of the female genitalia and urinary tract, female urology has become a discipline distinct from both urology and gynecology. However, there is significant overlap between this discipline and urogynecology, a sub-discipline of gynecology.
Pediatric urology
This specialty relates to problems specific to children. Common problems in this realm include issues with genitalia that fail to follow typical progressions of development, enuresis, undescended testicles, and vesicoureteral reflux. In order to have proper training to treat issues within this domain, a urologist will likely have done a fellowship in pediatrics.
Reconstructive urology
The last sub-discipline within the general urologic heading primarily deals with helping to fix problems of the genitourinary tract that require surgical reconstruction. Frequent sources of problems of this nature include childbirth, physical obstruction, diseases, trauma, and hysterectomies.
Common Urologic Disease
As the amount of different urologic specialists may suggest, medical problems requiring a urologist are varied and high in number. According to the American Urological Association Foundation (AUAF), these are some of the most common reasons that a patient may visit a urologist.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia is a condition involving a male’s prostate becoming enlarged, defined as being an enlargement of the prostate gland. When this occurs, the enlarged prostate can press on a male’s urethra. Since the urethra is the tube that carries urine from the bladder out of the body, when the prostate presses on it, it can cause difficulty with urination. Common signs and symptoms of this condition are primarily frequent urges to urinate, weak streams of urine, and a feeling that the bladder is not empty even after finishing urinating. Most cases can be monitored and controlled with medication, but some extreme cases may require surgery.
Urinary Incontinence
Urinary incontinence is considered to be a loss in bladder control resulting in uncontrollable urine leakages. While inconvenient and embarrassing, this issue is quite common. According to data provided by the UAUF, over 15 million people in the United States alone are affected by urinary incontinence on a regular basis. There are many factors that can lead to urinary incontinence, including diabetes, pregnancy/childbirth, overactive bladder, enlarged prostates, weak bladder, weak sphincter muscles that support the urethra, urinary tract infections, neurological diseases such as M. S. and Parkinson’s disease, spinal cord injury, and severe constipation. Frequently, these issues can be controlled by simply controlling fluid intake so that there is less liquid that the body needs to process but in some severe cases, a urologist may recommend a surgical option that may do a more effective job at permanently fixing the root issue.
Urinary Tract Infections
Urinary tract infections (UTIs) are caused by pathogens which have gotten into one’s lower urinary tract and cause infection. UTIs are much more common in women than in men: according to data provided by the UAUF, roughly 40% of women will contract a urinary tract causing noticeable symptoms at some point in their adult life, whereas only 12% of men will have similar symptoms. The most common symptoms of a urinary tract infection are frequent urges to urinate, pain or burning sensations while urinating, and a feeling that the bladder is not empty after urinating. Typically, urinary tract infections can be controlled by a course of antibiotics. However, in some extreme cases, urinary tract infections can migrate up the urinary tract to form kidney infections that may become more serious and require hospitalization. While rare, these may be serious and require emergency treatment.
Kidney and Ureteral Stones
“Stones” may develop along the urinary tract when small crystals accumulate in the urine and collect particles on them. Eventually, the accumulation of these particles may result in small stones becoming large and causing a patient significant pain upon expulsion. Kidney stones differ from ureteral stones in that ureteral stones form between the kidneys and the ureters (the tubes that carry urine from the kidneys to the bladder) and kidney stones form in the bladder. Most commonly, people can expel small kidney and ureteral stones by themselves. However, in cases of large stones, the stones may cause blockages that require medical attention. In these cases, surgical procedures may be necessary. The most commonly used technique for this type of surgery is called extracorporeal shock wave lithotripsy (ESWL). This process essentially uses sound waves to break up the stones to a point where the patient will be relatively comfortable while passing them.
A Brief History of Urology
The field of urology has ancient origins. While the field, as it existed in Egyptian and Babylonian times, was very different from the field as it currently exists, the study of urine as an indicator of full body health is not a new idea.
In its earliest form, then, the study of human urine color and urinary sediment was seen as an indicator of total health with little to no thought of urine indicator existing as an indicator of localized disease. The writings of Hippocrates is one of the earliest documents of the study of urine. His writings and the writings of his assistants primarily focused on the amount, size, location, and color of sediment found in the urine. Black, thick and “offensive” urine was considered to be the most concerning and most indicative of a patient’s poor health. They also sought to discern which part of the urinary tract was causing the issues presenting themselves within a patient’s urine. In this way, they began to distinguish problems of specific parts of the urinary tract as distinct from diseases associated with the body as a whole. For instance, the idea was recorded that bubbles in the urine were indicative of a problem with the kidneys that would likely last for a long time. Blood in the urine was associated with broken renal veins, inflammation of the kidneys, bladder ulcers, and diseases present in the parts of the body surrounding the bladder and urinary tract. He was quoted as having written that “Bloody urine does not indicate anything serious if it occurs rarely and without fever and pain, but when it appears often and one of these other symptoms is present, then it is a dangerous sign." Finally, Hippocrates provides a formal description of the symptoms of small stones being passed in the form of “sandy” particulate matter found in the urine that can be associated with penile discomfort.
In the Corpus Hippocraticum, the most famous collection of work performed by Hippocrates and his associates, the early methods of detection are described. In one section of it, the methods for detection of “acute and chronic catarrh of the bladder, inflammation of the urethra with a discharge of pus, periurethral and prostatic abscess, dysuria, stranguria, ischuria and vesical calculi” are described as primarily relying on palpation of the urinary tract as accessed via a patient’s rectum. Furthermore, there is evidence of the use of catheters as primary urological tools (though they appear to have not been used for the relief of bladder or kidney stones). Also included are some hypotheses for the causes of various problems surrounding the urinary tract. For one, the frequency with which a patient suffered from lithiasis was attributed to how often he or she consumed muddy or sandy water. Finally, wounds to the bladder were seen as being inevitably mortal.
Later in this work, there exists a description of treatment procedures for urinary stones. Hippocrates or one of his associates wrote that there were special cutters of “stone” who were distinct from the physicians of the time. Therefore it appears that there were medical professionals whose primary duty was to relieve patients of pain from one of the most common urologic problems that likely occurred during that era.
Around 300 B.C. is the first time that specialized catheters are described by a medical professional. Erasistratus proposed the S-shaped catheter, presumably indicating a relatively more in-depth understanding of the structure of the structure of the urinary tract. This is similar to one found in Pompeii that is known as a “double curvature” catheter. Furthermore, an Alexandrian surgeon known as Ammonius is credited with having invented an instrument that could be used to crush stones in the urinary tract. Think of this as an early analogue to the extracorporeal shock wave lithotripsy procedure described above!
Celsus, an early (second century) Greek philosopher and student of past medical inquiry, was perhaps the next person to further the study of urology. When describing symptoms of passing urinary stones, he wrote that “Those suffering from stone could be recognized by the following signs: The urine is voided with difficulty and in drops; occasionally it is passed involuntarily. It contains sand-like admixtures and at times bloody or purulent material. Some can only void in the upright posture; others only when lying down, and this is the case especially when the stone is large. Others can succeed best if they bend forward and lessen their pains by stretching the urethra. There is also a feeling of great heaviness, which is increased by running or by any movement. If the kidneys are diseased, then they are apt to be diseased for a long time.” He also provided his own ideas on the best ways to help oneself when dealing with such issues. Included in these, he recommends that patients eat foods that are not sour, spicy, or salty, give themselves enemas, and that they hydrate well by drinking “an abundance of water” and a mixture of substances that help to dilute the urine. Furthermore, he suggests that physicians help patients by inserting a catheter and monitoring the condition of the patient’s urine.
Perhaps the most famous section of Celsus’ text is one describing how to perform surgery on the portion of the urinary tract located between the bladder and the urethra. In this, he describes exactly how physicians can cut a patient open to perform “deep lithotomy” in order to extract stones that may be causing a blockage. This section of text was likely based on Alexandrian techniques and its importance and influence is best exemplified by the fact that the procedure, as Celsus described it, was used up until Renaissance times.
Following the tradition of building upon knowledge of urology based in studies from classical antiquity, Byzantine medical scholars largely founded their work in the work that Galen had done. In the fourth century, medical scholar Oribasius mentions several tumors, one of which is located in the bladder. According to modern analysis of his writing, this is largely one of the first prominent mentions of an enlarged prostate. Furthermore, two hundred years later, medical scholar Aetius includes a chapter on the formation and treatment of kidney stones. While lithotomy is mentioned as a possible treatment, it is not described in full and thus there is not any evidence of what the procedure looked like at this point in the development of urological science. Several different dietary and pharmaceutical treatments are mentioned as ways of increasing patient comfort and treating the stones. Furthermore, he advises that physicians perform a urethrotomy (cutting open of the urethra) in the case that a patient’s urethra is completely blocked by impacted stones.
Around the same period, several other physicians began to discuss methods of both treating and preventing urinary tract infections. Among different treatment strategies were the employment of diuretics, with the thought that they would help to flush out the pathogenic bacteria leading to infection and inflammation. Additionally, one physician named Alexander attempted to differentiate between diseases of the kidneys and diseases of the bladder by noting that “strangury usually points to disease in the bladder; if the urine contains pus, it is suggestive of the presence of ulcers in the bladder. If there is no pain or swelling in the region of the bladder and no retention, the disease has its seat in the ureters or the kidney. Suppurative inflammations of the kidney are characterized by fever, pains and chills. The patient experiences a sense of weight when lying on the healthy side and every effort increases the pain.” These thorough descriptions at an early stage in the development of urologic medicine helped to provide a strong foundation for the work of future scholars of the subject.
Around the 18th century, urologists began to look more closely at the chemistry of urine in order to diagnose and treat diseases of the urinary tract. Around this time period, studies on the pathology of different urological diseases by Bonet and Morgagni accurately demonstrated the relationship between ascites and the changes in the kidneys – confirming conjectures proposed by many of the early urological scholars such as Hippocrates, Galen, Aetius, Avicenna, and William of Saliceto. Furthermore, they were able to analyze the chemistry of urinary decomposition as a method of diagnosing cystitis. This, in turn, provided a basis for the separation of urea and ammonia in 1799. In doing so, they provided the groundwork for diagnosis of diabetes by noting differences in the chemical composition of those with and without the disease. All of these discoveries display the importance of the foundation that the early urological scholars had on studies even almost two millennia later.
As mentioned earlier, urology has developed very rapidly since these discoveries. The invention of very small robots, cameras, and various other tools used in urologic surgery has allowed the practice to become much less invasive and vastly improve patient comfort. Long gone are the days of using bronze catheters to attempt to physically crush kidney stones – sound waves now perform the same task with much less pain for the patient. While the basic principles of urology have been under development for centuries, the technological advances currently being employed in the field have provided such great increases in how carefully physicians can treat their patients that the field has recently advanced much faster than ever before.
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