Genitourinary Tuberculosis

Short reviewDr. Ravi Roshan KhadkaResident MS- Urology

BSMMU

Introduction• Tuberculosis (TB) has been a leading public health

problem, especially in the developing nations of Southeast Asia, causing approximately three million new cases and 7,00,000 deaths every year (WHO; 2001.)

• Genitourinary TB– Extrapulmonary sites account for 10% of tuberculosis cases. – Genitourinary TB accounts for 30% to 40% of all

extrapulmonary TB, second only to lymphonodal affection (Eastwood et al, 2001).

– In developing countries it occurs in as many as 15% to 20% of cases.

Aetiology• Mycobacterium tuberculosis,

– which reaches the genitourinary organs by the hematogenous route from the lungs. The primary site is often not symptomatic or apparent.

• Primary sites– The kidney and possibly the prostate

• All other genitourinary organs become involved by either ascent (prostate to bladder) or descent (kidney to bladder, prostate to epididymis).

• The testis may become involved by direct extension from epididymal infection.

Pathogenesis

• KIDNEY & URETER – When enough bacteria of sufficient virulence become lodged in the

kidney and are not overcome then clinical infection is established.– kidney progresses slowly; it may take 15–20 years to destroy a kidney– no clinical disturbance of any type until the lesion has involved the

calyces or the pelvis .– When the infection involves pelvic mucosa and the ureter, particularly

its upper and vesical ends ,it leads to stricture and obstruction (hydronephrosis).

– Ureteral stenosis may be complete, causing “autonephrectomy.” Such a kidney is fibrosed and functionless.

– The ureter undergoes fibrosis and tends to be shortened and therefore straightened. This change leads to a “golfhole” ureteral orifice.

– In the most advanced stage of renal tuberculosis, the parenchyma may be completely replaced by caseous substance or fibrous tissue. Perinephric abscess may develop

Pathogenesis

• BLADDER– Vesical irritability develops as an early clinical

manifestation.– Tubercles form later, usually in the region of the involved

ureteral orifice, and finally coalesce and ulcerate & ulcers may bleed.

– With severe involvement, the bladder becomes fibrosed and contracted; this leads to marked frequency.

– Ureteral reflux or stenosis and, therefore, hydronephrosis may develop.

Pathogenesis

• PROSTATE & SEMINAL VESICLES– The passage of infected urine through the

prostatic urethra ultimately leads to invasion of the prostate and one or both seminal vesicles.

– On occasion, the primary hematogenous lesion in the genitourinary tract is in the prostate.

– Prostatic infection can ascend to the bladder and descend to the epididymis.

Pathogenesis

• EPIDIDYMIS & TESTIS– Tuberculosis of the prostate can extend along the

vas or through the perivasal lymphatics and affect the epididymis.

– If the epididymal infection is extensive and an abscess forms, it may rupture through the scrotal skin, thus establishing a permanent sinus, or it may extend into the testicle.

Clinical Findings• Tuberculosis of the genitourinary tract should be

considered in the presence of any of the following situations:– Chronic cystitis that refuses to respond to adequate therapy,– the finding of sterile pyuria, – gross or microscopic hematuria, – a nontender, enlarged epididymis with a beaded or thickened

vas, – a chronic draining scrotal sinus, or – induration or nodulation of the prostate and thickening of one

or both seminal vesicles (especially in a young man). – A history of present or past tuberculosis elsewhere in the body.

Clinical Features

• There is no classic clinical picture of renal tuberculosis• Vague generalized malaise, fatigability, low-grade but

persistent fever, and night sweats.• Organ specific clinical features– Kidney:

• Asymptomatic • On occasion, however, there may be a dull ache in the flank.• Renal and ureteral colic (blood clot, secondary calculi, or a mass of debris) • Rarely, a painless mass in the abdomen.

Clinical Features

• Bladder—– The earliest symptoms of renal tuberculosis and

present as burning, frequency, and nocturia. – Hematuria is occasionally found and is of either

renal or vesical origin. – If ulceration occurs, suprapubic pain .

Clinical Features

• Genital tract– Tuberculosis of the epididymis usually presents as a

painless or only mildly painful swelling. An abscess may drain spontaneously through the scrotal wall.

– A chronic draining sinus should be regarded as tuberculous until proved otherwise.

– the tuberculous prostate shows areas of induration, even nodulation.

– The involved seminal vesicle is usually indurated, enlarged, and fixed.

Investigations

• The diagnosis rests on the demonstration of tubercle bacilli in the urine – Culture or – positive polymerase chain reaction (PCR).

• The extent of the infection is determined by imaging and cystoscopy

Urine analysis

• Persistent pyuria without organisms on culture means tuberculosis until proved otherwise.

• Acid-fast stains done on the concentrated sediment from a 24- hour specimen (60% positive).

• Demonstration of tubercle bacilli in the urine – Culture or – positive polymerase chain reaction (PCR).

X-RAY FINDINGS

• X-Ray KUB– Enlargement of kidney or obliteration of the renal

and psoas shadows (perinephric abscess). – Punctate calcification in the renal parenchyma – Renal stones.

IVU• Excretory urograms can be diagnostic if the lesion is

moderately advanced. • The typical changes include

– a “moth-eaten” appearance of the involved ulcerated calyces,– obliteration of one or more calyces, – dilatation of the calyces due to ureteral stenosis from fibrosis, – abscess cavities that connect with calyces, – single or multiple ureteral strictures, with secondary dilatation,

with shortening and therefore straightening of the ureter, – absence of function of the kidney due to complete ureteral

occlusion and renal destruction (autonephrectomy).

Ultrasound and computed tomography

• Ultrasound and computed tomography (CT) also show – the calcifications, – renal contractions and scars, – ureteral and calyceal strictures suggestive of

genitourinary tuberculosis. • Ultrasound has the advantage of low cost and low

invasiveness. • Contrast CT is highly sensitive for calcifications and

the characteristic anatomic changes

Cystoscopy and Cystogram

• Cystoscopy– clearly demonstrates the extent of the disease.– reveal the typical tubercles or ulcers of

tuberculosis. – Biopsy can be done if necessary.

• A cystogram may reveal ureteral reflux.

Supportive investigations

• CBC• Monteux test– Fifteen millimeters or more of induration is

considered positive in anyone.– Ten millimeters or more of induration is considered

positive in high risk for tuberculosis.• Renal Function– S.creatinine– DTPA renogram

Treatment• Genitourinary tuberculosis is extrapulmonary tuberculosis.• The primary treatment is medical therapy. • Currently surgical treatment is reserved for advanced cases,

often to correct the obstructive effects of fibrosis and scarring rather than the removal of infected tissues.

• TREATMENT OF OTHER COMPLICATIONS– Perinephric abscess must be drained, and nephrectomy should be

done either then or later to prevent development of a chronic draining sinus.

– If ureteral stricture develops on the involved side, ureteral dilatations offer a better than 50% chance of cure.

– The severely involved bladder may cause incompetence of the ureterovesical junction on the uninvolved side. some form of urinary diversion may be required.

Medical Therapy

• Genitourinary TB can safely be managed with short-course chemotherapy.

• Classically, antimycobacterial regimens rely on a first line of drugs, namely, rifampicin, INH, pyrazinamide, and ethambutol.

• A standard treatment regimen for tuberculosis requires 6 months of therapy.

Bangladesh National Protocol

Role of Surgery in GU TB

• Indications for surgical management follow broad lines: – Procedures to relieve obstruction and drain

infected material, – Definitive local treatment, – upper urinary tract reconstruction, lower urinary

tract reconstruction, and – surgery for genital TB.

Bladder Surgery

• Augmentation cystoplasty and bladder substitution are options in the management of the tuberculous contracted bladder. – A capacity of less than 100 mL is commonly the indication to

augment.• Extremely contracted bladders (thimble bladders of 20

mL capacity) are best managed by orthotopic bladder substitution (Hemal and Aron, 1999). – The general rules of incorporating the bowel into the urinary

tract apply, such as thoroughly evaluating renal functions, reconfiguring a low pressure reservoir (de Figueiredo et al, 2006),

Role of Nephrectomy

• Removal of an asymptomatic nonfunctioning kidney secondary to UGTB remains controversial.– The rationale for nephrectomy is that the poor blood flow

to a non-functioning kidney and the presence of necrotic tissue may prevent the penetration of anti-TB medication and lead to the persistence of viable organisms.

• Indications– the excision of a renal unit that is nonfunctioning despite

adequate drainage and medical treatment (Gupta et al, 2006). – extensive parenchymal destruction involving the whole kidney

associated with hypertension (Flechner and Gow, 1980). – Coexisting renal carcinoma also mandates nephrectomy.