Guide to urologists & the specialty

Urology is the branch of medicine that deals with the prevention, diagnosis, treatment and aftercare of diseases of the kidneys and urinary tract in women, men and children, as well as the male reproductive organs. Urologists also treat reproductive and sexual problems. As the specialty developed from surgery, all surgical therapies in this area are also part of the urologist’s remit.

Abstract

• Urology treats diseases of the urogenital system. This term covers the urinary and reproductive organs.
• The urogenital system (also: urogenital tract) falls under the specialties of urology and gynaecology. Urologists specialize in diseases of the male genital tract.
• Bladder, kidneys, prostate and co.: Examples of common urological diseases are kidney and urinary stones, benign enlargement of the prostate, urinary disorders and infections.
• Urology is also important for the detection and treatment of tumors in theurogenital tract, as three of the ten most common malignant cancer diagnoses are in the field of urology.
• The most common malignant tumor in men is prostate cancer.
• Erectile dysfunction is also a sensitive urological disorder that is often taboo and remains untreated.
• Many urological diseases can be prevented through lifestyle , and even 40 percent of cancers are considered preventable.

Profile Urology

Contrary to popular belief, urological diseases are numerous and widespread. Old and young, men, women and children – everyone can be affected. Urologists are doctors for all diseases and functional disorders of the urinary and reproductive organs, in short: for the urogenital system/genitourinary tract. However, they specialize in diseases of the male genital tract, which is why they are often referred to as “men’s doctors”. The urogenital system includes

The urinary organs

• Kidneys
• Ureter
• Urinary bladder
• Urethra

The sexual organs – here: of the man

• Penis
• Scrotum, testicles and epididymis
• Prostate
• Vas deferens and seminal vesicles

Further training as a doctor of urology

After studying medicine, further training in urology takes five years. In accordance with the 2018 model training regulations of the German Society of Urology (DGU), training has been focused on outpatient care since 2021, although inpatient care is of course still required. During these 60 months, students often operate independently. As the specialty has evolved from surgery, all surgical therapies in this field are also part of the urologist’s duties. The training to become a urological doctor is completed with an examination before the relevant state medical association.

Further specializations are possible during the training, for example:

• Additional title AndrologyThe specialist for male sexuality and reproduction – the counterpart to the gynecologist – is called an andrologist.
• Additional qualification in proctology: Proctologists, or bowel specialists, deal with the structures adjacent to the urinary tract, the rectum – i.e. the rectum and anal canal – and the pelvic floor.

Fields of activity

Urologists work in private practice or are employed as doctors in a clinic. The detection and treatment of tumors in the urogenital tract is particularly important to them, as three of the ten most common malignant forms of cancer are in the field of urology. First and foremost is prostate cancer, followed by bladder cancer, kidney cancer and testicular tumors in younger men.

Stone disease, benign prostate enlargement and urinary incontinence are also common in millions of men. And up to eight million men have erectile dysfunction. There are still many taboos to overcome here, because despite the high level of suffering, many sufferers remain silent out of shame.

The urologist’s field of work also includes male infertility, kidney disease or
transplants as well as foreskin constriction (phimosis), undescended testicles and nocturnal enuresis in children, local anesthesia and the examination of germ cells, blood, urine, etc. in the laboratory. Last but not least, urologists also deal with men’s health(andrology) and drug-based tumor therapy.

Common urological diseases

Problems with potency and fertility as well as prostate and bladder diseases are issues that men unfortunately usually only deal with when symptoms become noticeable. The most common diseases in urology include

Prostate carcinoma

It is a cancer of old age and not harmless: prostate cancer mainly affects men over 70, is the most common malignant tumor at 23% or 70,000 new cases per year (as of 2019) and the third most common cause of cancer death in men in Germany at just under 12%. However, if detected early, prostate cancer is over 70 percent curable. As with all types of cancer, there is an excellent chance of treatment, especially in the early stages, and life expectancy is not necessarily affected. However, if detected too late and treated too late, this type of cancer can quickly lead to death.

Benign prostate enlargement (benign prostatic hyperplasia, BPH)

If problems occur when urinating, an enlarged prostate can obstruct the flow of urine. The starting point is the part of the prostate that directly surrounds the urethra. Gradually, the urethra becomes constricted, which can lead to discomfort: The urinary stream becomes weaker and the urge to urinate more frequent. Only a urologist can check whether the change is benign or malignant.

Stone disease

Urinary stones are deposits of crystals that can occur throughout the urinary tract. Depending on their location, they are called ureteral, kidney or bladder stones. Kidney stones are among the ten most common reasons for admission to hospital.

Reasons for the development are a lifestyle with suboptimal habits (diets, lots of alcohol, lack of fluids, lack of exercise), metabolic disorders, recurrent urinary tract infections, congenital and acquired changes to the kidneys and urinary tract (constrictions, malformations, pregnancy, nerve damage).

Urinary stones form due to increased concentrations of calcium, uric acid and other substances in the urine; foods with a lot of oxalic acid, such as beet, spinach, chard, rhubarb, coffee, cola, chocolate and peanuts, have a favorable effect.

Symptoms are stabbing pains or colic that can radiate to the lower abdomen, groin and even the genitals, often accompanied by nausea and vomiting. Four out of five kidney stones can be excreted in the urine, as long as you drink enough and change your diet.

Women suffer from kidney or bladder stones just like men, but much less frequently because their urethra is shorter and bacteria ascend into the bladder more quickly. Women therefore have bladder infections more frequently.

Urinary incontinence

Bladder weakness and increasing urinary incontinence is age-related in many patients and, in women, is often the result of stress, childbirth or damage to the urethra. It is important to realize that incontinence is not a disease in its own right, but always the result of existing illnesses. The most common forms include slight urine leakage during physical exertion (stress incontinence) and a strong urge to urinate with involuntary urine leakage (urge incontinence). There are other types of incontinence that are differentiated according to certain criteria.

Renal insufficiency

The kidneys detoxify the blood and ensure that filtered pollutants are excreted in the urine. If both kidneys can no longer adequately perform their filtering function, this means an increased burden for the entire organism in the long term: “body waste” is no longer removed via the urine and accumulates in the blood; the blood is no longer sufficiently purified. Drivers of such a process are diseases such as diabetes mellitus or high blood pressure, but also medication.

Urologists differentiate between five stages of renal insufficiency, initially it is not noticeable or painful. However, those affected suffer from increased thirst and may have difficulty urinating. Those who do not consult a urologist at an early stage are sometimes not diagnosed until the kidneys are severely damaged.

Cystitis

If bacteria infect the urinary tract and, in the worst case, ascend to the bladder, they can cause cystitis. Due to their anatomy – short urethra – women are more frequently affected. Cystitis is contagious, especially for people living in the same household. Symptoms include a frequent urge to urinate with inadequate urination, pain radiating to the kidneys, a burning sensation when urinating and blood in the urine. A protracted, i.e. untreated cystitis can spread to the kidneys and cause inflammation there.

Erectile dysfunction (erectile dysfunction)

Erectile dysfunction can be caused by vascular changes, but also by hormonal disorders. If sexual enhancers are effective, the cause is probably in the small vessels. Risk factors for cardiovascular diseases are responsible for this. These need to be clarified, as does the question of whether there is diabetes and/or vasoconstriction in the pelvis, which does not provide enough blood in the urogenital tract to achieve an erection.

Diagnostics

Like every doctor, a urologist starts with a medical history. This is because not all diseases that fall within his area of expertise manifest themselves through local symptoms. During the consultation, the general state of health can be clarified as well as the current symptoms.

Various procedures are then used as part of the examination. In the case of women, attention is paid to the presence of assistance personnel.

• Palpation (palpation): External genital organs of the man and possibly the woman, urinary bladder, abdominal cavity (liver size, spleen, hernia, pressure pain, pain on release), kidneys
• Viewing (inspection): Abdominal cavity, anus, external genital organs of the man and possibly the woman
• Listening (auscultation): Intestinal sounds, kidneys
• Tapping (percussion): Urinary bladder
• Rectal examination (digital rectal examination, DRU): anus and prostate
• Ultrasound (sonography): Frequently used in urological patients, for example for abdominal and groin pain, urinary complaints, all types of kidney problems, urinary tract infections, pain in the abdominal cavity, erectile dysfunction, penile fractures, urethral stones, penile tumors, chronic pelvic pain, inflammation of the prostate, lymph node metastases in testicular tumors, not least in preparation for surgery
• Taking tissue samples (biopsy) for laboratory medical examinations
• Urinalysis
• Blood tests: Electrolytes, inflammation values, blood coagulation, kidney, heart, liver parameters, tumor markers, hormones
• Imaging procedures (CT/MRI): For many questions relating to the abdominal and pelvic area, kidneys, urinary tract
• Functional examinations (urodynamic examinations): If necessary, urinary stream measurements, urinary bladder pressure measurement

Depending on the diagnosis, it may be necessary for the urologist to consult a colleague from another specialty or refer patients accordingly.

Treatments

Modern options are available in urology, which are used depending on the disease and urgency. Many urological diagnoses can be treated on an outpatient basis; referral to a clinic is arranged by the urologist in private practice. Examples:

Outpatient

• Inflammations of the urinary tract, bladder, kidneys and renal pelvis are usually treated with antibiotics.
• Physiologically caused erectile dysfunction can also be treated with medication, for example in the case of poor blood flow to the cavernous bodies of the penis.
• No one has to put up with stress incontinence – a typical form of female incontinence. If there is no organic disease, the pelvic floor muscles can be strengthened with invigorating gymnastic exercises, Pilates and swimming. In addition to targeted physiotherapeutic pelvic floor training, weight reduction may also help.
• Ifrenal insufficiency is detected at an early stage, it can be treated conservatively using various methods. In diabetics, blood sugar levels must be optimally controlled. High blood pressure patients receive antihypertensive medication. A change in lifestyle, including abstaining from nicotine and painkillers (analgesics), has a supportive effect.

Stationary

• Stones that are stuck in the kidney or urinary tract are painful and dangerous, as they can lead to urinary retention. Clinics that specialize in surgical stone removal work with modern and endoscopic procedures and break up stones using lasers, ultrasound or shock waves, for example. To prevent “repeat offenders”, metabolic disorders and infections are treated with medication if necessary. A diet low in animal fats, purines, sugar, salt and oxalic acid also makes sense.
• Tumors or malformations that affect the function of organs or the body or have a negative impact on quality of life due to pain and emotional stress can be treated surgically.
• In the case of benign enlargement of the prostate, surgery is necessary if medication does not alleviate the symptoms satisfactorily or if problems such as residual urine, recurring urinary tract infections, bleeding or bladder stones occur.
• The kidneys and bladder can be colonized by tumours and cysts. Depending on the initial findings, treatment can be conservative; larger tumors may require surgical removal, even if they are benign. A kidney may have to be removed.
• In the case of late-stage renal insufficiency, only a donor kidney or dialysis can help.

Prostate screening

In addition to treatment, urologists are dedicated to prevention: early detection of prostate cancer and advice for patients who are susceptible to bladder or kidney stones.

Only a urologist can check whether an enlargement of the prostate is benign or malignant. Cancers grow in the outer zone of the gland – far away from the urethra, which is why they often do not cause any symptoms for a long time. When the first signs appear: Difficulty urinating, aching bones and weight loss, tumor is already large and has spread. A quarter of patients die as a result of the disease.

On the other hand, the tumor can be treated well if it is detected early. Men aged 45 and over are entitled to an annual examination of the prostate and external genitalia as a health insurance benefit. During the examination, the urologist inspects the external genitalia and palpates the prostate, the external genital organs and the lymph nodes. If a pathological process is suspected, an ultrasound-guided tissue biopsy is taken from the prostate and examined in the laboratory.

Regular early detection examinations offer the best chance of detecting a tumor at a treatable stage in good time.

Prevention

Many urological diseases can be prevented with an appropriate lifestyle, and even 40 percent of cancer diagnoses are considered preventable. It is now clear that a lack of exercise and overeating can also lead to urological conditions: urinary stones and erectile dysfunction, testosterone deficiency, urinary incontinence and renal insufficiency. These are all diseases that reduce quality of life, shorten lives and cost the healthcare system billions. Therefore, it is not only early detection that can save lives, but also targeted prevention for the bladder, kidneys, prostate and co. What does that look like? Like this, for example:

• Not smoking is the best protection against bladder cancer.
• Testicular cancer can be detected by palpation and, if detected early, is curable.
• Drinking enough, little to no alcohol and nicotine, normalizing body weight, exercise, a healthy and balanced diet (little meat, lots of fruit and vegetables, rarely sugar, rarely salt) and anti-stress techniques reduce the risk of prostate and kidney cancer and urinary stones, lower the likelihood of benign prostate enlargement, erectile dysfunction and impotence.
• Bladder infections and penis infections can be prevented by good, not excessive, genital hygiene, safe sex and a fluid intake of 1.5 to two liters per day.
• Urinating after sexual intercourse flushes pathogens out of the urethra.
• The partial or complete removal of the male foreskin (circumcision) probably reduces the risk of sexually transmitted diseases and minimizes the likelihood of penile cancer.
• The abuse of painkillers, even when prescribed by a doctor, is associated with kidney disease and kidney cancer.
• Stress incontinence can be prevented with exercise, sport and weight reduction.
• Conscious regular urination – four to seven times a day – and a high-fiber diet help to prevent hyperactive bladder and urge incontinence.
• Safer sex protects against sexually transmitted diseases.
• A healthy lifestyle also keeps sperm fit.

Questions and answers

Sources

• https://de.statista.com/statistik/daten/studie/601975/umfrage/gesamtversorgungsgrade-der-urologen-nach-bundeslaendern/
• https://www.aerzteblatt.de/treffer?mode=s&wo=17&typ=1&nid=100556&s=urologen
• https://www.maennergesundheitsportal.de/themen/urologische-erkrankungen/
• http://www.urologenportal.de/patienten/patienteninfo/patientenratgeber/nieren-und-harnwegsinfektionen.html
• https://www.leitlinienprogramm-onkologie.de/fileadmin/user_upload/Downloads/Leitlinien/Prostatatkarzinom/Version_6/LL_Prostatakarzinom_Langversion_6.01.pdf
• https://www.urologielehrbuch.de/was-ist-urologie.html
• https://www.urologenportal.de/fileadmin/MDB/PDF/Praevention.pdf