Understanding Genitourinary Tuberculosis: Symptoms, Diagnosis & Pathology

1. Urologic Tuberculosis Xu Ha Department of Urology, Tongji Hospital

2. Tuberculosis (TB) • Pathogen— Mycobacterium tuberculosis • Infected — one third of world's population • Organism — lung first, through bloodstream to other • Probability — exposure, size, and infectivity • Initial infection — most controlled and no clinical illness • Clinical disease — multiplication of dormant bacilli

3. Genitourinary TB • Account for 10% of tuberculosis cases • Most 20 to 40 years old • Male VS female — 2:1 • Very uncommon in children • Spread of organism to kidney through blood • Other parts become involved by direct extension

4. Pathologic Features Kidney • Caseating granuloma • Caseous abscess • Fibrosis • Calcification • Papillary necrosis • Calyceal stem or UPJ obstruction • Autonephrectomy Caseating granuloma

5. Fibrosis

6. Caseous abscess, Fibrosis and Calcification

7. Pathologic Features Ureter • Mucosa or submucosa tubercular nodule • Stricture formation • Granuloma • Fibrosis Ureter with calcification and stricture formation

8. Pathologic Features Bladder • Ureteral orifice inflamed and edematous • Ureteral orifice obstruction • Tuberculous ulcers • Tuberculous inflammation • Bladder wall fibrosis and contraction

9. Acutely inflamed ureteric orifice Tuberculous bullous granulations

10. Tuberculous golf-hole ureter severely withdrawn Acute tuberculous ulcer

11. Acute tuberculous cystitis with ulceration Healed tuberculous lesion

12. Clinical Manifestations The diagnosis of genitourinary TB should be considered in a patient presenting with vague, longstanding urinary symptoms for which there is no obvious cause!

13. Clinical Manifestations SPECIFIC - Genitourinary tract Lower urinary tract – 50 to 80 % • Burning , frequency , urgency , urge incontinence • Dysuria , hematuria • Suprapubic pain / perineal discomfort • Decreased stream , straining, ineffective voiding • Slough in urine

14. Clinical Manifestations Genital – Female • Menstrual irregularities • Pelvic pain syndrome • Infertility – 18 % Upper urinary tract symptoms • Pain - kidney and ureter region • Gross hematuria- 10 % Genital – Male • Hematospermia - 10 % • Azoospermia • S/S of chronic epididymorchitis

15. Clinical Manifestations Other systems • Respiratory - 12 % patients • Gastrointestinal - 10 % • Lymphoreticular Constitutional - 10 to 15 % • Evening rise of temperature • Weight loss • Anorexia

16. Diagnosis Laboratory Urinalysis and Culture • Acidic urine , sterile pyuria , microscopic hematuria • Guide for further investigation, especially in pauci-symptomatic patients • Fastidious / slow growth – difficult to culture – at least three, but preferably five

17. Diagnosis Laboratory Purified Protein Derivative (PPD, Tuberculin Test, Mantoux Test) • If Positive – supports the diagnosis • If Negative – can not exclude extrapulmonary TB • Response – HIV, Immunocompromised , Post-transplant pts

18. Diagnosis Laboratory Nucleic Acid Amplification (NAA) Testing—PCR • Multiple sample • Sensitivity from 87% to 95% (VS culture) • Specificity from 92% to 99.8% (VS culture) • Resistance mutations

19. Diagnosis Radiography • Plain Radiograph • Positive findings up to 50% on chest radiograph • Calcifications in 30% to 50% case on KUB

20. Diagnosis Radiography • Intravenous Urography (IVU) • Traditional gold standard tool • Replaced by CT in many institutions • Early signs: calyceal erosion and papillary irregularity • Most common: hydrocalycosis, hydronephrosis, orhydroureter

21. Diagnosis Radiography • Intravenous Urography (IVU)— kidney • Calyx distortion • Calyx fibration • Calyx occlusion • Calyceal destruction • Parenchymal destruction

22. Diagnosis Radiography • Intravenous Urography (IVU)— ureter • Dilatation above UVJ stricture • Rigid fibration • Multiple strictures

23. Diagnosis Radiography • Intravenous Urography (IVU)— bladder • Small and contracted (thimble bladder) • Irregular with filling defects • Asymmetry

24. Occluded calyx Severe calyceal and  parenchymal destruction

25. Stricture at the distal left ureter Contraction of the bladder left side

26. Diagnosis Radiography • Computed Tomography (CT) • Three-dimensional reconstructed images • At least the equal of IVU in identification • Findings with not specific

27. Computed Tomography (CT) • Calyceal abnormalities • Hydronephrosis or hydroureter • Autonephrectomy • Amputated infundibulum • Urinary tract calcifications • Renal parenchymal cavities Hydronephrotic in right kidney End-stage nonfunctioning atrophic left kidney with calcification.

28. Diagnosis Endoscopy • Cystoscopy and Biopsy • Rarely indicated in diagnosis • Must under general anesthesia • Assessing the disease extentor the response to chemotherapy • No Biopsy advised before medical therapy

29. Treatment • Successful treatment • Early diagnosis • Prompt initiation of adequate drug • Rest and nutrition • Urgical treatment for advanced cases

30. Treatment Medical Treatment • Multidrug treatment • Initial 6-month regimens of rifampicin, INH, pyrazinamide, and ethambutol • Administered in one dose • Dosage, toxicity, drug interactions

31. Treatment Antituberculous Drugs

32. Treatment Antituberculous Drugs

33. Treatment Surgical Therapy • Adjuvant to medical therapy • Focus on organ preservation and reconstruction • At least 4 to 6 weeks medical therapy before • Excision of diseased tissue and reconstructive

34. Treatment Surgical Therapy Excision of diseased • Nephrectomy • Partial Nephrectomy • Abscess Drainage

35. Treatment Surgical Therapy Indications for nephrectomy • A nonfunctioning kidney with or without calcification • Extensive disease involving the whole kidney, together with hypertension and UPJ obstruction • Coexisting renal carcinoma

36. Treatment Surgical Therapy Reconstructive Surgery • Ureteral strictures • Augmentation cystoplasty • Urinary conduit diversion • Orthotopic neobladder

37. Summary • Part of general tuberculosis caused by Mycobacterium tuberculosis • Vague, longstanding urinary symptoms with no obvious cause • Urinalysis and culture and radiography for diagnosis • Basilic medical treatment • Adjuvant surgical therapy

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