genitourinary tb - contains radiological findings of genitourinary tuberculosis including ivp,, hsg, usg and ct findings in kidney, ureter, urinary bladder, uterus and prostate

1. DR. ANNIE AGARWAL
23/02/2013

2.  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
resistant strains
 Important to diagnose as non specific clinical presentation
and progression to renal failure if undiagnosed and
untreated.
INTRODUCTION

3.  The kidneys are the most
common site of GUTB
 Causative organism :
Mycobacterium
Tuberculosis.
 history of previous clinical TB
(25%) with a lag time
of 2- 20 years

4. SPREAD
 Hematogenous spread - from the
kidneys, the bacilli can spread to the renal
tract, prostate and epididymis.
 Lymphatic spread
 Observed in two settings:
 commonly, as a late manifestation of
earlier clinical or subclinical
pulmonary infection
 rarely, as part of the multiorgan
infection (miliary tuberculosis)
 Rarely primary one—
BCG Tt for Ca bladder
Transplant recipient

5. CLINICAL FEATURES
 gross / microscopic hematuria
 sterile•pyuria
 Mild proteinuria
 urinary frequency, dysuria, ‘intractable’ UTI
 frequency, urgency, dysuria with involvement of bladder
 back, flank, or abdominal pain. : => extensive renal
disease
 Constitutional symptoms such as fever, weight loss,
fatigue, and anorexia are less common
 haemospermia
 ‘acute epididymo-orchitis’
 Hydrocele,discharging scrotal/perineal sinuses
 Infertility,spontaneous abortion,ectopic pregnancy.
 Menstrual irregularities

6.  Three other major complications of renal tuberculosis:
hypertension (RAS axis mediated)
super-infection (12 to 50%)
nephrolithiasis (7 to 18%)
 OTHER COMPLICATIONS:
 Perinephric inflammation
 Abscess formation :including psoas abscess
 Fistulae
 Sinus tract into adjacent tissues or viscera.

7. PATHOGENESIS

8. Progressive
involvement of renal
parenchyma
coalescence of
granulomas leading to
unifocal or multifocal
mass lesions
Seen in advanced renal
tuberculosis
Increase renal length
Increase thickness of
renal substance
Displacement of
collecting system.
Parenchymal surface
scarring over retracted
papillae or pelvis and
dilated/ deformed
calyces.
Associated calcification
or calculi
Impaired excretion of
contrast
Erosion of pyramid
Cortical / papillary
necrosis
Caliectasis
Cavity
Deformed calyx
Caseo –
cavernous type:
enlarged sac
filled with
caseous
material, +/-
calcification
Calcified
shrunken non
functioning of
kidney
Autonephrectomy : end
stage d/s
Focal or diffuse
involvement - fibrosis.

10.  Following the drainage of a cavity into
the collecting system, there is spread of
infection to other parts of the urinary
tract.
 Stimulation of scirrhous reaction causes
stenosis and obstruction of parts of the
collecting system.

11.  Common sites of
stricture:
 neck of a calyx –
hydrocalyx, regional
hydrocalycosis
 pelvi – ureteric junction –
generalised dilatation of
pelvicalyceal system.
 lower end of the ureter.

12. Imaging
 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

13. Plain radiograph of
abdomen
 Renal Size: Small, enlarged or normal
 Presence of scarring or focal bulge
 Calcification
 Calcification of ureter or urinary bladder :
rare
 Evidence of Skeletal Involvement : in hip,
sacroiliac joint, spine, paraspinal abscess
 calcification of lymph nodes, adrenal
gland – 10%

14. Calcification : attempt to heal and limit the
pathological processes – 50% - types
Dense punctate calcification
representing healed tuberculoma.
Amorphous granular associated
with granulomatous masses-
autonephrectomy

15. Chest x ray
 Abnormal in 50 %
 Active pulmonary tuberculosis – 5- 10%
 Sequelae of old tuberculosis of past
infection.

16. Intravenous urography
 >70% cases- single kidney involved
 IVP (abnormal in 85- 90%) though normal in initial
stages.
 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
 IVU-
 assess the extent and severity of involvement
 To monitor response to treatment
 To look for complications

17. 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
calyx.
Scarring of renal pelvis (Kerr kink)

18. Moth eaten appearance
Normal calices
Earliest abnormality –
an indistinct feathery outline
Irregularity of surface of one
or more papillae or calyces
with normal renal size and
contour.
Fuzzy & irregular calices due
to papillary necrosis.

19. 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
lower pole.

20. 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
(arrow).

21. Infundibular stenosis
causing phantom calyx
Phantom calix
Infundibular stenosis

22. Phantom calyces
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
RGP

23. Hiked up pelvis => pulled up
Cephalic retraction of the inferior medial
margin of the renal pelvis at the
ureteropelvic junction (UPJ)

24.  Cortical scarring with
dilatation & distortion of
adjoining calyces coupled
with strictures of the
pelvicaliceal system.
 Cause luminal narrowing
either directly or by causing
kinking of the renal pelvis at
the UPJ.
Kerr kink

25. If the ulcer or stricture extends to the renal pelvis or the
pelvic ureteral junction, urine outflow obstruction may
occur.
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
necrotic pus.
The kidney enlarges initially but subsequently may return to
normal or become atrophic.
infection may extend into peri- / pararenal space + psoas

26.  Some
nonspecifically
blunt calices in
addition to a track
leading to a cavity
(arrow).

27.  (A) ‘Cut-off’ upper pole
infundibulum. No filling of
calices in upper pole. Irregular
cavitation in remainder of the
kidney.
 (B) Pathological specimen
showing a fibrotic stricture of
the upper infundibulum (black
arrow) and a caseous
pyonephrosis occupying the
upper pole. Cavitation
elsewhere.

28.  Autonephrectomy.
 Diffuse, uniform, extensive
parenchymal
calcifications forming a
cast of the kidney with
autonephrectomy.
 End stage of GuTB.
Putty kidney

29.  Genitourinary tract tuberculosis. Lobar calcification in a large
destroyed right kidney in a patient with renal tuberculosis. Note the
involvement of the right ureter.

30. 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.

31. dilatation resulting from atony
and prolonged bacilluria
PIPE
STEM
URETER
irregular segments of ureter
due to mucosal ulcerations
necrosis of ureteral
musculature is accompanied
by fibrosis - stricture formation-
50%.
severe thickening of the wall
produces a rigid shortened
ureter with narrow lumen
beaded or
corkscrew
appearance.
Terminal
segment of
the ureter

32.  Ulcerations causing
mucosal irregularity of
ureter.
Saw tooth appearance

33.  Fusion of multiple strictures
may create a long, irregular
narrowing. Several
nonconfluent strictures can
produce a “beaded” or
“corkscrew” ureter
Beaded / Corkscrew ureter
Mucosal thickening of ureter

34.  Rigid ureter: irregular
and lacks normal
peristaltic movement,
fibrotic strictures noted.
 Note the distortion,
amputation and
irregularity of the upper
pole calices.
Pipe stem ureter
Old pipe stem

35. Urinary bladder
 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
filling defects
Advanced d/s – irregular
contracture with thick walls and
reduction of bladder capacity –
THIMBLE BLADDER.
Fibrosis in region of trigone
produces gaping of the UV
junction resulting in VUR.
Shrunken & calcification later

36.  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

37.  Diminutive and irregular
urinary bladder –
simulating a thimble.
Thimble bladder

38.  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.

39.  Diffuse reflux
nephropathy with
multiple blunted
calices.
 Left kidney
normal in size.
 Shrunken right
kidney.

40. Urethral tuberculosis
 Male urethra – uncommon, occurs secondry to
renal infection.
 The periurethral glands of Littre may become
distended with bacteria and leukocytes and may
lead to abscess formation.
 Associated with prostatic abscess or fistula
formation.
 Result in non specific stricture in bulbo-
membranous urethra.

42. Retrograde pyelography
 Indicated in patients with non functioning
kidney to demonstrate ureteric obstruction
and cavitation in kidney.

43.  Retrograde ureteropyelography showed an
atrophic right kidney with diffuse caliceal
dilatation, papillary necrosis, and infundibular
narrowing.

44.  mucosal
irregularities
and erosions of
the ureter.

45. ultrasonography
 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.

46. Kidney
 Focal lesion of varying echogenecity.
 Early stages – papillary lesions as areas of hypoechogenicity or
hypoechoic foci with echogenic walls or echogenic non shadowing
lesions.
 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
perinephric abscess.

47.  Sonogram of left kidney shows 1.5-cm hypoechoic nodule (arrowhead) in cortex
 USG
Early findings may be missed

48.  IVP: cobra head sign,
the lucent halo is
however thick, irregular
and less well defined.
Pseudoureterocele
Rao A, Yvette K, Chacko N. Tuberculosis of urinary bladder presenting as
pseudoureterocele. Indian J Med Sci 2005;59:272-3

49.  Usg is poor in assessing ureter but
shows back pressure changes and
adjacent retroperitoneal disease.
 UB- focal irregular thickening with
reduced capacity.
 Deformed shape and focal abnormalities
better appreciated following distension.

50. Computed tomography
 Indicated only in patients with strong clinical
suspicion but normal IVU and USG.
 Uses :MDCT:
 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

51. CT
 identifying renalcalcifications,
 Coalesced cortical granulomas containing either caseous
or calcified material
 Calices that are dilated
 and filled with fluid have an attenuation between 0 and 10
HU;
 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.

52.  Ureter : thickening of ureteral wall or pelvis
with periureteric inflammation
 Bladder Tuberculosis
 thickened bladder wall (= muscle
hypertrophy + inflammatory tuberculomas)
 filling defects (due to multiple granulomas)
 bladder wall ulcerations
 shrunken bladder - scarred bladder with
diminished capacity - thimble bladder•.
 bladder wall calcifications (rare)

53.  CT urogram shows severe nonuniform caliectasis and multifocal strictures (arrowheads) involving renal
pelvis and ureter.. Calcification (arrow) is noted in left distal ureter.

54.  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
(arrows)

55.  (a) Contrast-enhanced excretory-phase CT scan shows dilated
calices and narrowing of the infundibula (arrowheads).

56. 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.

57.  (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
ureter (arrow).

58.  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.

59. 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.

60. MRI
 MR urography: evaluate poorly or non
functioning kidney specially obstructive
form for demonstration of ureteric
involvement.
 MR – renal parenchymal changes and
details of PCS
 Used for evaluation of ureteral
peristalsis.

62. 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
cause)
 Tuberculous epididymitis
○ ascending / descending route of infection
 Tuberculous orchitis
○ direct extension from epididymal infection, rarely from
hematogenous spread

63. 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.’
 Cystourethrography-
○ early cases - filling of the prostatic ducts without evidence of
cavitation,
○ 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
and fibrosis.
○ hypoechoic irregular area in peripheral zone
○ hypoattenuating prostatic lesion
○ hypointense diffuse radiating streaky areas on T2WI (watermelon
sign•)
○ peripheral enhancement
○ Occasionally fistulous formation

64.  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.

65.  Prostatic abscess,
T2-weighted MRI
shows a peripheral
enhancing cystic mass
with radiating, streaky
areas of low signal
intensity.
Watermelon skin

66. Female genital tract - TB
 Hematogenous spread.
 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
extraperitoneal compartment

67. 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
with adhesions
 Long and dilated cervical canal & dye in cervical
crypts
 Bilateral cornual block
 Punctate opacification of crypts and diverticulae in
lumen of tubes

68.  HSG may demonstrate
a flask-shaped dilatation
of the fallopian tubes
due to obstruction at the
fimbria.
Flask shaped fallopian
tubes..

69.  Focal irregularity and
areas of calcification
occur within the lumen of
the fallopian tubes.
Cotton wool plug appearance..

70. Hydrosalphinx

71. Bilateral T.O.masses even after
ATT

72.  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.
Tufted appearance..

73.  Scarring fallopian
tubes.
 Irregular and rigid.
 Filling defect in uterine
cavity – adhesion.
Pipe stem
appearance

74.  Multiple constrictions along the course of fallopian
tube on HSG due to fibrotic strictures.
Beaded appearance..

75. Beaded appearance more on left
side

76. Left tube appears as if tubectomy
done also described as look of
sperm head

77. Both tubes eroded looking. Inner
lining of uterine cavity moth-eaten
appearance

78.  Scarring results in
a “T” shaped
uterine cavity with
intravasation of
contrast.
T-shaped uterine cavity

79. Appearance similar to Bilateral
tubal ligation. Elongation and
dilatation of cervical canal

80. Lymph node calcification

82. Bilateral cornual block &
intravastion of dye in vessels &
lymphatics.

83. Intravasation of dye into
myometriums and lymphatics and
left terminal hydrosalpingx

84. SUMMARY