Geriatric Urology
George W. Drach, MD,* and Tomas L. Griebling, MD
Urology is one of the surgical specialties that has been
most affected by the growing demographic of older adults
in the United States. Urological problems are common in
elderly people, and care of patients aged 65 and older rep-
resents a large proportion of many urologists practices.
However, this has also presented unique challenges to the
development of the field of geriatric urology as an identi-
fied subspecialty. Until recently, formal educational re-
quirements and opportunities in geriatric urology were
limited. In addition, there is a paucity of basic science and
clinical research related specifically to urological problems
in older adults, despite the growing numbers of patients in
this age group. This article reviews recent efforts to in-
crease the activity, content, and visibility of the field of ge-
riatric urology. Curriculum materials have been developed
for urology training programs, research needs have been
assessed and targeted, and a new professional organiza-
tion (the Geriatric Urology Society) has been established.
Current activities in the field of geriatric urology at the lo-
cal, regional, and national levels, and goals for the future
are reviewed. J Am Geriatr Soc 51:S355S358, 2003.
G eriatric patients constitute the great majority of pa-
tients seen in adult urologists offices. Yet, unfortu-
nately, until recently, focused education in geriatrics as it
pertains to urology has been woefully lacking in most resi-
dencies and continuing medical education programs. Be-
ginning about 8 years ago, after stimulation by the Ameri-
can Geriatrics Society (AGS), the Society of University
Urologists (SUU) developed an ad hoc committee to re-
view this situation and to propose educational objectives
for the teaching of residents in urology. Shortly thereafter,
some members of the American Urological Association
(AUA) realized that only minor segments of their national
programs discussed problems associated with geriatrics in
urology. One of the authors (GWD) devised, in conjunc-
tion with the officers of the AUA, program additions to
From the *Division of Urology and Institute on Aging, University of
Pennsylvania, Philadelphia, Pennsylvania; and Division of Urology and
Center on Aging, The University of Kansas, Kansas City, Kansas.
Address correspondence to George W. Drach, MD, 1st Floor, Rhoads
Pavilion, 3400 Spruce St., Philadelphia, PA 19104.
E-mail: drachgw@mail.med.upenn.edu
JAGS 51:S355S358, 2003
2003 by the American Geriatrics Society
enhance presentations in geriatric urology at the yearly na-
tional meeting of the AUA. Finally, the authors noted that
few young, developing academic faculty expressed interest
in geriatric urology as a field of scientific investigation.
One author (TLG) chose geriatric urology as a field of sub-
specialization in conjunction with specialty training in re-
constructive neurourology, urodynamics, and outcomes
research. He sought mentors from various related disciplines
including urology, geriatric medicine, and outcomes research
to help guide his fellowship studies. A Health Services Re-
search Scholar Award from the American Foundation for
Urological Diseases supported this work. More recently,
the addition of the Jahnigen Fellowship Program of the
AGS has supplemented faculty development opportunities
in the surgical and related specialties including urology.
It is the purpose of this review to cover these develop-
mental phases more carefully and to define the status of
geriatric urology as it exists now in U.S. urology teaching,
research, and practice. A great amount of the credit for
these advances goes to David H. Solomon, MD, who has
served as a guide and counselor to both authors for many
years. Credit also goes to the visionaries of the AGS who,
along with the John A. Hartford Foundation (JAHF), de-
veloped funding mechanisms that drove geriatric urology
(and many other geriatric specialties) forward.
UNIQUENESS OF GERIATRIC UROLOGY
Many published scientific articles and popular periodicals
predict that the U.S. population of older adults will in-
crease greatly by 2050.13 Thus, the promotion of geriatric
care within all specialties of medicine has been a high pri-
ority for the AGS over the past decade.4 Traditionally,
other medical and surgical specialties such as ophthalmol-
ogy, orthopedics, and cardiology have been emphasized
because they tend to serve the geriatric population. Never-
theless, it is our contention in urology that it holds a
unique position in provision of geriatric care because urol-
ogists manage personal, often very private, aspects of
the elderly adults physical and emotional well-being, such
as control of urination.5 One might refer to urologists as
the hidden providers of geriatric care, ultimately sought
out by many geriatric patients.
To illustrate this point, one must first review recent
data on the eight most common diagnoses in the aging
population, which can be determined through Medicare
diagnoses. Table 1 reviews these diagnoses. It is surprising
0002-8614/03/$15.00
S356 DRACH AND GRIEBLING
Table 1. Number of International Classification of Disease,
Ninth Revision, Diagnoses Reported by All Nonfederal
Physicians, in Rates Per 100, for Outpatient Encounters of
Patients Aged 65 and Older, 1999
Occurrence/
100 Age 65
Diagnosis and Older
Arthritis
Hypertension
Hearing Loss
Heart Disease
Orthopedic
Cataracts
Sinusitis
Diabetes
Kramarow et al, National Center Health Statistics, 1999.
to note that none of them refers specifically to a urological
problem. In fact, none relate directly to the major geriatric
urological diseases: incontinence, cancer, bladder outlet
obstruction, or urinary tract infection.610 Yet, if the pro-
portion of outpatient visits to urologists by individuals in
the geriatric age group (Table 2) is reviewed, it is noted
that urology accounts for the third most outpatient visits
by specialty, 46.2%, well ahead of many specialties that
treat the most common diagnoses noted in Table 1.
Another way to observe the effect of elderly patients
on urological practice is to compare the proportion of sur-
gery done by the average urologist on patients in the pedi-
atric age group (here defined as 015 years) and that on
the group aged 65 and older (Figure 1). By 2023, the esti-
mated percentage of the U.S. population aged 65 and
older will equal the percentage that is younger than 16. 6
Figure 1 indicates that perhaps 10% of urological surgery
overall occurs in children, whereas as much as 62% occurs
in the elderly. The significant increase in proportions of
genital surgery in adults in Figure 1 derives from the large
number of prostatic surgeries performed in urology.
Table 2. Percentage Distribution of Patient Visits by
Physician Specialty by Those Aged 65 and Older and
Enrolled in Medicare
Specialty
Ophthalmology
Cardiovascular
Urology
General internal medicine
General surgery
Neurology
Dermatology
Otolaryngology
Orthopedic
Family medicine
Psychiatry
Obstetrics and gynecology
JULY 2003VOL. 51, NO. 7 SUPPLEMENT JAGS
49
36
36 Figure 1. Proportions of urological operations. Bars depict per-
27 centage of surgical procedures performed on individuals
18 younger than 16 or aged 65 and older. Urinary refers to kid-
17 neys, ureters, and bladder. Genital refers to all male genitalia
12 including the prostate and the vaginal and peri-vaginal tissues
10 in the female.
From these data, one can see that urologists provide
significant services to older patients and must become ac-
complished in managing the overall problems of aging
seen in their practices. However, the large percentage of
older adults commonly seen in most urological practices
has presented a challenge to the development of geriatric
urology as a subspecialty. Many practicing urologists feel
that they already have strong baseline knowledge in geriat-
rics because they take care of many older adults. It can be
difficult to convey the need to expand their scientific and
clinical knowledge base in geriatrics as it relates to urol-
ogy. In addition, the unique needs of many elderly pa-
tients, particularly those with significant frailty or multiple
age-related comorbid diseases, are not commonly included
in urology training. Examples of such topics include the
identification and management of perioperative delirium,
fluid and acid-base balance, polypharmacy, and postoper-
ative pain management. These frail elderly patients repre-
sent some of the most complex individuals seen in urologi-
cal practice, and they often require specialized care.
The urological community is beginning to address
these needs, and a brief summary of these approaches
follows.
RESIDENCY EDUCATION
As noted above, learning objectives for Aging (Geriatric
Urology) have been added to the published volume of
teaching objectives of the SUU. Yearly letters to program
% directors have urged adoption of these objectives by the
residency programs. Although, in 2002, SUU attempted to
55.8 assess the degree of inclusion of the objectives in 124
53.9 training programs by survey, the overall responses to the
46.2 survey have been poor. Of 24 programs that have re-
38.9 sponded, six include specific geriatric education, and an-
32.9 other 10 indicate they plan to do so (unpublished data).
26.6 Clearly, more effort to encourage implementation of the
25.8 objectives for aging is necessary. There has been debate
24.8
also that, until specific changes are made to include geriatric-
22.5
focused material on in-service and board examinations, it
20.7
will be more difficult to implement materials in training
10.2
6.6
programs. These changes in urology examinations are in
progress.
JAGS JULY 2003VOL. 51, NO. 7 SUPPLEMENT
The authors universities have made some advances in
improving education in geriatric urology. At the Univer-
sity of Pennsylvania program development was helped by
an AGS grant Geriatric Education for Specialty Resi-
dents. This led to development of the following curricu-
lum for urology residents.
University of Pennsylvania residents do a 4-month ro-
tation that emphasizes outpatient urology. During that rota-
tion, they perform a number of activities in conjunction
with the Division of Geriatrics: attendance at weekly Geri-
atric Grand Rounds, weekly 1-hour meetings with the ge-
riatric urology mentor to review literature and texts (includ-
ing Geriatrics at Your Fingertips and The Geriatrics
Syllabus for Surgical Specialties) in that field, monthly 1-
hour meetings with urological and geriatric mentors to re-
view basic aspects of geriatric education, one afternoon of
geriatric home visits, and four afternoons of nursing home
visits. Once yearly, a geriatric urology 6-hour seminar
hosts an outstanding geriatric authority. Geriatric fellows,
urology residents, and faculty from both divisions attend.
In addition, one resident per year is chosen to attend the
annual meeting of the AGS. As one can see, this program
has been planned to increase awareness of and knowledge
about geriatric urology with minimum effect on other as-
pects of the program. Each resident spends about 3 hours
per week for 16 weeks for a total of 48 hours of geriatric
emphasis in a 5-year residency program.
The University of Kansas urology residency training
program has also included a strong content in geriatric
urology for their trainees. A grant award to one of the au-
thors (TLG) from the AGS and JAHF supported this work
in the first phase of the project, Increasing Geriatrics Ex-
pertise in Surgical and Related Medical Specialties. This
author holds a joint appointment in the Division of Urol-
ogy and the Center on Aging. Urology residents rotate on
this geriatric urology clinical service for at least 4 months
each year during their training and actively participate in
outpatient clinics and surgery. In addition, all of the fel-
lows in geriatrics and the internal medicine residents on
their geriatrics rotations spend several days in this clinic.
The emphasis is on geriatric urology problems, including
urinary incontinence and other voiding dysfunction, uri-
nary tract infection, and sexual dysfunction. The residents
and fellows in both disciplines have found the interactions
in these settings to be valuable for learning. These urology
clinics have been held at a time and place that are simulta-
neous with primary care geriatrics clinics. This has al-
lowed interaction between faculty geriatricians and urology
trainees. In addition, the urology residents are exposed to
other aspects of multidisciplinary geriatrics, including so-
cial work and pharmacy. Residents are encouraged to read
geriatric-specific materials from appropriate textbooks as
noted above. Attendance at didactic conferences and jour-
nal club is encouraged. Several urology residents and med-
ical students have participated in geriatric urology re-
search projects. Residents and fellows from the geriatrics
service also have opportunities to observe in the operating
rooms and urodynamics laboratory. The Urology Resi-
dency Program also recently cohosted a distinguished geri-
atrician as Visiting Professor for Urology and the Center
on Aging.
Resident evaluations of these experiences at both pro-
GERIATRIC UROLOGY S357
grams have been complimentary in most instance, but as a
comparison, residents in the University of Pennsylvania
program spend 8 months learning pediatric urology versus
48 hours learning geriatric urology, even though most of
them subsequently practice limited amounts of pediatric
urology after entering practice. Hence, there is a need to
develop much more emphasis on teaching geriatric urol-
ogy, which will involve larger numbers of patients in their
practices.
AUA ACTIVITIES IN GERIATRIC UROLOGY
Once again aided by substantial grants from the AGS and
JAHF, the AUA started programs of continuing medical
education (CME) enhancement in 1998, when the first
plenary panel on geriatrics was held. The second panel fol-
lowed in 1999. In 2000, the AUA held the first Geriatric
Forum, a 4-hour program presented as a part of the AUA
annual meeting. In 2001 and 2002, the AUA repeated the
forum concept. Attendance at each forum increased gradu-
ally, and finally, in 2002, those who attended met and
formed the Geriatric Urology Society. Hence, the interest
in geriatric urology continues to build annually. The fourth
Geriatric Urology Forum and meeting of the Geriatric
Urology Society was scheduled for the meeting of the AUA
in the spring of 2003.
UROLOGY ACTIVITIES IN AGS
Urology has also gained increased visibility within the ge-
riatric community. Two years ago, a symposium on Con-
troversies in Geriatric Urology was held at the annual meet-
ing of the AGS and chaired by one of the authors (TLG).
The panelists reviewed common clinical problems in urol-
ogy often seen in older adults. The session received excel-
lent reviews from the standing-room only audience. Over
the past several years, similar symposia have been orga-
nized at the annual AGS meeting in a variety of surgical
and related specialties. These have proven extremely popu-
lar and timely in content.
Most recently, the AGS has developed an organiza-
tional section devoted to the surgical and related special-
ties. One of the authors (GWD) chaired the first program
presented by this section at the AGS annual meeting. A
specific category for abstract submission on Surgery in
Older Adults has been developed for each annual AGS
meeting. Urology has been actively involved in this process
of section development.
UROLOGY RESEARCH AGENDA SETTING PROCESS
Urology was one of the 10 specialties targeted for inclu-
sion in the Research Agenda Setting Process (RASP) project
cosponsored by the AGS and JAHF. The purpose of the
project was to identify the current state of knowledge re-
garding urology and urological diseases in older adults.
The authors served as the content expert (TLG) and senior
advisor (GWD) in the development of the manuscript for
the discipline of urology. Specific topics included in this
review included urinary incontinence, urinary tract infec-
tion, genitourinary cancer, prostate disease, sexual dys-
function, stone disease, and renal transplantation. The
English literature was systematically reviewed as part of
manuscript development, and a monograph was produced
to reflect this review.
S358 DRACH AND GRIEBLING
It was interesting to note that, although an initial
search for these topics including search terms related to ag-
ing and geriatrics yielded several thousand references, there
were few randomized, controlled trials specific to basic
or clinical science in older adults. This finding emphasized
the need to encourage investigators to pursue rigorous re-
search in the field of geriatric urology. It is critical that all
programs continue to expand the knowledge base in this
field.
Findings from this project have been used to develop a
monograph (currently in production) regarding the state
of knowledge in each of the included disciplines. From this
work, an agenda for suggestions for future research is
being developed. There is clearly a critical need for well-
designed basic science and clinical studies related to the
major topics in geriatric urology.
EXPECTATIONS FOR FUTURE DEVELOPMENTS
IN GERIATRIC UROLOGY
Residency Education
It is predicted that as the percentage of older adults in the
population increases, the need for more formal education
in geriatric urology will also increase. Work is currently
ongoing to increase geriatric-specific content on the in-
service and board examinations in urology. Work to en-
courage the adoption of the geriatrics curriculum pro-
posed by the SUU will continue. The goal will be to have
formal geriatric content included in all urology residency-
training programs in the United States.
Geriatric Urology Society
The Geriatric Urology Society has been formed as an affil-
iate of the AUA as previously described. The authors cur-
rently serve as the president pro tem (GWD) and secretary
pro tem (TLG) of the organization. Formal bylaws have
been established, and it is hoped that membership and
participation in the organization will continue to grow
with time. This represents a significant step in the develop-
ment of geriatric urology as a subspecialty because it will
provide a national forum for interaction and discussion
among urologists and other colleagues interested in the
field of geriatric urology.
The authors have noted many parallels in the develop-
ment of the Geriatric Urology Society and the Society for
Pediatric Urology (SPU) within the discipline. The SPU has
a sizable membership and powerful voice within the field
of urology, and it is hoped that the Geriatric Urology Soci-
ety will follow a similar path.
CME Activity
CME is developed and implemented by many different or-
ganizations and in many different ways in the United States.
Because geriatric patients form such a large subset of most
urology practices, there will continue to be a growing need
for CME materials focused on the urological needs of
JULY 2003VOL. 51, NO. 7 SUPPLEMENT JAGS
older adults. Special emphasis will need to be placed on is-
sues traditionally felt to be out of the realm of typical geri-
atric practices, including management of the common geri-
atric syndromes in the perioperative patient. Urology has
also become a chronic care specialty for many older pa-
tients, and the nonsurgical urological care of older adults
needs to be included in these CME materials.
Research
Research efforts in the field of geriatric urology continue
to expand. There is a need for more research, both at the
basic science and clinical levels, to help advance under-
standing of urological diseases in older adults. Target
areas have been identified as part of the RASP project. The
RASP report encourages new and current investigators to
become involved in research related to geriatric urology.
In addition, the scientific community needs to continue to
encourage funding agencies, both public and private, to
support research endeavors related to urological diseases
in older adults. By supporting and expanding research ef-
forts, urology will help to directly affect the urological
care of current and future generations.
ACKNOWLEDGMENTS
Direction, encouragement, and support from the AGS and
the JAHF have enabled urology to move into the world of
geriatric emphasis. This resulted in development of new
objectives for urology residency education in aging, aided
establishment of the Geriatric Urology Society, and fur-
thered the outlook for research in geriatrics as it pertains
to urology. The authors are indebted to AGS and JAHF
for this support, and the discipline of urology joins us in
this indebtedness.
REFERENCES
1. Centers for Disease Control and Prevention. National Center on Health Sta-
tistics. Data Warehouse on Trends in Health and Aging. Atlanta, GA: Cen-
ters for Disease Control and Prevention, 2000.
2. Administration on Aging. U.S. Department of Health and Human Services. A
Profile of Older Americans. Washington, DC: U.S. Department of Health
and Human Services, 2000.
3. Social Security Bulletin, Annual Statistical Supplement. 2000.
4. Solomon DH, Burton JR, Lundebjerg NE et al. The new frontier. Increasing
geriatrics expertise in surgical and medical specialties. J Am Geriatr Soc
2000;48:702704.
5. Dugan E, Roberts CP, Cohen SJ et al. Why older community dwelling adults
do not discuss urinary incontinence with their primary care physicians. J Am
Geriatr Soc 2001;49:462465.
6. Umlauf MG, Goode S, Burgio KL. Psychosocial issues in geriatric urology.
Problems in treatment and treatment seeking. Urol Clin North Am 1996;23:
127136.
7. Ouslander JG. Aging and the lower urinary tract. Am J Med Sci 1997;314:
214218.
8. Zakaria L, Anastasiadis AG, Shabsigh R. Common conditions of the aging
male: Erectile dysfunction, benign prostatic hyperplasia, cardiovascular dis-
ease and depression. Int Urol Nephrol 2001;33:283292.
9. Perczek RE, Burke MA, Carver CS et al. Facing a prostate cancer diag-
nosis: Who is at risk for increased distress? Cancer 2002;94:2923
2929.
10. Shortliffe LM, McCue JD. Urinary tract infection at the age extremes. pediat-
rics and geriatrics. Am J Med 2002;113(Suppl. 1A):55S66S.