Genitourinary TB

Dr ALEXANDRE
NYIRIMODOKA,MD,MMED,FCS(ECSA)
UROLOGIST
RMH
 outline
Definition
Epidemiology
GUTB development
Classification
Risk factors
Clinical presentation
Work up
management
 definition
Urogenital TB (UGTB): infectious inflammation
of Urogenital system caused by Mtb or M.
bovis.
Urological tuberculosis (UTB): infectious
inflammation of the urinary system in female
patients and isolated or in combination with
the genital system in male patients, caused by
Mtb or M. bovis.
Genital tuberculosis (GTB): infectious inflammation
of the female or male genitals, , caused by Mtb or
M. bovis.
Kidney tuberculosis (KTB): infectious inflammation
of kidney parenchyma, caused by Mtb or M. bovis.
Urinary tract tuberculosis (UTTB): infectious allergic
inflammation of calyx, pelvic and upper and lower
urinary tract caused by Mtb or M. bovis.
 epidemiology
1/3 of the world’s population has latent
tuberculosis (TB)
Latent TB patient has 10% risk of having
active TB in life time
TB is 2nd killer worldwide due to a single
infectious agent
Urogenital TB IS a 2nd most common EPTB
TB is a leading killer of people living with HIV
 GUTB development
MTB arrive in genital urinary tract via 4 routes:
hematogenous spread of MTBC ( the most
common)
Ascending or retrograde infection
contiguous spread from other organ systems or
direct inoculation.
autoinoculation of external genitalia from infected
stool or urine
 Classification
1. Urinary TB:
 KTB (nephrotuberculosis)
TB of kidney parenchyma (stage 1, nondestructive form)
TB papillitis (stage 2, small-destructive form)
Cavernous KTB (stage 3, destructive form)
Polycavernous KTB (stage 4, widespread destructive form)
 UTTB
always secondary to KTB
stages are edema, infiltration, ulceration, and fibrosis
 Bladder TB
stage 1, tubercle infiltrative;
stage 2, erosive ulcerous;
stage 3, spastic cystitis
 stage 4, real microcystitis up to full
obliteration
 CON’T
MGTB:
TB epididymitis (unilateral or bilateral);
 TB orchiepididymitis (unilateral or bilateral);
 Prostate TB (infiltrative or cavernous forms);
 TB of the seminal vesicles;
 TB of the penis.
FGTB
tuberculous salpingitis
Endometrial TB
Ovarian TB
Cervical TB
Vulvar TB

IV. Generalized UGTB: simultaneous lesion of urinary organs and genitals,

always considered complicated.
 RISK FACTORS
TB contact
 TB localization, active or cured, especially disseminated
forms;
 urinary tract infection (UTI) with frequent recurrence,
resistant to standard therapy;
UTI with persistent dysuria, leading to decreasing
bladder volume;
pyuria;
 pyospermia and/or hemospermia;
scrotal, perineal and lumbar fistula.
 CLINICAL PRESENTATION
flank pain (up to 80%)
dysuria (up to 54%).
 If the urinary tract is involved, renal colic
(24%)
Gross hematuria (up to 20%)
perineal pain and dysuria
Hemospermia
Edema, swelling and pain of the scrotal organs
 CON’T
PE
attention should be paid to any fistula.
hard painful enlarged epididymis intimate welded
with testis is palpated in acute TB epididymitis
epididymis is hard, enlarged, and painless with
clear border from the testis; in chronic form
enlarged tuberous prostate gland with weak pain
 investigation
Urinalysis. Leukocyturia is found in 90-100% of
patients with KTB
The current gold standard for the diagnosis of
GU TB is urine acid fast bacilli (AFB) culture.
One single Mtb cell evidentiary confirm UGTB
 Con’t
Histological investigation:
epithelioid granuloma,
caseous necrosis, but this is rapidly replaced with
fibrous tissue.
Imaging
Ultrasound investigation may give indirect evidence of
UGTB only
Transrectal ultrasound investigation may reveal
hypoechoic and hyperechoic lesions of the prostate
and prostatolithiasis
 Con’t
plain radiography is indicated for patients
suspected for UGTB
Retrograde urethrography should be performed
in all patients with genital TB to exclude caverns
of the prostate
Cystoscopy is indicated for all UGTB patients
having dysuria
Ureteropyeloscopy may accidentally reveal TB
ulcers,
 Con’t
• Prostate biopsy should be made only after
urethrography for excluding caverns.
• Scrotal organs biopsy, Fine needle aspiration
cytology (FNAC) may be useful in the diagnosis
of TB of external male genitals
 Management
Medical management
Successful medical treatment of TB requires multiple
drugs
Treatment should start with INH, rifampin, pyrazinamide
and ethambutol.
FBC,LFT, RFT, HIV and hepatitis B and C has to be tested
before starting ttt.
Directly observed therapy (DOT) (6 months )
Pyridoxine (vitamin B6) minimizes peripheral
neuropathy induced by INH
 Surgical management
Surgical procedures goals
relieve urinary obstruction
drain infected material,
remove nonworking infected kidneys in cases
resisting cure,
 improve medically resistant hypertension
to reconstruct the urinary tract
 Con’t
Preoperative anti TB (4-6 weeks) reduces the
frequency of postoperative complications
ureteral stenting or percutaneous
nephrostomy (PCN) for tuberculous ureteral
strictures limits the loss of renal function
Nephrectomy in a nonfunctional kidney or
recurrent TB despite optimal medical therapy
 Con’t
Strictures of the UPJ and ureter may be temporarily
stented to allow improvement of renalfunction
Upper and mid ureteric strictures are rare and can be
treated by endourologic treatment.
Lower ureteric stricture are treated by open surgery.
Augmentation cystoplasty and bladder substitution
are options
Bladder TB grade 4 (microcystitis) is indicated for
cystectomy followed by enteroplasty
 Con’t
Bladder neck contracture & urethral strictures
are treated endoscopically
surgery for genital TB is considered only for
patients in whom medical therapy has failed
 references
 campbell walsh urology 11th edition
Ekaterina Kulchavenya, Urogenital tuberculosis:
definition and classification Ther Adv Infect Dis
(2014) 2(56) 117122
 Ekaterina Kulchavenya, Best practice in the
diagnosis and management of urogenital
tuberculosis Ther Adv Urol (2013) 5(3) 143–151
Urogenital TB patient classification in seven Groups
According to Clinical and Radiological Presentation