Tuberculosis Of The Genitourinary Tract

TUBERCULOSIS OF THE GENITOURINARY TRACT

Wu Yudong The First Teaching Hospital of Zhengzhou University

General Principle The same characteristics as tuberculosis in other organs A disease of young adults(60% of patients are between the ages of 20 and 40) A little more common in males than in females

ETIOLOGY Pathogenous organism: Mycobacterium tuberculosis Primary site: lungs often not symptomatic or apparent Route: hematogenous

ETIOLOGY In the genitourinary tract Primary sites: kidney and prostate Infection route: ascent: prostate to bladder descent: kidney to bladder, prostate to epididymis direct extension: epididymis to testis

Pathogenesis Kidney and Ureter Pathological tuberculosis

Clinical tuberculosis

Pathogenesis Bladder Vesical irritability :early clinical manifestation Tubercles: in the region of the involved ureteral orifice Coalesce and ulcerate: bleeding Fibrosed and contracted: marked frequency Ureteral reflux or stenosis: hydronephrosis

Pathology Depending on the virulence of the organism and the resistance of the patient, tuberculosis is a combination of caseation and cavitation and healing by fibrosis and scarring

Pathology Kidney and Ureter Tubercle foci: the basic lesion in tuberculosis "autonephrectomy”: Ureteral stenosis may be complete, kidney is fibrosed and functionless. Under these circumstances, the bladder urine may be normal and symptoms absent

Pathology Bladder mucosa inflamed tubercles form (white or yellow raised nodules surrounded by a halo of hyperemia) break down to form deep, ragged ulcers With mural fibrosis severe vesical contracture, reflux may occur

Clinical finding Symptoms There is no classic clinical picture of renal tuberculosis. Most symptoms of this disease, even in the most advanced stage, are vesical in origin (cystitis)

Clinical finding Symptoms Kidney and ureter Usually: completely asymptomatic On occasion: dull ache in the flank renal and ureteral colic Rarely: painless mass in the abdomen

Clinical finding Symptoms Bladder Earliest symptoms :burning, frequency, and nocturia occasionally: Hematuria Late stage: vesical irritability become extreme. If ulceration occurs, suprapubic pain may be noted when the bladder becomes full

Clinical finding Symptoms Genital tract-Tuberculosis of the prostate and seminal vesicles usually causes no symptoms tuberculous epididymitis: mildly painful swelling An abscess A chronic draining sinus

Clinical finding Signs Kidney---usually no enlargement or tenderness External genitals--Epididymis: thickened, nontender, or only slightly tender cannot be differentiated from the testis on palpation in the advanced stages Vas deferens: thickened and beaded Scrotum: chronic draining sinus hydrocele occasionally Prostate and seminal vesicles: These organs may be normal to palpation Ordinarily prostate: areas of induration, even nodulation Seminal vesicle: indurated, enlarged, and fixed

Diagnosis Tuberculosis of the genitourinary tract should be considered in the presence of any of the following situations: (1) chronic cystitis that refuses to respond to adequate therapy (2) the finding of pus without bacteria in a methylene blue stain or culture of the urinary sediment (3) gross or microscopic hematuria (4) a nontender, enlarged epididymis with a beaded or thickened vas (5) a chronic draining sinus, or (6) induration or nodulation of the prostate and thickening of one or both seminal vesicles (especially in a young man)

Diagnosis The diagnosis rests on the demonstration of tubercle bacilli in the urine by culture. The extent of the infection is determined by (1) the palpable findings in the epididymides, vas deferentia, prostate, and seminal vesicles (2) the renal and ureteral lesions as revealed by excretory urograms (3) involvement of the bladder as seen through the cystoscope (4) the degree of renal damage as measured by loss of function (5) the presence of tubercle bacilli in one or both kidneys

Diagnosis Laboratory Findings Urinary culture or methylene blue stain: pyuria without organisms Acid-fast stain: positive in at least 60% of cases Urinary tubercle bacilli culture ： positive Tuberculin test ： A positive test: hardly diagnostic A negative test: speaks against a diagnosis

Diagnosis X-Ray Findings A plain film of the abdomen Enlargement of one kidney Obliteration of the renal and psoas shadows Punctate calcification in the renal parenchyma Renal stones are found in 10% of cases Calcification of the ureter is rare

Diagnosis X-Ray Findings Excretory urogram (1) a "moth-eaten" appearance of the involved ulcerated calyces (2) obliteration of one or more calyces (3) dilatation of the calyces due to ureteral stenosis from fibrosis (4) abscess cavities that connect with calyces (5) single or multiple ureteral strictures, with secondary dilatation, with shortening and therefore straightening of the ureter (6) absence of function of the kidney due to complete ureteral occlusion and renal destruction (autonephrectomy)

Diagnosis Instrumental Examination Cystoscopy may reveal the typical tubercles or ulcers of tuberculosis Biopsy can be done if necessary Severe contracture of the bladder may be noted A cystogram may reveal ureteral reflux

Differential Diagnosis Chronic nonspecific cystitis or pyelonephritis Acute or chronic nonspecific epididymitis

Treatment Tuberculosis must be treated as a generalized disease This means that the basic treatment is medical. Surgical excision of an infected organ, when indicated, is merely an adjunct to overall therapy

Treatment Renal Tuberculosis medical regimen: (1) isoniazid, 200-300 mg orally once daily (2) rifampin, 600 mg orally once daily (3) ethambutol, 25 mg/kg daily for 2 months, then 15mg/kg orally once daily (4) streptomycin, 1 g intramuscularly once daily (5) pyrazinamide, 1.5-2 g orally once daily

Treatment Renal Tuberculosis medical regimen: First-line drugs: isoniazid, rifampin, and ethambutol Second-line drugs: aminosalicylic acid (PAS), capreomycin, cycloserine, ethionamide,pyrazinamide, viomycin

Treatment Renal Tuberculosis most authorities advise appropriate medication for 2 years Gow (1979) finds that a 6-month course of drugs is adequate: 600 mg of rifampin, 300 mg of isoniazid, 1 g of pyrazinamide, and 1 g of vitamin C daily for 2 months, followed by 900 mg of rifampin, 600 mg of isoniazid, and 1 g of vitamin C 3 times/week for 4 months

Treatment Renal Tuberculosis If, after 3 months, cultures are still positive and gross involvement of the affected kidney is radiologically evident, nephrectomy should be considered

Treatment Vesical Tuberculosis Treat the "primary" genitourinary infection Vesical ulcers that fail to respond: Transurethral electrocoagulation Vesical instillations of 0.2% monoxychlorosene(Clorpactin) Contracture of the bladder: augmentation cystoplasty

caecum

Treatment Tuberculosis of the Epididymis Treatment is medical

If after months of treatment an abscess or a draining sinus exists, epididymectomy is indicated

Treatment Tuberculosis of the Prostate and Seminal Vesicles Only medical therapy is indicated

Although a few urologists advocate removal of the entire prostate and the vesicles