Genitourinary Tuberculosis

URINARY TUBERCULOSIS:
FEATURES:
  • Bladder tuberculosis is almost always secondary to renal tuberculosis
  • Tuberculosis of the urinary tract arises from hematogenous infection from a distant focus which is often impossible to identify. 
  • The disease starts at the ureteric opening, the earliest evidence being pallor of the mucosa due to submucosal edema.
  • Subsequently tiny white transluscent tubercles develop all over. Gradually these tubercles enlarge and may ulcerate (but do not cause bladder perforation).
  • These tubercles lend 'cobblestone' appearance on cystoscopy.
  • There is considerable submucous fibrosis which causes diminished capacity of bladder. 
  • Scarred & fibrosed, small capacity bladder is k/a thimble bladder.
  • The fibrosis which usually starts around the ureter, contracts to cause a pull at the ureters. 
  • This either leads to a stricture or displaced, dilated and rigid wide mouthed ureter k/a golf hole ureters. this almost always leads to ureteral reflux.
  • Sterile pyuria is consistent finding
  • Urinary frequency, 
  • dysuria,
  • nocturia, 
  • hematuria, and 
  • flank or abdominal pain are common presentations
  • Most common site of genitourinary tuberculosis is - kidney
DIAGNOSIS:
  • The tubercle bacilli can be identified on AFB staining of 24 hr urine specimen or the first morning urine sample collected on 3 successive days.
  • AFB staining is positive in about 60% of cases - Smith Urology
  • Diagnosed more commonly in females, in whom it affects the fallopian tubes
  • In male patients, genital TB preferentially affects the epididymis
  • Renal Tuberculosis 
FEATURES:
  • Early Clinical Features:
  1. Earliest and often the only presentation of TB kidney is Increased frequency
  2. Symptoms of cystitis;
  3. Microscopic or macroscopic hematuria;
  4. Pyuria with negative bacterial culture (`sterile pyuria');
  5. Constitutional symptoms.
  6. The lesions are usually confined to one kidney, originates in the Renal pyramid
  7. A group of tuberculous granulomas in a renal pyramid coalesces and forms an ulcer. Mycobacteria and pus cells are discharged into the urine 
  • Late Clinical Features:
  1. Nephrolithiasis and ureteral colic;
  2. Intractable frequency and urgency;
  3. Refractory hypertension;
  4. Renal insufficiency due to obstructive nephropathy.
COMPLICATIONS:
  • Untreated, the lesions enlarge and a tuberculous abscess may form in the parenchyma.
  • The necks of the calyces and the renal pelvis stenosed by fibrosis confine the infection so that there is tuberculous pyonephrosis which is sometimes localised to one pole of the kidney.
  • Extension of pyonephrosis or tuberculous renal abscess leads to perinephric abscess and the kidney is progressively replaced by caseous material (putty kidney) which may be calcified (cement kidney).
DIAGNOSIS:
  • At any stage the plain radiograph may show areas of calcification (pseudocalculi).
  • Less commonly the kidneys may be bilaterally affected as part of the generalised process of miliary tuberculosis
  • Renal tuberculosis is often associated with tuberculosis of the bladder and typical tuberculous granulomas may be visible in the bladder wall. 
  • In the male, tuberculous epididymo-orchitis may occur without apparent infection of the bladder.
  • IVU (Intravenous urography)is the most sensitive technique for detecting early renal TB. 
  • Early renal TB-IVP is most sensitive imaging modality
  • Earliest urographic findings in renal TB is irregular calyceal contour which occur secondary to papillitis.
  • Characteristic urographic finding in renal TB is ‘phantom calyx’ which refers to an obstructed, nonfunctional calyx proximal to an infundibular stricture.
  • Early signs of ureteral TB includes dilation, ulceration and mucosal irregularity.
  • Advanced renal TB - CT > IVP > USG ( order of sensitivity)

Exam Question
  • Investigation of choice for advanced renal tuberculosis is CT
  • Intravenous urography is the most sensitive imaging modality to detect early renal tuberculosis
  • Sterile Pyuria is characteristically seen in Renal Tuberculosis
  • Most common route of infection in kidney tuberculosis is hematogenous
  • Earliest and often the only presentation of TB kidney is Increased frequency
  • Cobblestone mucosa,Thimble bladder,Golf hole ureter are the Cystoscopic findings in TB bladder
  • Most common site of genitourinary tuberculosis is kidney
  • Renal tuberculosis originates in the Renal pyramid

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