Exactly what is functional urology? Is it a defined field, real subspecialty, or a catch all phrase used by many, but to mean different spheres of practice? I think everyone would agree on what it is not: dash, it is not the diagnosis/ management of urologic cancer or stone disease, unless they somehow affect lower urinary tract (LUT) function, and then it includes only the latter considerations. OK, we have established that. Now, what is it, really? Where does one look to find an acceptable answer - manuscripts, texts, meetings incorporating the term, chapter titles within major texts, artificial intelligence responses from various sources, residency and fellowship curricula? I have looked at all of those. There is only one text that I know of that has incorporated the term in its title: Practical Functional Urology (2016, Springer International Publishing), edited by John Heesakkers, Chris Chapple, Dirk De Ridder, and Fawzy Farag. I wrote the preface, but mistakenly did not realize that I should have tried to provide some all-encompassing term or description for the subjects included. The lead chapter was a consideration of lower urinary tract and pelvic floor structure, gross and microscopic, and the principles underlying the neurophysiology and neuropharmacology of the lower urinary tract. Chapters on pathophysiology, evaluation, and management of the following entities followed:
- Neurogenic lower urinary tract dysfunction (LUTD)
- Overactive bladder
- Bladder pain syndrome/interstitial cystitis
- Stress urinary incontinence in women
- Stress urinary incontinence in men
- Pelvic organ prolapse
- Urinary tract infection
- Male LUT symptoms, including OAB, detrusor underactivity, benign prostate enlargement or hyperplasia, benign prostate obstruction, urethral stricture or other urethral pathology
- Reconstructive surgery (included were fistula repair, augmentation cystoplasty)
- Erectile dysfunction (including pertinent andrology)
- Urinary retention and bladder emptying disorders (admittedly repetitive)
- Catheter management
- Nocturia
In selecting these topics, the editors provided what I believe can be inferred as the first reasonable listing of topics which would be considered as falling under the term functional urology. Do these subjects have anything in common? They all represent benign conditions (except for malignant fistula), they all present symptomatically, and they all negatively affect quality of life. Are there common considerations regarding corrective measures for these problems? There are: to improve function and restore it to as close to normal as possible, to remove factors which could further harm the function under consideration (including the upper urinary tract and renal function for. LUT D), and to improve quality of life.
What topics are not included in this 2016 list that should be? On. Looking through the sections and individual chapters in the all-encompassing Campbell-Walsh-Wein n Urology textbook( 2026, Elsevier Press, Dmochowski, Kavoussi, Peters, eds), I found these subjects which could be included:
- Infection and inflammation. This encompasses not just urinary infection, but benign yet troublesome problems such as prostatitis, urethritis, orchitis, epididymitis, and related pain syndromes.
- Sexually transmitted diseases
- Cutaneous diseases of the external genitalia
- Tuberculosis and parasitic diseases of the urinary tract
- Priapism (some would include under erectile dysfunction)
- Peyronies disease (some would include under erectile dysfunction)
- Male infertility
- Sexual dysfunction in women
- Transitional and adolescent urology
- LUTS in renal or other transplant patients
- Aging and geriatric urology (related to the LUT)
- LUT considerations in other than binary individuals
Some (or many) individuals who consider themselves as functional urologists will wish to exclude some or many (or all) of the 12 subjects above from their practice, and even some of the subjects considered in the Heesakkers et al book. So, a precise and specific definition of functional urology or a functional urologist is not possible.
What, then, is the core of functional urology, and what should it include? I would argue that LUTD in all sexes, both non-neurologic and neurologic in origin, is the core, ie, failure of the LUT to fill with or store urine normally, due either to reasons related to th bladder, the outlet or both; or , failure of the LUT to empty normally, due to factors related to an abnormality of the bladder, the outlet or both; in some instances there may coexist a problem with filling/storage and with emptying. The basic armamentarium of the functional urologist includes the includes the expertise to accurately diagnose and manage these entities. This, in my opinion, is the “inner circle”. Just outside this, in a concentric and surrounding circle, are all the other issues included by Heesakkers et al in their text, although each of these need not be included within a single individual’s repertoire. A further outer circle includes some of the 12 other topics listed above- my personal choices would be #s 1,2,3,5,6,10,11, and 12. A functional urologist, then, may choose to include any entities from circles 2 and 3, but must include all from the inner circle, the core.
That being said, however I think that everyone who considers themselves a functional urologist is, first and foremost, a urologist who should be familiar with the principles of initial evaluation and management of the urologic patient, detailed in chapters 1-8 of Campbell-Walsh-Wein Urology, enabling them to detect certain symptoms and signs requiring other than LUT evaluation and/or referral to a colleague with special training, experience, expertise or interest in a certain area. The functional urologist should not have to struggle with properly evaluating a testicular or renal mass, hematuria, or giving guideline-based advice about prostate cancer screening, for example, and then making the appropriate decision regarding management or referral.
Alan Wein, MD, PhD, FACS, Professor of Clinical Urology, Department of Urology, Desai Sethi Urology Institute (DSUI), University of Miami Miller School of Medicine, University of Miami Health Systems, Miami, FL