'And Abraham took his son Ishmael and all that were born in his house and circumcised the flesh of their foreskin'
Arguably, urology is the first surgical speciality mentioned in the Chumash. As well as instructing Abraham to perform circumcision, further urological references are also seen in the instructions of who can serve in the temple (Vayikra 21, 17–21): “Speak to Aaron saying ‘any of your offspring… shall not come to offer… a man who is blind or lame or whose nose has no bridge or who has one limb longer than the other… or has crushed testicles’.’’
There is also a reference in Devarim (23, 5-22) where we read: “A man with crushed testicles or a severed organ shall not enter into the congregation of the Lord.”
Many urological diseases affect men and women as they age. The population of the UK, now over 60 million continues to age, the average life expectancy of a child born today being over 78 for a boy and over 82 for a girl. This ageing population will require urological care.
The Prostate
The prostate gland is located at the base of the bladder and produces some of the fluid men produce when they ejaculate.
As we get older, the gland grows. It surrounds the urethra, the passage urine passes through from the bladder, and as it grows it can restrict the flow of urine, making it more difficult for men to be able to relieve themselves.
Symptoms that can result from this are a difficulty initiating the flow of urine, or “hesitancy” as urologists call it, a slow, prolonged flow, and dribbling at the end of urination.
Other symptoms include getting up at night to pass urine, frequency in the daytime and urgency.
Occasionally, men suddenly can become completely unable to pass urine, resulting in urinary retention.
Should you seek advice from a urologist, they will take a history and examine you, including a rectal examination to assess the size and nature of the prostate.
Tests will be organised including a urine specimen, an ultrasound scan of the kidneys and bladder and a flow test to measure how quickly urine passes. These tests are all simple and non-invasive.
Treatment options include lifestyle changes — for example cutting out caffeine and drinking less in the evening.
There is also medication to improve flow by relaxing the muscle within the prostate (this treatment was in fact discovered by Israeli urologist Marco Caine back in the late 1970s), and medication to shrink the prostate.
A number of surgical options are available; all the different procedures performed remove prostate tissue, all are performed through the urethra so there’s no scar, and all require a day or two with a catheter to drain urine after the surgery.
You should discuss the surgical options with your urologist. No one treatment is particularly better than another; they all have pros and cons.
Prostate cancer is diagnosed in approximately 47,000 men every year — that’s 130 men every day. One man dies from prostate cancer every hour — a total of more than 10,800 men every year in the United Kingdom.
The diagnosis of prostate cancer involves a discussion about symptoms initially with your GP. If you have a strong family history of prostate cancer — one or two close relatives with prostate cancer, particularly if they were diagnosed under the age of 65— then you should consider speaking to your general practitioner about whether you should be tested even if you don’t have any symptoms.
Initial assessment is a digital rectal examination and a blood test to measure prostate specific antigen (PSA).
The PSA test doesn’t tell you if you have or haven’t got prostate cancer, but it helps to inform your doctor taking the blood test and other factors into account, as to whether further investigations are appropriate. These other tests might include an MRI scan of the prostate gland and the pelvis, and a biopsy of the prostate.
If diagnosed with prostate cancer, don’t panic. Often these are slow growing cancers and many men live a very long time after a diagnosis.
Your urologist may discuss treatment which could be medical therapy, but if the tumour is confined to the prostate and you have a life expectancy of more than 10 years then you may be offered radiotherapy, brachytherapy (radioactive seeds placed in the prostate) or surgery which in many centres is now performed as a keyhole operation, assisted by a robotic surgical device.
More details of the investigation and treatment can be found at www.prostatecanceruk.org.
The treatment of prostate cancer can have an effect on erectile function and continence so, before deciding on any treatment, you should discuss the implications of any intervention with your urologist and with your partner.
Other Urological Conditions.
The field of urology includes the treatment of kidney cancer, which affects about 12,000 people a year in the UK, and bladder cancer affecting approximately 10,000 people. If you develop blood in the urine you should see your doctor very quickly. It may be a symptom of something quite simple, a urinary tract infection or a kidney stone, but it may be the harbinger of something more significant such as kidney or bladder cancer.
If you do have blood in your urine, you should see a urologist after seeing your GP. A urine specimen will be taken to see if there’s an infection, and a scan of the kidneys and bladder performed.
A cystoscopy is then carried out where appropriate. This involves passing a telescope through the penis or urethra into the bladder. It’s done with you awake normally, stings a little but actually is pretty well tolerated. Treatment will depend on what is found.
Urology also looks after men suffering from erectile dysfunction or impotence. Don’t be afraid or nervous about talking to your doctor about this. We understand it’s something you may not be used to speaking to someone about, but we’re very used to discussing problems men have getting erections.
If you are interested in still having an active sex life and it’s not working quite right, speak to your GP and if needed speak to a urologist — there are things we can do and explain to you.
Kidney stones do affect the elderly, though are most common in younger adults. I am the senior clinician in the stone unit at Guy’s and St Thomas Hospitals in London and have treated patients with stones aged from 11 months to 91 years.
Sometimes the stone may pass spontaneously, but treatment nowadays is always minimally invasive, using either shock wave treatment from the outside or telescopes passed through the urethra into the kidney or through the skin in the flank directly into the kidney. Cure rates are very high.
Women (and less commonly men) with incontinence should seek advice. Don’t just accept it. There are a number of different types of incontinence, depending on whether it occurs with coughing or sneezing, or whether it occurs with a degree of urinary urgency among others. Again, there are things we can do to solve it so speak to your GP about a referral; treatment will again be lifestyle advice, medication or surgery depending on the cause.
If you wish to get further advice about any urological condition, the British Association of Urological Surgeons of the Royal College of Surgeons of England has information which can be accessed at www.BAUS.org.uk/patients/.
Other useful sites for advice are www.mayoclinic.org/diseases-conditions/ and the website of the American Urological Association, www.urologyhealth.org/.
This in an edited version of a talk given as part of the Jewish Care Health Insights series. Jonathan Glass is consultant urologist at Guy’s & St Thomas NHS Hospitals and The London Clinic
