Tuberculoma--localized caseating lesion, most commonly upper pole. nidus of infection enlarges and ruptures into a neighboring calyx, discharging necrotic caseous material--distorting the calyx---smudged papillae due to surface irregularity of the papillae, a moth-eaten calyx (early sign), irregular tract formation from the calyx to the papilla, and large irregular cavities with extensive destruction secondary to papillary necrosis. Cavitation within the renal parenchyma may be detected as irregular pools of contrast material. Mass lesion-cavity/hydrocalcyses
Genitourinary tract tuberculosis. Plain radiograph of the abdomen in a patient with calcified seminal vesicles due to tuberculosis. Note the amorphous and speckled calcification in the right kidney.
Plain radiograph of the abdomen demonstrates extensive calcification in the left kidney, which was nonfunctional (the putty kidney), consistent with autonephrectomy from tuberculosis.
Figure 4a. (a) Retrograde ureteropyelogram shows globular calcific areas of increased opacity in the medial upper pole of the right kidney (arrowheads). The calices are markedly enlarged with ill-defined margins (white arrows). Small, irregular collections of extracaliceal contrast material are also present (black arrows). (b)Magnified view from a retrograde ureteropyelogram of the right ureter shows mucosal irregularities and erosions (arrowheads).
Genito urinary tuberculosis
DR. ANNIE AGARWAL
young to middle-aged adults.
M/F ratio= 5:3
Uncommon in children
Approximately 20-30% of extra-pulmonary infection
Increase in incidence with HIV epidemic and multi drug
Important to diagnose as non specific clinical presentation
and progression to renal failure if undiagnosed and
The kidneys are the most
common site of GUTB
Causative organism :
history of previous clinical TB
(25%) with a lag time
of 2- 20 years
Hematogenous spread - from the
kidneys, the bacilli can spread to the renal
tract, prostate and epididymis.
Observed in two settings:
commonly, as a late manifestation of
earlier clinical or subclinical
rarely, as part of the multiorgan
infection (miliary tuberculosis)
Rarely primary one—
BCG Tt for Ca bladder
gross / microscopic hematuria
urinary frequency, dysuria, ‘intractable’ UTI
frequency, urgency, dysuria with involvement of bladder
back, flank, or abdominal pain. : => extensive renal
Constitutional symptoms such as fever, weight loss,
fatigue, and anorexia are less common
Hydrocele,discharging scrotal/perineal sinuses
Infertility,spontaneous abortion,ectopic pregnancy.
Three other major complications of renal tuberculosis:
hypertension (RAS axis mediated)
super-infection (12 to 50%)
nephrolithiasis (7 to 18%)
Abscess formation :including psoas abscess
Sinus tract into adjacent tissues or viscera.
involvement of renal
granulomas leading to
unifocal or multifocal
Seen in advanced renal
Increase renal length
Increase thickness of
scarring over retracted
papillae or pelvis and
Impaired excretion of
Erosion of pyramid
Cortical / papillary
Autonephrectomy : end
Focal or diffuse
involvement - fibrosis.
Following the drainage of a cavity into
the collecting system, there is spread of
infection to other parts of the urinary
Stimulation of scirrhous reaction causes
stenosis and obstruction of parts of the
Common sites of
neck of a calyx –
pelvi – ureteric junction –
generalised dilatation of
lower end of the ureter.
High dose IVU – traditional gold standard
CT – new standard
Pyelography (ante/retrograde) – limited use
Plain radiographs – important
CXR,spine X-Ray,X-Ray KUB
US – limited value
Nuclear Perfusion Scan – function
MRI – little application
Plain radiograph of
Renal Size: Small, enlarged or normal
Presence of scarring or focal bulge
Calcification of ureter or urinary bladder :
Evidence of Skeletal Involvement : in hip,
sacroiliac joint, spine, paraspinal abscess
calcification of lymph nodes, adrenal
gland – 10%
Calcification : attempt to heal and limit the
pathological processes – 50% - types
Dense punctate calcification
representing healed tuberculoma.
Amorphous granular associated
with granulomatous masses-
Chest x ray
Abnormal in 50 %
Active pulmonary tuberculosis – 5- 10%
Sequelae of old tuberculosis of past
>70% cases- single kidney involved
IVP (abnormal in 85- 90%) though normal in initial
Diagnosis can be made with certainity on urography only if
lesion is ulcerated into calyx.
Miliary tubercles – involve both the kidneys.
globally poor renal function
assess the extent and severity of involvement
To monitor response to treatment
To look for complications
Imaging findings :
Parenchymal scars & Irregularity of the papillary
tips - “moth-eaten” calices
Small cavities in the papillae
communicate with the collecting system
fibrotic reaction develops, stenosis and strictures of
the caliceal infundibula - Infundibular strictures
can lead to localized caliectasis or phantom
Scarring of renal pelvis (Kerr kink)
Moth eaten appearance
Earliest abnormality –
an indistinct feathery outline
Irregularity of surface of one
or more papillae or calyces
with normal renal size and
Fuzzy & irregular calices due
to papillary necrosis.
IVP of 32-year-old woman. A, left renal parenchymal mass (arrows) and left hydroureter due to left
distal ureteral stricture (arrowheads). B, magnification of left kidney shows irregular caliceal
contour as moth-eaten appearance (arrows) of upper calix and multiple cavities (arrowheads) of
Golf ball on a tee
On IVP :
Collecting system shows contrast material
in a large papillary cavity, the “golf ball” (∗).
Blunted calyx, the “tee,” is adjacent
Decreased nephrographic opacity and nonfilling of the collecting system
elements at the lower pole of left kidney – phantom calyces (ghost : exist, but
not visualised, the same are visualized on RGP).
Ghost - like
Hiked up pelvis => pulled up
Cephalic retraction of the inferior medial
margin of the renal pelvis at the
ureteropelvic junction (UPJ)
Cortical scarring with
dilatation & distortion of
adjoining calyces coupled
with strictures of the
Cause luminal narrowing
either directly or by causing
kinking of the renal pelvis at
If the ulcer or stricture extends to the renal pelvis or the
pelvic ureteral junction, urine outflow obstruction may
IVUmay show delayed function, clubbed calyces, or
absence of function.
Some show Hydronephrosis - irregular margins and filling
defects owing to caseous debris.
If tuberculous infection extends directly to the rest of the
kidney, the entire kidney becomes a bag of caseous
The kidney enlarges initially but subsequently may return to
normal or become atrophic.
infection may extend into peri- / pararenal space + psoas
blunt calices in
addition to a track
leading to a cavity
(A) ‘Cut-off’ upper pole
infundibulum. No filling of
calices in upper pole. Irregular
cavitation in remainder of the
(B) Pathological specimen
showing a fibrotic stricture of
the upper infundibulum (black
arrow) and a caseous
pyonephrosis occupying the
upper pole. Cavitation
Diffuse, uniform, extensive
calcifications forming a
cast of the kidney with
End stage of GuTB.
Genitourinary tract tuberculosis. Lobar calcification in a large
destroyed right kidney in a patient with renal tuberculosis. Note the
involvement of the right ureter.
Almost always secondry to renal tuberculosis – 50% cases.
Spread of infection by bacilluria.
ureteral involvement is usually unilateral, bilateral
changes are asymmetric when they occur.
The most common site of involvement is the lower
third of the ureter.
Renal damage secondry to ureteral strictures may be more
severe than the effect of original parenchymal involvement.
Dilatation and stenting of the ureter may restore ureteral
patency and salvage a kidney.
dilatation resulting from atony
and prolonged bacilluria
irregular segments of ureter
due to mucosal ulcerations
necrosis of ureteral
musculature is accompanied
by fibrosis - stricture formation-
severe thickening of the wall
produces a rigid shortened
ureter with narrow lumen
Fusion of multiple strictures
may create a long, irregular
nonconfluent strictures can
produce a “beaded” or
Beaded / Corkscrew ureter
Mucosal thickening of ureter
Rigid ureter: irregular
and lacks normal
fibrotic strictures noted.
Note the distortion,
irregularity of the upper
Pipe stem ureter
Old pipe stem
Inv. in later course of d/s in 1/3 rd cases
Tubercular cystitis- edema
of bladder mucosa
Large tuberculomas in
vesical wall – manifest as
Advanced d/s – irregular
contracture with thick walls and
reduction of bladder capacity –
Fibrosis in region of trigone
produces gaping of the UV
junction resulting in VUR.
Shrunken & calcification later
Genitourinary tract tuberculosis. Intravenous urography series in a man with
renal tuberculosis shows marked irregularity of the bladder lumen due to
mucosal edema and ulceration
Diminutive and irregular
urinary bladder –
simulating a thimble.
IVP film-The lower end of the right ureter demonstrates an irregular caliber
with an irregular stricture at the right vesico-ureteric junction. Note the
asymmetric contraction of the urinary bladder, with marked irregularity due
to edema and ulceration.
normal in size.
Male urethra – uncommon, occurs secondry to
The periurethral glands of Littre may become
distended with bacteria and leukocytes and may
lead to abscess formation.
Associated with prostatic abscess or fistula
Result in non specific stricture in bulbo-
Indicated in patients with non functioning
kidney to demonstrate ureteric obstruction
and cavitation in kidney.
Retrograde ureteropyelography showed an
atrophic right kidney with diffuse caliceal
dilatation, papillary necrosis, and infundibular
and erosions of
Role of sonography :
Guidance for interventional procedures of
percutaneouys nephrostomy (PCN)
Antegrade dilatation of ureteral stricture
Drainage of perinephric abscess.
Not a primary modality used for diagnosis:
Unable to show early calyceal changes.
No information about status of renal function.
Focal lesion of varying echogenecity.
Early stages – papillary lesions as areas of hypoechogenicity or
hypoechoic foci with echogenic walls or echogenic non shadowing
Sloughed calyx – echogenic flap separated from normal calyceal wall.
Large liquefying conglomerate cavities or dilated calyces formed as a
result of infundibular stricture appear as hypoechoic nodules or masses.
PCS- hydronephrosis or calyectasis.
The communicating tract from a cavity appears as a sonolucent track
entering the dilated calyx.
Heterogenous echotexture of the parenchyma or normal appearing
parenchyma may be seen in diffuse involvement.
May demonstrate hydronephrosis, parenchymal calcification and
Sonogram of left kidney shows 1.5-cm hypoechoic nodule (arrowhead) in cortex
Early findings may be missed
IVP: cobra head sign,
the lucent halo is
however thick, irregular
and less well defined.
Rao A, Yvette K, Chacko N. Tuberculosis of urinary bladder presenting as
pseudoureterocele. Indian J Med Sci 2005;59:272-3
Usg is poor in assessing ureter but
shows back pressure changes and
adjacent retroperitoneal disease.
UB- focal irregular thickening with
Deformed shape and focal abnormalities
better appreciated following distension.
Indicated only in patients with strong clinical
suspicion but normal IVU and USG.
Renal and extra renal spread of disease.
Length of ureteric stricture
Adjoining retroperitoneal disease
Associated spinal or solid organ involvement.
excretory urography is sensitive in the
detection of early urothelial mucosal changes
Coalesced cortical granulomas containing either caseous
or calcified material
Calices that are dilated
and filled with fluid have an attenuation between 0 and 10
debris and caseation, between 10 and 30 HU;
putty-like calcification, between 50 and 120 HU; and
calculi, greater than 120 HU.
Cortical thinning is a common CT finding and may be
either focal or global.
Parenchymal scarring is readily apparent at CT.
Fibrotic strictures of the infundibula, renal pelvis, and
ureters may be seen at contrast-enhanced CT and are
highly suggestive of tuberculosis.
CT urogram shows severe nonuniform caliectasis and multifocal strictures (arrowheads) involving renal
pelvis and ureter.. Calcification (arrow) is noted in left distal ureter.
A, Contrast-enhanced CT scan obtained at level of right renal hilum
shows wedge-shaped hypoperfused areas (arrowheads).
B, CT scan - hypoperfused areas (arrowheads) and focal caliectasis
(a) Contrast-enhanced excretory-phase CT scan shows dilated
calices and narrowing of the infundibula (arrowheads).
53-year-old man with tuberculosis involving collecting system. Contrast-
enhanced CT scan of left kidney shows uneven caliectasis caused by
varying degrees of stricture at various sites.
(a) Contrast-enhanced nephrographic-phase CT scan shows dilated
calices and thinning of the renal cortex (arrow). (b) Magnified view
from a contrast-enhanced nephrographic-phase CT scan obtained
caudad to a shows mural enhancement and thickening of the proximal
Renal Tuberculosis. Coronal reformatted non-enhanced CT scan of the
abdomen and pelvis demonstrates a small, left kidney containing
globular calcifications (white circle) pathognomonic for renal tuberculosis.
CT scan shows dense calcification
replacing right kidney, so-called “putty
kidney.” in NCCT
The left kidney shows large,
dense, oval calcifications.
Low-density areas in the right
kidney probably represent
foci of caseous necrosis.
MR urography: evaluate poorly or non
functioning kidney specially obstructive
form for demonstration of ureteric
MR – renal parenchymal changes and
details of PCS
Used for evaluation of ureteral
Male Genital Tuberculosis
seeding from infected urine or via the bloodstream.
The most common manifestation is tuberculous
prostatitis, less common is epididymo-orchitis
calcifications in 10% (diabetes more common
○ ascending / descending route of infection
○ direct extension from epididymal infection, rarely from
Prostatic involvement :
Plain radiographs-dense calcification within the prostatic bed
Cavities/ abscesses--discharge into the surrounding tissues sinuses or
fistulae to the perineum or rectum ‘ watering-can perineum.’
○ early cases - filling of the prostatic ducts without evidence of
○ Advanced cases the ducts may be greatly dilated.
○ Varying degrees of destruction of prostatic parenchyma with
sloughing may produce irregular cavities.
Tuberculous prostatitis / prostatic abscess: caseation, cavitation
○ hypoechoic irregular area in peripheral zone
○ hypoattenuating prostatic lesion
○ hypointense diffuse radiating streaky areas on T2WI (watermelon
○ peripheral enhancement
○ Occasionally fistulous formation
Prostatic tuberculosis. Contrast-enhanced CT scan shows a well-
defined hypoattenuating lesion within the prostate gland
(arrowhead). Scrotal tuberculosis. US image of a testis shows a
nonspecific focal area of hypoechogenicity, which proved to represent
caseous necrosis secondary to tuberculosis.
shows a peripheral
enhancing cystic mass
with radiating, streaky
areas of low signal
Female genital tract - TB
Associated wet or dry peritonitis
strongly associated with infertility in women,
rates of successful pregnancy remain low
even after treatment.
Salpingitis (94%): mostly bilateral
Tuboovarian abscess: extension into
HSG - GTB
obstruction and multiple constrictions of the fallopian tubes.
Rigid pipe-stem tubes
A clubbed ampula with retort-shaped hydrosalpingx
Vascular or lymphatic intravasation of contrast
Small shrunken uterine cavity with filling defects
Long and dilated cervical canal & dye in cervical
Bilateral cornual block
Punctate opacification of crypts and diverticulae in
lumen of tubes
HSG may demonstrate
a flask-shaped dilatation
of the fallopian tubes
due to obstruction at the
Flask shaped fallopian
Focal irregularity and
areas of calcification
occur within the lumen of
the fallopian tubes.
Cotton wool plug appearance..
Caseous ulceration of the
mucosa of the fallopian tube
produces an irregular contour
of the lumen of the tubes.
Diverticular cavities may
surround the ampulla and
give a “tuft” like appearance.
Thick arrow – hydrosalphinx.
Irregular and rigid.
Filling defect in uterine
cavity – adhesion.
Multiple constrictions along the course of fallopian
tube on HSG due to fibrotic strictures.