MULTIMODALITY

IMAGING OF
GENITOURINARY
TUBERCULOSIS

Oleh:
dr. Christa Levina Daniswara

Narasumber:
dr. Titik Yuliastuti, Sp.Rad(K)
Introduction
Introduction
• Tuberculosis (TB) is the worldwide leading cause of death among
people inflicted with a chronic infectious disease.

• TB prevalence has increased over the past few decades. This increase is
mainly attributed to AIDS epidemic, an increasing number of drug
resistant Mycobacterium TB strains and evolving global migration
trends.

• The genitourinary system is the most commonly affected extra-

pulmonary site, accounting for 15-20% of TB infections outside of the
lung.

• It is estimated that 25% of patients with genitourinary TB had a prior

pulmonary TB infection.
Introduction

Genitourinary TB is challenging to diagnose because of its variable

clinical and radiological presentations that often mimic other diseases

Early diagnosis requires a high level of clinical suspicion as well as

familiarity with characteristic TB imaging features on excretory
urography, CT, MRI and USG.

The final diagnosis is made when imaging features are correlated with
laboratory data including urine cultures and histologic analysis.
Etiopathogenesis of Genitourinary TB

Pathogen then phagotized

Inhalation of M.
by intra-alveolar Ghon’s focus
tuberculosis into the alveoli
macrophages

Bacilli within the lymph

nodes eventually reach the Some bacilli enter the
Usually the mycobacteria
thoracic duct and enter the lymphatic system and form
remain latent in lung
venous circulation resulting Ghon’s foci in regional
granulomas / lymph nodes
in seeding of different lymph nodes
organs
Renal TB - Etiopathogenesis
Tuberculosis bacilli to the
renal parenchyma and immunocompetent patients
formation of small renal
cortical granulomas
Reactivation, enlargement
Cell-mediated immunity in
and coalescence of these
granulomas may occur if the
arrests bacterial replication
host immunity is
 inactive granuloma
compromised

Caseating granuloma and Reactivation  capillary

papillary necrosis  erosion
and rupture into the calyces
 renal pelvis, ureters,
bladder and other
genitourinary organs.
rupture and spread of
bacteria to the renal medulla,
causing papillitis that extend
into the proximal loop of
Henle
Renal TB - Etiopathogenesis
Immune-mediated
Calcium salt deposition Secondary hypertension
response  fibrotic
within the renal may result from
tissue formation and
collecting system leads reduction of the renal
calcium salt deposition
to calcified stone blood flow in cases of
within renal
formation severe unilateral TB.
parenchyma

End-stage fibrosis and

subsequent obstructive
uropathy can eventually
result in
autonephrectomy
Etiopathogenesis
• Urinary TB (UTB) is diagnostically challenging as its presentation is
often vague, and symptoms can be intermittently chronic.
• Initial presenting complaints include lethargy, low grade fever, and
weight loss.
• Recurrent urinary infections that do not respond to antibiotics should
raise clinical suspicion for UTB.
Standard urine cultures are
Painless macroscopic
not beneficial  3 first
Bladder  increased Sterile pyuria, hematuria, hematuria (10%) ;
morning void urine
urgency to void and proteinuria microscopic hematuria
samples (tested for acid
(50%)
fast staining and cultures)
Imaging Modalities

Fluoroscopic • IVU, HSG, voiding cystourethrography

• Gold standard for evaluating early stages of genitourinary TB
studies  detect mucosal and urothelial abnormalities

USG, Cross- • Distinguish between a variety of genitourinary lesions 

sectional granuloma, abscess or neoplasms.
• Surroundings structures  vasculature, lymph nodes, secondary
imaging signs of the the disease, and complications.
Conceptual Framework
Bladder
TB
Ureteral Urethra
TB l TB

Renal Imaging Genital

TB Modalities TB
Renal TB
• Typical case : calcifications (50%)

Fig 1. Anteroposterior abdominal radiographs showing amorphous (A) and lobar renal calcifications (B)
Renal TB
Early Late
Radiographic Radiographic
Findings Findings

Strictures  calyceal
Calyceal dilatation or
irregularities amputated
infundibulum

Renal scarring,
parenchymal
calcifications
EXCRETORY UROGRAPHY

Fig 3. Excretory urography  infundibular stricture

Fig 2. Excretory urography of a patient with renal TB with
(arrow) and hydrocalycosis of the left kidney
marked renal calcifications and normal kidney function
(arrowhead)
 Fig 6. (A) Early and (B) late excretory urography a large right
renal cavity (arrow) that fills with contrast in late films.

Fig 5. Excretory urography amputated right upper renal calyx

CT SCAN

Fig 7. Delayed axial contrast enhanced CT  severe hydronephrosis of the right kidney and no calyceal opacification
Fig 8. Axial non-contrast CT of a renal TB showing large dense right renal calcification (A). Axial contrast-enhanced CT
of a different patient showing an atrophic calcified right kidney (B).
Fig 9. Non enhanced CT image showing right renal parenchymal scarring and renal calcifications
Fig 10. Intra- and extrarenal TB manifestations on CT imaging (A) Axial contrast-enhanced CT images of renal TB showing
severe left hydronephrosis with cortical atrophy (A) and local extension into posterior pararenal space. Axial non contrast
CT showing left psoas TB abscess.
Fig 11. Renal TB pseudotumor (A) non contrast and (B) contrast-enhanced axial CT image of a renal TB patient show
isodense soft tissue lesion at the medial aspect of left kidney that did not enhance (B)
MRI

Fig 12. (A) Axial T2WI of a renal TB patient showing severe right renal hydronephrosis. (B) T1-weighted showing a
hypointense signal lesion at the medial aspect of left kidney that becomes hyperintense on T2-weighted image, and
showing no contrast uptake on post contrast image (D).
USG

Fig 13. (A) USG of a renal TB showing mild irregular calyceal dilatation with irregular wall (arrow) and debris (arrowhead).
(B) Markedly dilated calyces ( C ) Mass like lesion “pseudotumor” (D) Cavitary lesion with echogenic calcification
Ureteral TB
• Majority of ureteral TB cases results from secondary spread of renal
TB.
• The most commonly affected sites are the ureterovesical junction and
the upper two-thirds of the ureter.

TB spreads from renal

Ureteric fibrosis leads to
parenchyma  mucosa Ureteral shortening and
ureteral strictures with
irregularities and ulcerations straightening
beaded appearance
within the collecting system
Fig 14. Excretory urography of a renal TB patient showing multiple left ureteric
strictures (arrows) and a beaded appearance of the ureter

Fig 15. (A) Antegrade pyelogram : ureteric stricture and fistula tract to the
skin (B) Fluoroscopic-guided retrograde pyelogram  ureteric irregularities
and disfigured calyces
Fig 16. Axial (A) and sagittal (B) contrast enhanced CT image of the abdomen in a patient with renal TB showing wall
thickening and wall enhancement of the ureter.
Bladder TB
• Begins at the ureteral orifice and is almost spread from renal TB.

Superficial inflammation
with bullous edema, Inflammation involves Fibrotic and calcified
ulceration, and detrusor muscle  mural bladder with reduced
granulation around a fibrosis cavity.
ureteral orifice

Ureteral fibrosis leads to

stricture formation  Vesicoureter Reflux
hydronephrosis
Fig 17. Ascending cystography patient with bladder TB showing contracted urinary bladder with diffuse irregular urinary
bladder wall thickening (A) Left vesico-ureteral reflux secondary to fibrosis at the trigonum, irregular ureteric wall (B)
Urethral TB
• Secondary to genital TB and most commonly spreads from the
prostate in males.
Fibrotic
Periurethral
urethral
abscess
strictures

Lower urinary
Perineal /
tract
scrotal fistulas
obstruction
Male Genital TB
• Isolated epididymal TB is more common in children and is secondary
to hematogenous spread of infection.
• In adults  epididymis and testis are often concomitantly involved
(due to direct spread from the urinary tract).
Epididymal
induration and Epididymal or
Scrotal sinus tract
nodular beading of scrotal mass
vas deferens

Hemospermia,
penile ulcer
EPIDIDYMIS
Fig 18. (A) Epididymis
is diffusely enlarged
and heterogeneously
hypoechoic (B) with
complex fluid
collection
Fig 19. TB orchitis (A)
testis with multiple
hypoechoic lesions (B)
complex fluid
collection (C ) complex
TESTIS hydrocele
SCROTUM

Fig 20. TB of the scrotum in different Fig 21. TB scrotal abscess as Fig 22. USG shows a sinus tract (arrow)
patients. USG images shows a localized fluid collection. draining the TB scrotal abscess.
thickened scrotal skin.
Fig 23. MRI TB epidymitis. Coronal Fig 24. TB epididymoorchitis. Sagital T2WI (A) and sagittal T1WI post contrast
T2 MRI of the scrotum showing a (B), MRI of the scrotum showing multiple high signal intensity testicular
bulky epididymal head. lesions consistent with cysts, hydrocele and bulky heterogenous epididymis
due to inflammation.
SEMINAL VESICLES
Fig 25. Axial contrast enhanced CT
scan showed enlarged
heterogeneously enhancing seminal
vesicles.
PROSTATE
Fig 26. Contrast-enhanced CT
images of pelvis in a patient with
TB abscess showing marginally
enhancing hypodense cystic
lesion in the prostate.
Female Genital TB
• Female patients with genital TB may present with menstrual
irregularity, lower abdominal pain, pelvic inflammatory disease, or
infertility.

Tubo-ovarian
TB salpingitis Peritonitis
abscess

Cervicitis,
Endometritis
vaginitis
Fig 27. HSG in a patient with TB salpingitis and
endometritis showing areas of constriction
and dilatation in the right fallopian tube. This
findings are consistent with Asherman’s
Syndrome.
Fig 28. TB ovarian abscess. Axial
non-contrast CT (A) showing a
soft tissue-like density right
ovarian lesion with air-fluid
lesion. MRI of TB ovarian
abscess (B-D) showing high
signal intensity turbid fluid and
low intensity fibrous wall of a
gas-containing abscess.
Treatment of Genitourinary TB
• The mainstay of genitourinary TB
treatment.
• 2 phases recommendation :
Surgical
intensive and continuation phases.
• In patient with HIV, prednisone
may be used. • Nephrectomy
• Timing of anti TB initiation relative • Bladder or ureter reconstructive surgery
to anti-retroviral therapy variable • Catheter drainage for TB abscess
according to CD4 count and clinical • Ureteral stenting and percutaneous
context. nephrostomy tube

Medical
Conclusion
• The genitourinary tract is the most common site for extra-pulmonary
TB infection.
• Despite the challenging clinical presentation of genitourinary TB,
certain imaging characteristics aid in the diagnostic process.
Terima Kasih