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Tuberculosis of the Genitourinary System
The genitourinary system is a common site of extrapulmonary tuberculosis (TB). Genitourinary
tuberculosis (GUTB) may involve the kidneys, ureter, bladder, or genital organs. Clinical
symptoms usually develop 10-15 years after the primary infection. Only about a quarter of
patients with GUTB have a known history of TB; about half of these patients have normal chest
radiography findings.
Pathophysiology:
Growing granuloma may erode into the calyceal system, spreading the bacilli to the renal pelvis,
ureters, bladder, and other genitourinary organs. Depending on the status of the patient's
defense mechanisms, fibrosis and strictures may develop with chronic abscess formation.
Ureteral TB often causes ureteral strictures and, sometimes, hydronephrosis.
Presentation:
Persons with GUTB rarely display the typical symptoms of TB.
1-The most common symptoms of GUTB, in descending order of frequency, include increased
frequency of urination (during the day initially but at night later in the disease course), dysuria,
frank pain, suprapubic pain, blood or pus in the urine, and fever.
2-Urinary urgency is relatively uncommon unless the bladder is extensively involved.
3-Patients with GUTB may present with a painful testicular swelling, perianal sinus, or genital
ulcer.
4-Asymptomatic patients are not uncommon. Unexplained infertility in both men and women is
sometimes attributable to GUTB.3
Physical examination:
1-While the hallmark of GUTB is sterile pyuria.
2-Gross hematuria occurs in 10% of cases and is usually total and painless. Microscopic
hematuria is present in 50% of cases.
3-Tender testicular or epididymal swelling, beading of the spermatic cord, and
epididymocutaneous sinus formations may develop.
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Differential Diagnoses:
1-Renal Cell Carcinoma
2-Schistosomiasis
3-Medullary sponge kidney
4-Pyonephrosis
5-Renal echinococcosis
6-Fungal infection
7-Bladder cancer
8-Psoas abscess with calcification
9-Calyceal diverticula
Laboratory Studies:
1-Tuberculin skin test results are positive in about 90% of patients, but this finding denotes only
prior inhalation of mycobacteria rather than active disease.
2-Complete blood cell count, sedimentation rate, serum chemistry, and C-reactive protein
studies are helpful to assess the severity of disease, renal function, and response to treatment.
3-Serial early-morning urine collection for acid-fast smear (at least 3) is a specific (89-96%) ,
4-Serial urine cultures are still considered the criterion standard for evidence of active disease,
with sensitivity of 65% and specificity of 100%..
Imaging Studies:
Radiography
Chest and spine radiographs may show old or active lesions. In 50% of patients, chest
radiographic findings are negative. Kidney, ureter, and bladder (KUB) radiographs reveal
calcifications in the kidney and ureter in approximately 50% of patients
Intravenous pyelography and voiding cystography
Sonograms may reveal cystic or cavitary lesions, cortical scarring, hydronephrosis, and abscess
in kidneys
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In recent years, high-resolution transrectal ultrasonography (TRUS)
CT scanning with contrast
Renal nuclear scan findings are nonspecific but can be used to assess kidney function and to
monitor the effects of therapy.
MRI, hysterosalpingography, and image-intensifier endoscopy are sometimes useful to reveal
radiographic changes in genitourinary tuberculosis (GUTB).
Treatment:
Medical Care
Standard treatment is rifampin, INH, pyrazinamide, and ethambutol for 2 months, then
rifampin and INH for 4 more months unless resistance to either agent exists; if so, obtain a
follow-up sensitivity report.
Indications for prescribing steroids include the following:
1-Severe bladder symptoms
2-Tubular structure involvement (eg, ureter, fallopian tubes, spermatic cord)
Surgical intervention:
Indications
1-Hydronephrosis
2-Progressive renal insufficiency secondary to obstruction
3-Nonfunctioning or poorly functioning kidneys
4-Stricture of vas deferens that is causing infertility
5-Persistent pain
6-Severe, persistent, or recurrent uterine bleeding
7-Possible neoplasm
Ablative surgery
1-Partial or total nephrectomy
2-Epididymectomy
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Reconstructive surgery
1-Ureteric or urethral dilatation
2-Stent
3-Resection
4-Replacement or reimplant
5-Urinary diversion
5-Augmentation cystoplasty
Complications:
1-Stricture. 2-Obstruction . 3-Superinfection . 4-Abscess
5-Sinus formation. 6-Renal hypertension .
7-Scarring of renal parenchyma, loss of renal function, and, eventually, end-stage renal disease
8-Stricture and obstruction of ejaculatory duct or vas deferens may cause azoospermia and
sterility. Similarly, involvement of fallopian tubes or endometrium may lead to infertility, which
is common in developing countries
By:TWANA NAWZAD