Genitourinary

tuberculosis
dr. Jeremy Thompson Ginting
CONTEN
TS
EPIDEMIOLOGY
DEFINITION
PATHOGENESIS
CLASSIFICATIO
N DIAGNOSIS
TREATMENT
 OVERVIEW
• Described as the second “great imitator” (after syphilis; Sievers, 1961), TB can mimic many other diseases
and complicate the correct diagnosis and treatment of infected patients.
• Tuberculosis (TB) can affect any organ system of the body, including the genitourinary (GU) tract.
• Untreated, GU TB can lead to irreparable tissue damage with serious consequences such as renal failure
and infertility, making it critical for clinicians to consider TB in the differential diagnosis of GU disorders.
• First identified by Robert Koch in March, 24 1882
• WHO estimates 8,6 million new case occured in 2012
• 1,3 million deaths from TB worldwide

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 EPIDEMIOLOG
Y • The World Health Organization (WHO) 2013 estimates that one-quarter of the world’s population is infected with MTBC
in its latent form.

• In 2016 there were 10.4 million new cases of active TB disease and 1.7 million deaths from TB worldwide, a continued
decline since the year 2000. TB mortality has fallen by 45% since 1990 (WHO, 2016).

• In the United States, there were 9272 reported cases of active TB in 2016 (2.9 per 100,000 persons).

• Extrapulmonary infection about 10% of all TB cases

• In developing country, 15%-20% patient with Pulmonary TB were also Extrapulmonary infection

• More than 90% of GU TB cases occur in developing countries, where the frequency approaches 15% to 20% of patients
with pulmonary TB. In contrast, the frequency of GU TB in developed countries is 2% to 10% of patients with pulmonary
TB (Figueiredo and Lucon, 2008).

• In the United States, GU TB is the third most common form after pleural and lymphatic TB and is found in 27% of
extrapulmonary cases (Daher et al., 2013).

• Eighty percent of GU TB occurs in the kidney (Wong et al., 2013; Yadav et al., 2017).

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Urogenital Tuberculosis (UGTB) coined by
Porter in 1894

1937 Wildbolz suggested the term

Genitourinary Tuberculosis (GUTB)
DEFINITION
Kidney Tubeculosis (KTB), which is usually
primary, is diagnosed more often than
Genital Tubeculosis.
However, the term UGTB is more correct

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR,
Campbell MF. Campbell-Walsh urology. 12th ed. Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Urogenital tuberculosis (UGTB) – infectious inflammation of any
urogenital organ – isolated or in combination (kidney and/or male or
female genitals)

Kidney tuberculosis (KTB) – infectious inflammation of kidney

parenchyma

Genital tuberculosis (GTB) – infectious inflammation of the female or

male genitals

Urinary tract tuberculosis (UTTB) – infectious inflammation of calyx,

pelvic and upper and lower urinary tract, always secondary to kidney
TB and should be considered as a complication of kidney TB .

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Etiology

Mycobacterium tuberculosis
• Acid-fast
• Slow divided
• Death in sunray

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Transmission

• Hematogenous : Kidney, Prostate, Epididymis,

Fallopian tube (women)
• Direct : ureter, bladder, urethra

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Pathogenesis
Hematogenous
Dissemination

Renal Parenchymal Renal Parenchymal

(Perilobular Area) (Subcortical Zone)

Favourabl Unfavourable Renal

e - Necrosis
- Fibrosis Cavity

TB Papillitis Cavernous Kidney Polycavernous Kidney

- erodes into w/o communication to With communication to
papilla pyelocaliceal system pyelocaliceal system
Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Genitourinaria TB Classifications
• Kidney
• Ureter
• Bladder
• Epididymis, Vas deferens,
Testicle
• Prostate and seminal vesicle
• Urethra

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Classification
sKidney Tuberculosis
There are four stages to be considered for Kidney tuberculosis :
Stage 1: TB of kidney parenchyma (non-destructive form, KTB-1).
Stage 2: TB papillitis (small-destructive form, KTB-2).
Stage 3: Cavernous kidney TB (destructive form, KTB-3).
Stage 4: Polycavernous kidney TB (widespread-destructive form,
KTB-4).
Complications of kidney TB are chronic renal failure, fistula, high
blood pressure

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
Fig. 60.2. Kidney-ureter-bladder radiographic Fig. 60.4. Severe calyceal and
view in a patient with left renal tuberculosis
Fig. 60.3. Occluded calyx
parenchymal destruction.
with associated calcifications.

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
Fig. 60.6. CT after oral contrast medium in a patient with bilateral Contrasted tomographic image of a patient with renal
tuberculosis. The right kidney is hydronephrotic secondary to tuberculosis and end-stage renal disease showing
infundibular stenosis but has retained good function. The left enlargement of the pyelocalycial system of the left
kidney is an end-stage nonfunctioning atrophic kidney with kidney and right kidney exclusion. Adapted with
calcification.2 permission from Lima and others.1

1. Lima NA, Vasconcelos CC, Filgueira PH, Kretzmann M, Sideaux TA, Feitosa Neto B, Silva Junior GB, Daher EF, 2012. Review of genitorurinary tuberculosis with focus on end-stage
renal disease. Rev Inst Med Trop Sao Paulo 54: 57–60.
2. Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed. Philadelphia, PA: Elsevier
Saunders; 2021. p: 1713-1725
 Axial CT revealing tiny granulomas (arrows) in both kidneys, better appreciated on the (R). A left renal
abscess with perinephric extension. Note bilateral fascial thickening (arrowheads), additional (B) axial and
(C) coronal CT images revealing site of rupture into the perinephric space (arrows). Drainage catheters are
noted bilaterally. Merchant, et al.: Renal tuberculosis‑part II (CT and MRI)

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
A non-contrast abdominal CT showed chronic perirenal abscess might look similar to renal tumor on the right kidney and
enlarges with the size of 16 x13 x12.5 cm (A,B). right staghorn stone with the size of 30x21 mm(C, green lightning), and
perinephric fat infiltration (D, white arrow head).
 Renal Tuberculosis

Elizabeth De Francesco Daher,Geraldo Bezerra da Silva Junior, and Elvino Jose´ Guarda˜o Barros.Review: Renal Tuberculosis in the Modern Era. Am. J.
Trop. Med. Hyg., 88(1), 2013, pp. 54–64
Clinical Manifestation
• Early granulomatous kidney disease  proteinuria, pyuria, and loss of kidney function. Isolated
hematuria is another possible manifestation of renal TB.

• Urinary symptoms suggestive of urinary tract infection, accompanied by pyuria and hematuria with no
bacterial growth, suggest urogenital TB.

• Advanced disease may cause obstructive uropathy, bladder defects, and loss of kidney function.

Elizabeth De Francesco Daher,Geraldo Bezerra da Silva Junior, and Elvino Jose´ Guarda˜o Barros.Review: Renal Tuberculosis in the Modern Era. Am. J. Trop. Med.
Hyg., 88(1), 2013, pp. 54–64
 URETER
• Saw tooth
• Ulcerations causing mucosal irregularity of
ureter
• Corkscrew
• Fusion of multiple strictures may create a long,
irregular ureter
• Pipe Stem
• Rigid ureter: irregular and lack normal peristaltic
movement, fibrotic,strictures noted.

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 BLADDER
A, Extensive tuberculosis of the kidney and
ureter with calcification and stricture
formation.
B, Acutely inflamed ureteric orifice.
C, Tuberculous bullous granulations.
D, Acute tuberculous ulcer.
E, Tuberculous golf-hole ureter.
F, Tuberculous golf-hole ureter, severely
withdrawn.
G, Healed tuberculous lesion.
H, Acute tuberculous cystitis with ulceration.

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Testis, Epididymis, Vas Deferens

Ultrasonography of testis showing multiple hypoechoic lesions inside the

right testis in gray-scale image (A) and color-Doppler image (B).

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 PROSTATE
• Hematogenous spread and urinary route
• Mainly been described in
immunocompromised patients

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Diagnosi
s
Clinical:
No specific signs, are vague and depend on many factors
Clinical features:
• Torpid, latent, obscure course predominates
• Flank pain (80%) and haematuria (20%)
were diagnosed significantly more
• Frequency of pyuria and dysuria(54%)
• Renal colic (24%)

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 DIAGNOSIS
• Exact diagnosis is challenging
• Wide Range of non-spesific urologic symptoms
• Lower urinary tract symptom
• Storage symptom 50%
• Haematuria 30%
• Passage of caseous material, necrotic renal papilary tissue, clot or stones
10%
• Constitutional symptom : mild fever, anorexia, weight loss, night sweats
20%
• Renal failure 7%
• May be found on workup for infertility (epididimal and vasal obstruction)
Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 DIAGNOSIS

Exact Diagnosis  Present of

Mycobacterium tuberculosis

• Urinalysis
• Urine Culture
• Tuberculin Test
• DNA TB NOT WIDELY AVAILABLE

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Diagnosi

sTests to detect M tuberculosis
 Urine culture is the gold standard
 Several early morning mid-stream urine (3-6x)
 Cultured in Lowenstein-Jensen medium
 Takes 6-8 weeks to grow
 Sensitivity 10.7% - 90%

 Ziehl-Neelsen’s stain for AFB

Cek M, Lenk S, Naber KG, et al. EAU guidelines for the management of genitourinary tuberculosis. Eur Urol. 2005 Sep;48(3):353-62. Figueiredo AA,
Lucon AM. Urogenital tuberculosis: update and review of 8961 cases from world literature. Rev Urol. 2008;10(3):207-217.
  Tests to detect M tuberculosis

 Nucleic acid amplification techniques – polymerase chain reaction (PCR)

 Results in 24-48 hours
 Sensitivity >90%, specificity >85%

 Histologic features from biopsy specimens

 About a third of GUTB is confirmed with these 2 tests

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
  Radiology investigations

 Chest radiograph: 75% positive findings

 IVU: 63% abnormal features
 KUB radiograph: 16% have renal calcification
 CT scan: renal scarring, infundibular stenosis, calyceal dilatation, non-
functioning kidney

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 o Others
 Urinalysis: pyuria, albuminuria, haematuria
 Tuberculin skin test: 88% positive (but not specific)

Detection of mycobacteriuria has decreased up to 44 %, mostly because of widespread

use of antibiotics
Reasons for late diagnosis

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
  Cystoscopy and biopsy

 Sometimes needed
 To obtain urine from lateralising disease or haematuria
 Biopsy of ulcers or tubercles to exclude malignancy
 However, biopsy is contraindicated in acute TB cystitis

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 TREATMENT

• Medical Therapy
• Early diagnosis
• Prompt initiation
• Adequate drug regiment
• Surgical Therapy
• Balanced medical-surgical approach is ideally aimed at the
preservation of renal (organ) function and eradication of
mycobacteria

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Medical Therapy

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 Surgical Therapy

• 55% of patients with genitourinary TB will require surgical

intervention
• The role of surgery has changed in the era of effective
antitubercular treatment
• Surgical intervention  medical treatment to preservation and
restoration of organ function
• Indications
• Relieve obstruction and drain infected material
• Definitive local treatment
• Upper/lower urinary tract reconstruction

Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 • Surgical  best carried out after an
initial 4 to 6 weeks of medical
treatment.

• This interval allows intense

inflammatory changes to resolve
and lesions to stabilize, permitting a
better assessment of the extent of
destruction, and hence doing the
appropriate procedure
Alicia H. Chang, MD, MS, Brian G. Blackburn, MD, and Michael Hsieh, MD, PhD in:Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology. 12th ed.
Philadelphia, PA: Elsevier Saunders; 2021. p: 1713-1725
 SUMMARY
• Genitourinary TB is caused by
Mycobacterium tuberculosis
• Prompt diagnosis is a mandatory
• Medical-surgical approach is ideally aimed
at the preservation of organ function