Urologist: diseases of the urinary system

A urologist is a physician who diagnoses and treats diseases of the kidneys, ureters, bladder, urethra, and male reproductive organs. Their responsibilities include benign conditions, oncological diagnoses, urogenital infections, stones, urinary disorders, and male fertility issues. Modern professional societies emphasize the interdisciplinary nature of the specialty and the importance of working in collaboration with nephrologists, oncologists, gynecologists, and general practitioners. [1]

European guidelines are regularly updated and set the standard for evidence-based care in key areas of urology: urinary tract infections, urolithiasis, lower urinary tract symptoms in men, trauma, oncology, pediatric urology, and neurourology. These are not "rigid protocols," but rather guides for choice that take into account patient preferences, risks, and local resources. [2]

Urological practice today relies on measurable outcomes and risk stratification. An example is the update on microhematuria, which has developed risk levels and indications for cystoscopy, imaging, and the use of urinary biomarkers in specific patient categories. This approach reduces unnecessary testing in low-risk patients and accelerates the diagnosis of oncopathology in high-risk patients. [3]

Screening and early detection are determined by the quality of evidence and the balance of benefits and harms. For prostate cancer, informed patient decision-making, intervals for re-evaluation, and individualization based on age, family history, and ethnic factors are key. [4]

Table 1. The role of a urologist: what he does and what he doesn’t do

Direction	What's included	What is not included
Diagnostics	History taking, physical examination, cystoscopy, uroflowmetry, transrectal and transabdominal ultrasonography, laboratory tests	Long-term management of chronic kidney disease without urological indications for intervention
Treatment	Drug therapy, minimally invasive and open surgeries, shock wave lithotripsy, endourology, rehabilitation plan design	Radiation and drug oncotherapy as the main treatment in the absence of a urological component
Prevention	Prevention of stone recurrence, infection prevention, risk factor modification, screening as indicated	Universal checkups without regard to evidence and individual risk
Coordination	Interaction with oncologists, nephrologists, andrologists, physiotherapists, speech therapists in neurourology	Management of non-urological conditions

When and why to see a urologist

Reasons for consultation include blood in the urine, pain in the lower back or side, frequent or painful urination, sudden urinary retention, incontinence, weak stream, nocturnal awakenings, episodes of renal colic, as well as male infertility, pain or heaviness in the scrotum. Any acute symptoms with fever and chills accompanied by pain in the side or lower abdomen require urgent care due to the risk of pyelonephritis with bacteremia. [5]

Red flags include visible blood in the urine, acute scrotal enlargement in an adolescent with pain and nausea, sudden inability to urinate, severe pain with vomiting, severe weakness of the urinary stream with infection and fever, and progressive weight loss associated with urinary symptoms. These signs require urgent evaluation and treatment. [6]

Children need a urologist for cryptorchidism, hydrocele, complicated phimosis, nocturnal enuresis with alarming symptoms, and any presentation of "acute scrotum," where the viability of the testicle is decided in the first few hours. Guidelines emphasize early correction of an undescended testicle and urgency if torsion is suspected. [7]

For middle-aged and older men, a urologist helps with lower urinary tract symptoms, erectile dysfunction, urogenital infections, stone recurrence prevention, and early detection of prostate cancer. Decisions are made collaboratively after an explanation of the expected benefits and risks. [8]

Table 2. Red flags and actions

Symptom	What's alarming	Action
Visible blood in urine	Age over 35, smoking, exposure to aromatic amines	Exclude urinary tract tumor: cystoscopy and risk-stratified imaging [9]
Acute pain in the scrotum	Sudden nausea, absent cremasteric reflex	Immediate surgical evaluation, time measured in hours [10]
Fever and pain in the side	Suspected acute pyelonephritis	Initiate therapy and imaging as indicated immediately [11]
Urinary retention	Pain, bladder fullness	Decompression, search for the cause, prevention of complications [12]

Diagnosis and screening: how a urologist makes decisions

The assessment begins with a consultation and physical examination, basic blood and urine tests, uroflowmetry, residual urine measurement, and, if necessary, cystoscopy and imaging. For microscopic hematuria, a risk stratification model is used, where observation and renal ultrasonography are indicated for low-risk patients, while cystoscopy and more detailed imaging are indicated for intermediate and high-risk patients. A new version adds a role for urinary biomarkers in selected patients. [13]

Early detection of prostate cancer is based on informed patient decision-making. The American Urology Society and the American Society of Urological Oncology recommend discussing prostate-specific antigen testing starting at age 45 or 50, depending on risk factors, and repeating it every 2-4 years if the risk is low, and more frequently if the test is elevated or if there is a significant history. The U.S. Preventive Services Task Force recommends discussing the test in men aged 55-69 and advises against routine screening in men aged 70 and older. [14]

Regarding male fertility, international guidelines recommend a comprehensive male examination in conjunction with the female one. The 2024 update covers indications for varicocele treatment, algorithms for assessing spermatogenesis, examination for obstructive azoospermia, and fertility preservation before gonadotoxic therapy. [15]

In pediatrics, early correction of cryptorchidism and algorithms for "acute scrotum" are emphasized. In neurourology, updates clarify the management of urinary disorders associated with nervous system lesions. This is important for timely referral and selection of treatment strategies. [16]

Table 3. Prostate screening: how to build a dialogue

Group	When to discuss prostate-specific antigen	Reassessment interval	Comment
Standard risk	From 50 years old	2-4 years	A joint decision between the doctor and the patient, taking into account the density and rate of change of the indicator [17]
Increased risk	Since 45 years old	Individually more often	Family history, African descent, combined factors [18]
Over 70	Generally not recommended	Not applicable	Exceptions in case of high life expectancy and patient's strong desire [19]

Lower urinary tract symptoms and benign prostatic hyperplasia

Lower urinary tract symptoms in men include storage and voiding disorders: frequent urination, nocturia, urgency, weak urinary stream, and a feeling of incomplete urination. The causes are multifactorial and not limited to prostate enlargement, so treatment is selected based on the predominant symptoms, prostate volume, and residual urine. [20]

Initial strategies include lifestyle education, fluid and stimulant management, bladder training, and pharmacotherapy. The choice of medication depends on the symptom profile and comorbidities. If the effect is insufficient or complications arise, minimally invasive techniques and endoscopic surgeries with proven efficacy and safety are considered. [21]

The updates emphasize that combination therapy with alpha-blockers and reductase inhibitors is appropriate for large prostates and those at risk of progression, antimuscarinics and beta-tri-agonists are appropriate for those with predominantly storage symptoms, and intraprostatic steam thermotherapy and other minimally invasive techniques have niche indications. The choice should be personalized. [22]

Surgical approaches include transurethral resection, endoscopic enucleation, and laser technologies. European guidelines systematize the evidence and offer algorithms for selecting interventions based on the size of the gland, anticoagulation, and patient preference. [23]

Table 4. Drug groups for lower urinary tract symptoms

Group	When is it prescribed?	What is important to discuss
Alpha blockers	Fast relief from obstructive symptoms	Orthostatic hypotension, interactions [24]
Reductase inhibitors	Large prostate volume and risk of progression	Slow effect, decrease in prostate volume over time [25]
Antimuscarinic agents	Dominance of urgency and frequency	Dry mouth, constipation, caution with high residual urine [26]
Beta-tri-agonists	Urgency, frequent urges	Possible increase in pressure, combination with antimuscarinic agents [27]
Phosphodiesterase type five	Associated erectile dysfunction and symptoms	Combined effect on erection and accumulation symptoms [28]

Urinary tract infections

For uncomplicated recurrent infections in women, diagnosis verification, elimination of warning signs, and targeted prevention are important. American urologists have updated their guidelines, placing greater emphasis on non-antibacterial measures and rational antibiotic prescribing, which helps reduce resistance and side effects. [29]

Asymptomatic bacteriuria is treated only in specific situations: in pregnant women and before invasive urinary tract procedures. In other groups, including the elderly in long-term care homes and patients with catheters, treatment does not improve outcomes and increases the risk of resistance. This is one of the most common sources of unnecessary antibacterial therapy. [30]

European guidelines for urologic infections describe severity stratification, indications for imaging, and principles of empirical therapy, with mandatory clarification based on culture results. In febrile upper urinary tract infections, early initiation of therapy and assessment of the risk of complications are critical. [31]

Prevention includes a fluid regimen, normalization of body weight, glycemic control, correction of factors that impair bladder emptying, and, in selected women, behavioral measures, vaginal estrogens in postmenopause, and individually selected antibacterial prophylaxis according to strict indications. [32]

Table 5. Tactics for common clinical scenarios of infections

Scenario	Basic steps	Special instructions
Recurrent uncomplicated infection in a non-pregnant woman	Confirm diagnosis, symptom diary, cultures	Consider non-antibacterial strategies and targeted prophylaxis [33]
Asymptomatic bacteriuria	Do not treat except in pregnant women and before invasive uroprocedures.	Minimize unnecessary urine testing in asymptomatic patients [34]
Febrile upper urinary tract infection	Early initiation of therapy, assessment of severity, imaging as indicated	Adjust based on the results of sowing and sensitivity, monitor for complications [35]

Urolithiasis: from acute care to relapse prevention

In renal colic, the main goals are rapid pain relief, ruling out infected obstruction, and assessing the need for urgent drainage. Imaging and laboratory diagnostics are selected based on the clinical presentation and the presence of risk factors. European guidelines were updated in 2024 to clarify the indications for imaging and management. [36]

After the acute episode has resolved, prevention of recurrence and metabolic assessment are essential. Patients at risk for recurrent stone formation are recommended to undergo basic and extended metabolic testing, a food and fluid diary, and adjustments to diet, sodium, and protein. American and European guidelines converge on key management steps. [37]

Preventive measures include adequate fluid intake to achieve a daily urine output of approximately 2-2.5 liters, moderate salt intake, adequate dietary calcium, limiting excess animal protein, and correcting oxalate and purine levels according to the type of stone. Citrates are indicated for hypocitraturia, and thiazide diuretics are indicated for hypercalciuria. [38]

The choice of stone removal method depends on the size, location, and density of the stone, as well as the patient's characteristics. Medication-assisted removal for small stones, extracorporeal shock wave lithotripsy, ureterorenoscopy, and percutaneous nephrolithotomy are used. Guidelines offer algorithms for selection and monitoring of results. [39]

Table 6. Prevention of stone recurrence: a practical plan

Direction	Target	Step example
Hydration	Daily diuresis is about 2-2.5 liters	Distribute water evenly throughout the day [40]
Nutrition	Reducing oxalates, moderating protein and salt	Normal intake of calcium from food, limiting excess salt [41]
Medicines	Correction of metabolic disorders	Potassium citrate for hypocitraturia, thiazide for hypercalciuria as indicated [42]
Control	Evaluation of effectiveness	Repeated analyses and imaging according to the observation plan [43]

Male infertility and sexual health

The updated guidelines emphasize the need for a comprehensive male examination, not just a semen analysis. They include a medical history, an examination for varicocele, a hormonal profile, genetic testing when indicated, ultrasonography, and an assessment of lifestyle factors. This ensures individualized treatment and the logistics of assisted reproductive technologies, if necessary. [44]

Varicocele remains the most common potentially correctable cause of male infertility. Surgical correction is recommended for clinically evident varicocele, abnormal sperm counts, and couple-specific infertility. In adolescence, treatment is individualized based on testicular volume and symptoms. [45]

Sexual function is closely linked to urinary disorders and overall cardiometabolic stress. A comprehensive assessment and correction of lifestyle factors, treatment of concomitant conditions, and rational choice of therapy help improve both erectile function and urinary quality. The European Guidelines for Male Sexual and Reproductive Health consolidate previous documents into a single set. [46]

Fertility preservation before gonadotoxic treatments should be discussed in advance, with a cryopreservation plan and subsequent use routes. The management of such patients requires coordination with oncologists and reproductive specialists. [47]

Table 7. Steps for assessing male infertility

Step	What does it include?	For what
Basic assessment	History, examination, two spermograms	Confirm the problem and select the direction of deepening [48]
Hormones	Testosterone, gonadotropins, prolactin when indicated	Identify endocrine causes and correction points [49]
Genetics	Karyotype, microdeletions, CFTR as indicated	Prognosis and choice of treatment tactics [50]
Visualization	Ultrasonography of the scrotum and prostate according to indications	Detect varicocele, obstruction, inflammation [51]

What to prepare for your visit and how to plan your route

For the visit, it's a good idea to prepare a list of medications, a brief history of symptoms, recent test and imaging results, and a list of goals and concerns. This expedites diagnosis and the development of a treatment plan. During the appointment, indications for additional testing are clarified, treatment options, expectations, and milestones are discussed. [52]

The treatment plan includes observation with lifestyle modifications, drug therapy, minimally invasive interventions, and surgery. Decisions are made collaboratively, based on evidence, individual risk, and preferences. It is important to discuss potential side effects, monitoring timelines, and criteria for plan modifications in advance. [53]