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Last Updated: Sunday, 20 January 2008, 00:04 GMT
Inside Medicine: The urologist
Mr Julian Shah

In a series focusing on medical specialisms, the BBC News website meets Julian Shah, a consultant urologist.

Urology is the branch of medicine that focuses on the urinary tracts (where urine is stored and eliminated) of males and females, and on the reproductive system of males.

WHAT IS YOUR JOB?

I am a consultant urologist based at University College Hospital London, the Royal National Orthopaedic Hospital and at the King Edward VII's Hospital Sister Agnes.

A urologist is a surgeon who looks after management of the urinary tract - that includes the kidneys, bladder and urethra, plus the prostate and the genitalia in the male.

There are different types of urologist who work in different fields with special interests.

My special interest is female and reconstructive urology, which includes the management of incontinence and bladder reconstruction.

The other special interest that I have is neurourology - the dysfunction of the urinary tract caused by neurological disease such as multiple sclerosis and spina bifida. The bladder becomes affected by damage to the nerve supply.

WHAT IS THE MOST COMMON CONDITION?

Incontinence is one of the more common problems that I deal with, although we do deal with many other problems that affect the urinary tract.

I had a man of 50 who had spina bifida and had been incontinent all his life. He was a very wealthy man and had everything he wanted except continence.
Julian Shah

Incontinence is more common in females and is usually related to muscles weakened by childbirth - this is known as 'stress' incontinence.

There is another type of incontinence called "urge" incontinence. This is where a patient has an urgent need to go the toilet. They may not get there in time and leak urine.

Men suffer from incontinence usually as a result of surgical operations, such as those for prostate cancer or to relieve an obstruction, or they can have an overactive bladder giving rise to urge incontinence.

WHAT IS THE MOST COMMON PROCEDURE?

Treatment depends upon the nature of the condition.

For the "overactive" or "unstable" bladder the first thing is to find out about fluid intake and check that the patient does not have an infection or a more sinister cause. Once such causes are excluded the patient is taught bladder retraining - learning how to delay the urine flow and hold on to the urine.

If that does not work we use medications.

If that still does not work we go on to procedures such as botox injections in the bladder wall or less commonly operations on the bladder to enlarge it.

In the female, the management of stress incontinence depends on whether it is associated with weakness of the pelvic floor/prolapse or not. If it is we may use open surgery (colposuspension).

We often use slings which are very popular - where a mesh-like tape is placed under the urethra like hammock to keep it in its normal position. This can be performed as a day case.

We may also inject silicon into the urethra to provide support and closure "from the inside".

We use pelvic floor exercises - the pelvic floor is a "hammock" of muscles which support the bowel and bladder. Pelvic floor, or Kegel, exercises involve clenching the muscles you would use to prevent yourself urinating.

There is an artificial urinary sphincter - which uses compression to prevent urine leakage.

More recently there are male slings coming on the market, but they are relatively new.

WHAT IS THE HARDEST THING ABOUT YOUR JOB?

Dealing with complex issues takes time, which we don't always get.

We feel we should be left to do what is appropriate for patient management with appropriate support.

We try very hard to maintain a high standard, which is very important.

WHAT IS YOUR MOST SATISFYING CASE?

I think any patient who is incontinent and made continent tends to be very grateful, especially patients with spinal cord injuries or patients in wheelchairs - people who have been wet all their lives for instance.

I had a man of 50 who had spina bifida and had been incontinent all his life. He was a very wealthy man and had everything he wanted except continence.

After investigation and treatment he was perfectly dry and his life was transformed. We do see a lot of patients like that whose lives are transformed by our interventions.

Patients are sometimes too shy to come forward and do not realise there is anything for them - there are probably tens of thousands of people out there who do not realise there is something that can be done for them.

This especially applies in other countries in Europe where these things are more taboo than they are in England.

WHY DID YOU CHOOSE THIS SPECIALITY?

I always wanted to be a surgeon.

Choosing Urology was just by chance. It wasn't a speciality we were much exposed to in medical school. I just happened to be training in surgery and then worked for a urologist in Nottingham and was inspired by him.

IF YOU HAD YOUR TIME AGAIN WOULD YOU CHANGE YOUR SPECIALTY?

No, I don't think so.

WHICH SPECIALTY WOULD YOU HAVE GONE INTO IF NOT YOUR OWN?

Probably plastic surgery because it is reconstructive and that is what I do nowadays anyway for the bladder and urinary tract.

You are creating something, not just cutting out cancers all the time.

HOW DO YOU SEE THE ROLE DEVELOPING IN THE FUTURE?

It is quite interesting as the role of training has been changed.

The training programmes have been shortened. The trainees have a reduced three-year-programme. The concept is "Office urology" - a more diagnostic role than a hospital-based interventional surgical speciality and perhaps closer to GP's.

There will be more highly trained and more specialist urologists who will be fewer in number, and will specialise in cancer or andrology (male urinary health) or female reconstruction.

Whether these proposals will come to fruition as yet we are not sure

CV - Mr Julian Shah
1972: Awarded Edward Ward Prize in Surgical Anatomy
1984: Became a Senior Lecturer in Urology, Institute of Urology, University College London
2001: Joined King Edward VII's Hospital Sister Agnes as a Consultant Urologist




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