Mycobacterium tuberculosis is the most common cause of genitourinary tuberculosis (GUTB). It typically spreads hematogenously from the lungs to the kidneys and then descends through the urinary system, causing infections in the kidneys, ureters, bladder, urethra, and genitals. Diagnosis involves urine culture and biopsy showing caseating granulomas. Imaging finds changes like calcifications. Treatment is with standard anti-TB medications for 6 months. Surgery may be needed for drainage or reconstruction to relieve obstruction.

1. Dr B.Gopal

2.  Mycobacterium tuberculosis
 Mycobacterium bovis
 Mycobacterium africanum
 Mycobacterium microti

3. 1.Hematogenous
-common type of spread
-common sites of hematological seeding kidney and
epididymis from their it spread to other parts of
genitourinary system
2.Desending and asending through urinary system
-Less common then hematological spread
- Desending -from kidney to ureter , bladder
- Ascending – bladder irrigation with BCG
vaccination ( developed in 0.9% patients )

4. 3. Spread from surrounding organs
-direct spread from spine , psoas abscess
-GIT – Enteroreanal , enterovasical fistula
4. Direct inoculation
-autoinoculation on external genitalia from infected
stools and urine
-person to person genital inoculation after contact with
infected genitals and oral lesions
5. Lymphatic spread

5. Signs and symptoms of GUTB are often non specific
A patient with lower urinary tract symptoms
(frequency, urgency and nocturia) associated with
dysuria and/or haematuria for at least 2 weeks, which
has not responded to a 3–7 day course of antibiotics.
Typical features of TB
fever ,Weight loss,Night sweats ,Malaise
seen in only 20% of GUTB

6.  80% GUTB involves kidney
 Mostly asymtomatic until it reach the bladder
 Heamturia - macrohematuria 50% cases
microhematuria – 10 % cases
 Renal angle pain and tenderness – renal abscess
 Sinus tract in flank
 Suprapubic pain – cystitis

7. Rout of spread
Miliary Tb – mainly involves cortical part of
kidney and forms cortical white nodules
Ascending infection –mainly involves medulla and
forms cavitatory lesions
-The cortical granulomas may remain dormant,
asymptomatic, and stable for as long as 10 to 15
years

8. • BLOOD STREAM
• PERIGLOMERULAR CAPILLARIES
• GRANULOMA FORMATION
• CASEATION CAVITIES
• CHRONIC PHYLONEPHRITIS , ABSCESS FORMATION
• AUTONEPHRECTOMY

10.  33 % cases of renal TB
 2 Types
Caseo-cavernous :viable tissue replaced with
granulations ,cavities and exudats with or without
calcification
Fibrotic : viable tissue replaced with sever
scarring and calcification ( shrunken kidney )

11. Route of infection -desent of infection from kidney
Presentation : chronic dullaching pain due to uretric
block (hydronephrosis)
Common site- distal end of ureter (VUJ)
Granulation along the wall
-> scarring
-> stricture formation
-> urinary obstruction
-> renal failure

12. Route
- desending from kidney and ureter – involves
orifices area
-Lymphatic spread – other areas
 Common site –dome of bladder
 Mucosal inflammation
 mucosal scarring
 bladder contracture
 thimble bladder

13. Presentation
Acute phase –irritative bladder symptoms like
burning micturation , increased frequency
,hematuria
Chronic inflammation (contracted bladder)-
urinary incontinence

14. Route of spread
Hematogenous spread –peripheral part of
prostate , urethral sparing asymptomatic ,
progress to calcification ,hard prostate
Urinary spread – prostate , urethra involved
,presented as bacterial prostitis with severe pain
-TB prostate suspected when there is a chronic
prostitis that persisting after antibiotic theraphy

15. Route
Through vas deferens –from testis ,epididymis
Through urethra –from kidney , bladder , prostate
 Presentation – infertility
 Other -low volume ejaculation ,Oligospermia
,azoospermia .
O/E
-early stage – enlarged seminal vesicles
-advanced cases – hard nodules

16.  Urethra and penis normaly resistant to TB
Penis
Skin inflammed
 papule , keratotic plaques(lupus vulgaris )
 cavernous tissue
 fibrosis
 distorted penis
Glans
-papulonecrotic tuberculid

17. Orificial TB- rapid necrosing form ,
autoinoculation of from infected stools , urine
Urethra – stricture urethra, hematuria ,
hematospermia

18. Epididymis
 Second most common site of hematogenous seeding
 Bilateral involvement can be noted in 34% cases
 Granulation
 nodular epididymis
 adherent to skin
 ulceration

19. -Spread from epididymis
-Normal tissue replaced with granulations and
fibrosis
On palpation –hard mass look like malignancy
Acute cases- present with sever pain
Chronic cases- sinus tract in scrotum

20. Urine examination
Sterile pyuria – routine culture is negative
but numerous WBC present
Hematuria , Proteinuria
Urine culture
gold standard for GUTB
First void urine sample
5 samples on consecutive days
Sensitivity 80 -90%

21.  Urine cultures are carried out on standard solid
media optimized for mycobacterial growth,
namely egg-based (Löwenstein- Jensen) or
agar-based (e.g., Middlebrook ) media
 Antibiotic sensitivity –for first line anti-TB
drugs

22. PCR can detect
 low bacterial load
 culture fail to isolate the organism
Highly sensitive ,specific and rapid results

23. Tuberculin skin test
Purified protein derivative (PPD) -a standard dose of 5
tuberculin units (0.1 mL) is injected intradermal
Read after 48-72 HRS
Tuberculin test is nondiagnostic
Induration <5mm Induration>10mm Induration >15mm
-HIV cases
-silicosis cases
-Old TB cases
-on immunosuppresive
therapy
-child age <5 yrs
Residents
,immigrants from
high prevalence
countries
Persons with no riskfactors for TB

24. Interferon gamma release assays
-measures the level of IFN-α produces in response to
MTBC specific antigen
Histology
Caseating granulomatous lesions

25. Plain x ray ( x ray KUB)
-shows calcification in kidney, ureter ,
bladder, prostate
-papillary necrosis in kidney – triangular
ringlike calcification
-Fibrotic and autonephrectomy –cement or
putty kidney
CXR – exclude co-commitent pulmonary TB

27. Anatomical and functional details
Kidney –gold standerd for early TB
Initial erosive changes in urothelium loss of sharpness
& edges irregularity
Calyceal erosion – mouth eaten appearance
Filling defects and cavities
Phantom calyx – when calyx or infundibulum stenosed

29. Ureter
- Calcified , straightend ,pipestem ureter
- Beaded corkscrew appearance
- Scarring and angulation of UPJ –hike up pelvis
Bladder
Small contracted bladder

30. -Replaced the IVU
-Calcifications,scarring , signs of obstruction
-perinehric ,psoas abscess
Pathology of prostate and seminal vesicals
Disadvantages
-less sentive for detecting early changes of TB
-highly radiation then IVU

32. When CT /IVU contraindicated
-renal insufficiency
-allergic to contrast
Percutaneous/endoscopic contrast injection
Can obtain a urine sample from the upper tract

33.  Limited role in diagnosis of TB
 Used in pediatric and pregnant patients
 Mainly used for testis ,epididymis,
prostate ,seminal vesicals (trans rectal)
Kidney –abscess , hydronephrosis

34.  Local hyperthermia ,
 Mucosal erosion ,
 ulceration,
 granulomatous lesion
 Biopsy -doubt of malignancy

36. Major criteria Minor criteria
-granulomatous lesion on HPE
-AFB positive on urine/HPE
-Positive PCR
-CT/IVU changes suggestive of
TB
-hematuria
-raised ESR
-pulmonary changes of old TB
healing granulations
One major and two minor diagnostic

37. Aims of treatment are:
 to achieve TB cure
 to prevent the long term sequelae
 to restore normal anatomy if it has been
distorted.

38.  2RHZE/4RHE
 Duration Six months
 First line treatment for adults and children
with urinary TB

41.  Assess response to treatment at 8 weeks –
resolution of systemic symptoms, improvement in
urinary symptoms, check renal function.
 Repeat imaging may be indicated, especially if
partial or impending ureteric stricture was
identified at diagnosis.
 Obstruction can occur as a late complication as the
healing of the lesion results in fibrotic stricture.
 If early morning urine culture is positive at
diagnosis, this may be repeated at 8 weeks, and at
the end of ATT.

42.  Relieve the urinary obstruction
 Drain infected material
 Removing non functioning kidney
 Reconstruction of urinary tract
 Emergency surgery required in uremia and
sepsis

43. Dj stenting
hydronephrosis secondary to stricture involving the
pelvi-ureteric junction or the ureter
Percutaneous nephrostomy
-when DJ stenting failed
-segmental hydronephrosis
Complications – tuberculous cutaneous fistula

44. Indications
 Nonfunctional kidney with recurrent TB after
optical medical treatment
 Nonfunctional kidney with medical resistant
hypertension
Partial Nephrectomy
 Partial nephrectomy is permissible only where
parenchymal destruction is clearly localized
 calcified polar cavitary lesion or localized lesions
that progress to calcification despite 6 weeks of
adequate medical therapy

45. Endoscopic management
– short stricture
DJ stenting , balloon dilatation
follow-up – USG or IVU
Open surgical management
- long,complex stricture
PUJ stricture – pyeloplasty
uretrocalicostomy (ureter to calyx)
Ureter – excision of diseased segment with aqeuate
mobilization ,primary tension free uretroureterostomy

46. Lower uretric stricture
Uretrocystostomy
Psoas hitch (5 cm )
-If the bladder capacity is normal,
-psoas hitch can be performed for
small length strictures of
the lower ureter

47. Boari’s flap
If the bladder capacity is normal, Boari flap
may be employed for long lower ureteric
stricture

48. Ileal ureteral substitution
 For long ureteric strictures involving almost
the whole length of ureter or upper ureteric
strictures require ileal replacement of ureter
 The contraindications -baseline renal
sufficiency with serum creatinine value of >2
mg/dl
 An isoperistaltic segment of ileum is used and
the lumen can reduced by tailoring

49. 1.Augmentation 2.Substution of bladder
cystoplasty
-Ileocecum , sigmoid ,large intestine, stomach

50.  Bladder neck constriction –transurethral
incision
 Urethral stricture –dilatation
urethroplasty

51.  Epididymis- epididymectomy
 Epididymis +testis – scrotal orchidectomy
 Prostate abscess – trans rectal drainage

52. Thank you