Genitourinary Tuberculosis

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Etiology
Genus Mycobacterium

Weakly gram+ive,Acid fast

 Disease of young to middle-aged adults as genitourinary

disease occurs 5 to20 years after primary pulmonary infection pulmonary TB)

M/F ratio= 5:3(In contrast to other forms of non-

Approximately 20-30% of extra-pulmonary

infection(second most frequent form of non pulmonary TB)

Seen in approximately 4% to 8% of non-HIV infected

 Hematogenous spread

Rarely primary one

Transplant recipient

 25% of the patients with genitourinary tuberculosis

have a history of diagnosed tuberculosis.

In an additional 25% to 50% of patients, changes

compatible with old pulmonary tuberculosis can be found on chest x-ray films.

Pathogenesis caseation fibrosis

The small silent renal microgranulomas resulting from

silent haematogenous dissemination are typically found bilaterally in the renal cortex factors permit the bacilli to proliferate. proximal tubule.

These cortical granulomas remain dormant until unknown

If enlarging granuloma rupture, delivers organisms into the

 Bacilli in the nephron are trapped at the level of

loop of henle,where they multiply and survive well possibly on account of impaired phagocytosis in the hypertonic environment.
Clinically important renal tuberculosis,

therefore, is usually initially localized to the medulla and is usually unilateral.

 Progressive destruction with cavity formation Papillary necrosis tuberculous pyonephrosis (caseocavernous renal

tuberculosis) are common in advanced disease. Communication with the collecting system usually is responsible for the spread of bacilli to the renal pelvis, ureter & bladder

 Fibrosis accompanies the granulomatous process

infundibular strictures and renal pelvic kinking

obstructive uropathy

The end-stage kidney is nonfunctional

URETER Results in

Ulceration,fibrosis,stricture,calcification Most common site is ureterovesical f/b pelviureteric

BLADDER--Involvament starts from ureteric

orifice , which contracts..then inflammation spreads deep.fibrosis results in Small,contracted with stiff wall bladderTHIMBLE BLADDER

Genital TBAlways by hematogenous spread FemaleFallopian tube most common,50%

involve

uterus

MaleProstate,seminal vesicles,epididymis Rarely involve urethraUrethral

stricture,periurehral abscess or fistula formation results

Pathology: Gross

Renal tuberculosis. Photograph of a cut gross specimen shows multiple, predominantly peripheral, white tuberculous granulomas throughout the kidney.

Photographs of a cut gross specimen show the early necrosis of the medullary tip (black spot in a). Once devitalized, the papilla sloughs off, leaving a defect (cavity in b)

Calcification in advanced lesions is common and may be focal or generalized, which produces a putty or cement kidney.

Pathology: Microscopic
Caseating granuloma

Bilateral microscopic renal

involvement is the rule.

Clinical Features
Insidious

mode of presentation, with approximately 20% of cases diagnosed unexpectedly at operation or autopsy.

A high index of suspicion enables early diagnosis

One measure of the frequently occult nature of urinary

tract tuberculosis comes from Lattimer's report in which 18 of 25 physicians with renal tuberculosis being diagnosed only after far-advanced cavitary disease had developed.

Risk factors
close contact with sputum positive individual P/H/O pulonary TB, immunosuppression, HIV infection, diabetes mellitus renal failure elderly patients with TB elsewhere

 Approximately 75% of patients present with symptoms

suggesting urinary tract inflammation. -Dysuria

-Mild or moderately severe back or flank pain -Recurrent bouts of painless gross hematuria-10% -Nocturia (due to conc. Defect) -Pyuria (esp. episodic)

 Bladder symptoms in advanced cases (urgency, frequency)

Paucity of constitutional symptoms usually associated with

tuberculosis such as fever, weight loss, night sweats, and anorexia. foci of tuberculosis

Constitutional symptoms should lead to a search for other

Tubercular interstitial nephritis

Hence, it is important that the diagnosis is

considered in all patients with equal-sized smooth kidneys without a clear-cut renal diagnosis, especially in high-risk groups considered.
Mallinson et al. Quarterly Journal of Medicine

In such patients renal biopsy should always be

1981

Glomerular Diseases
Rare association with

-dense deposit disease -Mesangio-capillary glomerulonephritis

Amyloidosis

Chronic tuberculosis sometimes leads to amyloidosis and in India is a not uncommon cause of renal amyloid and renal failure

 Three other major complications of renal tuberculosis:

hypertension (RAS axis mediated) super-infection (12 to 50%) nephrolithiasis (7 to 18%).

Female--Infertility,menstrual

disturbances,vaginal discharge,pelvic pain

Male--Scrotal pain or

swelling,haemospermia,superficial penile ulceration

Diagnosis Urine analysis Essentially every patient with established urinary tract tuberculosis has an
abnormal urinalysis with pyuria, hematuria, or both. infection 50% having microscopic hematuria

20%OF GUTB pt. hv secondary becterial

Sterile pyuria

the old clinical teaching that the asymptomatic patient with pyuria, particularly with an acid urine and a urine culture that fails to reveal conventional bacterial pathogens, must be considered as having tuberculosis until proved otherwise remains true today

Another indicator is failure of the patient's symptoms to respond to conventional antibacterial treatment

 Early-morning urine specimens are preferred Sterile container

three to five daily specimens

Preferably immediate examination, if delay unavoidable

sample must be refrigerated, not freezed.

 concentrated by centrifugation.

Smears prepared from sediment

Z-N staining.

Problem of E.M.s(Mycobacteria Smegmatis)

G.U.T.B. should never be diagnosed solely on the basis

Culture
Gold standard positive in 80% to 90% of cases Decontamination of sediment. main problems:

-COST -AVAILABILITY -DELAYS

 newer commercial media (BACTEC..)

-faster (about 10 days) -but expensive++, -technical demanding -not useful for control in high prevalence

Imaging
High dose IVU traditional gold standard CT new standard Pyelography (ante/retrograde) limited use Plain radiographs important

CXR,spine X-Ray,X-Ray KUB US limited value Nuclear Perfusion Scan function MRI,Arteriography little application Anterograde pyelography

Radiology
X-Rays
Plain films of the abdomen-

-genitourinary calcifications (present in up to 50%) as well as other extrapulmonary foci of mycobacterial disease (vertebral, mesenteric lymph node, adrenal glands) may be present (approximately 10%) -MULTIPAL ILL-DEFINED,IRREGULAR CORTICAL CALCIFICATION

Chest radiographs show evidence of tuberculosis in 50%

Plain radiograph of the abdomen demonstrates extensive calcification in the left kidney, which was nonfunctional (the putty kidney), consistent with autonephrectomy from tuberculosis.

USG
-initial investigation of choice Cavities Obstruction

Early findings may be missed

Sonogram of left kidney shows 1.5-cm hypoechoic nodule

(arrowhead) in cortex

Intravenous pyelography & CT urogram findings

Intravenous urography - most useful to provide images

of detailed anatomy and FUNCTION to show the commonly occurring multiple lesions

Renal calcification is common (24-44%)

Cortical scarring papillae (moth-eaten) irregular due to inflammation and

 Hicked-up pelvis (Kerr kink sign) Infundibular strictures Hydrocalyces without dilatation of renal pelvis, or Hydronephrosis "Putty kidney" Autonephrectomy small, shrunken kidney with dystrophic

calcification

 When ureters are involved, usually the upper or lower third

(more common)

Beading (sawtooth ureter) Corkscrew ureter Pipe stem ureter

Bladder involvement rarely leads to calcification of wall

(think schistosomiasis) fistula formation

Reflux, thickening of bladder wall (thimble bladder),

IVP of 32-year-old woman. A, left renal parenchymal mass (arrows) and left hydroureter due to left distal ureteral stricture (arrowheads). B, magnification of left kidney shows irregular caliceal contour as moth-eaten appearance (arrows) of upper calix and multiple cavities (arrowheads) of lower pole.

 Genitourinary tract tuberculosis. Lobar calcification in a

large destroyed right kidney in a patient with renal tuberculosis. Note the involvement of the right ureter.

 IVP film-The lower end of the right ureter demonstrates an irregular

caliber with an irregular stricture at the right vesico-ureteric junction. Note the asymmetric contraction of the urinary bladder, with marked irregularity due to edema and ulceration.

 Genitourinary tract tuberculosis. Intravenous urography series in a

man with renal tuberculosis shows marked irregularity of the bladder lumen due to mucosal edema and ulceration

 Renal Tuberculosis. Coronal reformatted non-enhanced CT

scan of the abdomen and pelvis demonstrates a small, left kidney containing globular calcifications (white circle) pathognomonic for renal tuberculosis.

Click icon to add picture

PUTTY KIDNE Y.

A, CT urogram shows severe nonuniform caliectasis and multifocal strictures (arrowheads) involving renal pelvis and ureter.Calcification (arrow) is noted in left distal ureter. (arrowhead).

B, Contrast-enhanced CT scan shows wall thickening and enhancement of left ureter

Limitations May be normal in patients with early genitourinary

tuberculosis.

Calcification may occur in patients with Diabetes mellitus

and schistosomiasis. Brucellosis also may mimic tuberculosis.

A congenital megacalyx and focal papillary necrosis may

mimic renal tuberculosis radiologically.

 Genitourinary tract tuberculosis. Lateral view of the abdomen in a

patient with schistosomiasis shows tubular calcification of the ureters in contrast to the speckled calcification in tuberculosis.

Radiograph of the pelvis in a patient with schistosomiasis shows fine linear calcifications of the bladder wall with normal volume. In tuberculosis, the bladder is contracted and demonstrates speckled calcification

Cystoscopy
Cystoscopy under general anaesthesia with

adequate muscle relaxation helps to visualize the mucosal lesions,golf hole ureteric orifice.or the reflux of toothpaste like caseous material
Biopsy during acute stage is avoided for fear of

dissemination of T.B

Aspirated pus and caseous material generally contain

few viable mycobacteria so it is more rewarding to examine biopsies of the surrounding tissue.

Clinical Management

Two goals

conservation of tissue and function

antimycobacterial cure.

Antimicrobial cure
It is a common practice for clinicians to treat GUTB for

periods longer than six months.

DOTS is the most effective way

Standard Category I regimen is effective for the treatment

of patients with GUTB

RNTCP- DOTS Therapy

Genito-urinary

T.B. -- Cat I

(HRZE)2 + (HR)4

Drug Isoniazid Rifampicin Pyrizinamide Ethambutol Streptomycin

Intr. Dose 10mg/kg 10mg/kg 35mg/kg 25mg/kg 15mg/kg daily

Streptomycin- max. dose 750 mg in pts. <50 yrs age

Dose modification in renal failure

INH Rifampicin Pyrazinamide no adjustment

Drug

Cr. Clearance Dose interval

Ethambutol 10-50 ml/min 24-36 hrs <10 ml/min 48 hrs after HD Streptomycin 10-50 ml/min avoid 24-72 hrs

<10 ml/min

Treatment monitoring

RNTCP guidelines- silent.

After 2 month of therapy3 urine cultures If negative- continue therapy At the end of therapy 3 consecutive negative samples Repeated after 3 months and at 1 year.

Treatment monitoring
IVP
-at the end of 2 months -and at the completion of Tt.

In case of renal calcification- yearly 3 urine examinations

up to 10 years.

What is the role of corticosteroids?

Another area of controversy in the treatment of GUTB is

the utility of corticosteroids in the prevention of complications such as ureteric stricture/fibrosis

Lack of RCTs on this issue

it seems unlikely that corticosteroids would be able to

reduce the development of complications such as ureteric obstruction in patients with GUTB. This issue is worth investigating

Surgical Management
Atleast 4 weeks of chemotherapy required before

surgery exccept in early stenting for ureteral strictures

Today the primary form of surgical intervention is in the

relief of strictures, particularly those of the ureters, which can result from the scarring process.

Thus, ureteral dilatations, ureteral reimplantations, and in

some cases, relief of intrarenal obstruction to urine flow are important aspects of the modern function-conserving approach to urinary tract tuberculosis

 Less commonly, patients whose bladders have been badly

scarred by the tuberculosis process have such poor bladder function that bladder augmentation or even urinary diversion may be necessary to deal with unbearable urinary frequency, inadequate emptying, or both.

nephrectomy
Rare event now a days

End-stage tuberculous kidneys with complications

- bacterial sepsis -Hemorrhage -Intractable pain -Newly developed severe hypertension -Inability to sterilize the urine because of patient unreliability -Coexiting carcinoma