Tuberculosis

1. Prepared by
Dr. Jihad Ajlan
Supervised by
Dr. Abdulsamad Alsanpani
‫اليمنية‬ ‫الجمهورية‬
‫والسكان‬ ‫الصحة‬ ‫وزارة‬
‫البول‬ ‫المسالك‬ ‫جراحة‬ ‫الختصاص‬ ‫العربي‬ ‫المجلس‬
‫ية‬
‫صنعاء‬ ‫مركز‬
-
‫اليمن‬
‫هيئة‬
‫المستشفى‬
‫الجمهوري‬

2. • Tuberculosis (TB) can affect any
organ system of the body, including
The genitourinary (GU) tract.
• TB of the genitourinary tract is
caused by M. tuberculosis.
• It has a higher incidence in ♂ than ♀.
• Treatment of bladder cancer with
intravesical BCG has also been
reported as a cause of urogenital TB.
• This disease is spread hematogenously
from the lungs and into the affected organ
system or by direct extension.
• Most patients with genitourinary tuberculosis
are immunocompromised, so assessment
of HIV infection status is important
INTRODUCTION

3. • Urinary tuberculosis is a
disease of young adults (60%
of patients are between the
ages of 20 and 40)
• Tubercle bacilli may invade one
or more (or even all) of the
organs of the genitourinary
tract and cause a chronic
granulomatous infection

4. Pathogenesis of tuberculosis of the urinary tract.

5. EFFECTS ON THE GENITOURINARY TRACT
Kidney
Hematogenous spread causes granuloma
formation in the renal cortex, associated
with caseous necrosis of the renal papillae
and deformity of the calyces, leading to
release of bacilli into the urine. This is
followed by healing fibrosis and
calcification, which causes destruction of
renal architecture and autonephrectomy.
Ureters
Spread is directly from the kidney and can
result in stricture formation (vesicoureteric
junction, pelviureteric junction, and mid-
ureteric) and ureteritis cystica.
Caseating granuloma
Caseous abscess
Fibrosis
Calcification
 Papillary necrosis
Calyceal stem or UPJ obstruction
Autonephrectomy

6. Prostate and seminal vesicles
Hematogenous spread causes cavitation
and calcification, with palpable, hard-
feeling structures. Fistulae may form to
the rectum or perineum.
Epididymis , Spermatic Cord
The vas deferens is often grossly
involved; fusiform swellings represent
tubercles that in chronic cases are
characteristically described as beaded
Bladder
Infection is usually secondary to renal
infection, The bladder wall becomes
edematous, red, and inflamed, with
ulceration and tubercles (yellow
lesions with a red halo). Disease
progression causes fibrosis and
contraction (resulting in a small
capacity ‘thimble’ bladder), obstruction,
and calcification.

7. Caseating granuloma
Fibrosis

8. Retrograde pyelogram shows multiple infundibular
stenosis and papillary necrosis characteristic of
tuberculosis.
CT shows severe shrinkinging, lack of
function, and amorphous calcification of the right kidney
(tuberculous autonephrectomy).

9. Caseous abscess, Fibrosis and Calcification

10. Ureter with calcification and stricture
formation
execretory urography shows mild stricture of the
distal right ureter (arrow). Strictlre are also present in
the proximal ureters bilaterally.

11. Tuberculous bullous granulations Acute tuberculous ulcer

12. Tuberculous golf-hole ureter
severely withdrawn

13. CLINICAL FINDINGS
The diagnosis of genitourinary TB should be considered in a patient presenting with vague,
longstanding urinary symptoms for which there is no obvious cause
• The typical TB constitutional symptoms of fever, weight loss, night sweats, and
malaise are present in fewer than 20% of patients
• Up to 50% of patients with GU TB have only dysuria on presentation, 50% have
storage symptoms, and 33% have hematuria and flank pain
• Renal colic occurs in fewer than 10% of patients and corresponds to the passage of
necrotic papillary tissue, clots, stones, and caseous phlegmon in patients with
severe
• Typical laboratory findings include sterile pyuria and/or hematuria. This combination
is found in more than 90% of GU TB patients in developing countries.

14. TUBERCULOSIS OF THE GENITOURINARY TRACT SHOULD BE CONSIDERED
IN THE PRESENCE OF ANY OF THE FOLLOWING SITUATIONS:
(l) Chronic cystitis that refuses to respond to adequate therapy
(2) The finding of sterile pyuria;
(3) gross or microscopic hematuria
(4) non tender, enlarged epididymis with a beaded or thickened vas;
(5) a chronic draining scrotal sinus; or
(6) Induration or nodulation of the prostate and thickening of one or
both seminal vesicles (especially in a young man).
A history of present or past tuberculosis elsewhere in the body should
cause the physician to suspect tuberculosis in the genitourinary
tract when signs or symptoms are present.

15. DIAGNOSIS
Labaratory
• Urinalysis and Culture
1. Acidic urine , sterile pyuria , microscopic hematuria
2. The sensitivity of urine AFB cultures is as high as 80%.
3. Persistent pyuria without organisms on culture means tuberculosis until
proved otherwise
4. Cultures for tubercle bacilli from the first morning urine are positive in a very
high percentage of cases of tuberculous infection. If positive, sensitivity tests
should be ordered. In the face of strong presumptive evidence of tuberculosis,
negative cultures should be repeated. Three to five first morning voided
specimens are ideal.

16. POSSIBLE CAUSES OF STERILE PYURIA
• Genitourinary tuberculosis (TB)
• Urolithiasis
• Recently treated urinary tract infection (UTI)
• Urinary tract malignancy
• Chlamydial urethritis
• Papillary necrosis
• Prostatitis
• Interstitial cystitis

17. Purified Protein Derivative
:(PPD, Tuberculin Test, Mantoux
Test)
 If Positive – supports the
diagnosis.
 If Negative – can not
exclude extrapulmonary TB
LABARATORY

18. CRITERIA FOR TUBERCULIN POSITIVITY, BY RISK GROUP

19. Nucleic Acid Amplification (NAA) Testing—PCR
 Multiple sample.
 The tests have reported sensitivities ranging
from 87% to 96% when compared with
culture.
 Specificity from 92% to 99.8% (VS culture)
 Resistance mutations
LABARATORY

20. Plain Radiography.
• The kidney-ureter-bladder (KUB)
radiograph will frequently demonstrate
calcifications caused by TB, which are
present in more than 50% of patients
The KUB film can also show ureteral
calcifications, Bladder wall calcifications
are not very common except in late cases
of bladder contraction. Calcifications of the
prostate and seminal vesicles are seen in
10% of patients
• Chest x-ray
Abnormal in 50% of patients
DIAGNOSIS
RADIOLOGY
Kidney-ureter-bladder radiographic view in a patient
with left renal tuberculosis with associated
calcifications.

21. Intravenous Urography
(IVU)
• Is the gold standard for imaging
early renal TB
• Calyceal erosions have a moth-
eaten appearance
• Filling defects may be seen
RADIOGRAPHY

22. Occluded calyx.

23. Severe calyceal
and
parenchymal
destruction

24. Stricture at the distal left ureter.

26. The cystogram portion of an intravenous
pyelogram in
a patient with left renal tuberculosis. Note the
contracted left side of the bladder that is
secondary to fibrosis from the tuberculosis

28. CT REVEALS :
• calcifications,
• scarring,
• obstruction
• Hydronephrosis or
hydroureter
• Autonephrectomy
COMPUTED TOMOGRAPHY (CT)
The right kidney is hydronephrotic secondary to
infundibular stenosis the left kidney is an end-stage
nonfunctioning atrophic kidney with calcification.

30. Adult male with tuberculosis (TB)
of the epididymis. CT reveals a
tubular soft tissue swelling
(arrow) extending cranially from
the left epididymis, compatible
with spread of the TB infection
to the spermatic cord and
adjacent tissues.

32. Coronal MRI of the kidneys in a
47 year old woman
demonstrates gross widening
of the calices due to multiple
strictures of the caliceal
infundibulae on the right side,
from urinary tract tuberculosis.
The lesion in the liver is an
incidentally detected
hemangioma.

33.  Rarely indicated in diagnosis
 Must under general anesthesia
 Assessing the disease extent
or the response to
chemotherapy
 No Biopsy advised before
medical therapy
CYSTOSCOPY AND BIOPSY

34.  Multidrug treatment
 Initial 6-month regimens of
rifampicin, INH,
pyrazinamide, and
ethambutol
 Dosage, toxicity, drug
interactions
THE EUROPEAN ASSOCIATION OF
UROLOGY GUIDELINES RECOMMENDS 2 OR
3 MONTHS OF INTENSIVE TRIPLE DRUG
THERAPY (INH, RMP, AND EMB) DAILY
FOLLOWED BY 3 MONTHS OF
CONTINUATION THERAPY WITH INH AND
RMP TWO OR THREE TIMES PER WEEK.
TREATMENT
MEDICAL TREATMENT

37. SURGICAL THERAPY
 Adjuvant to medical therapy
 Focus on organ preservation
 The optimal timing of surgery is 4 to 6 weeks after the initiation of medical
therapy. This delay allows active inflammation to subside, the bacillary load to
decrease, and lesions to stabilize.
 Excision of diseased tissue and reconstruction
About 55% of patients with GU TB will require surgical management
during the course of their disease

38. NEPHRECTOMY
• Indications
–nonfunctioning kidney with or without calcification
–extensive disease involving the whole kidney, together with
hypertension and UPJ obstruction
–coexisting renal carcinoma

39. PARTIAL NEPHRECTOMY
• Localized polar lesion containing calcification that has failed to respond after
6 weeks of intensive chemotherapy
• Area of calcification slowly increasing in size and may gradually destroy the
whole kidney

40. 1. Solitary Ureteric stricture:
A-Lower part
 Dilatation or balloon dilatation or endoureterotomy and stenting
 Ureteroneocystostomy
 Ureteroneocystostomy + psoas hitch or Boari’s flap
B-Middle part
 Dilatation or balloon dilatation or endoureterotomy and stenting, or
ureteroneocystostomy + psoas hitch or Boari’s flap according
 to the nature and location of the stricture
 Intubated ureterotomy
 Interposition with appendix on the right side ileal replacement

41. C-Upper part
 Dilatation or balloon dilatation or endoureterotomy and stenting*
 Percutaneous nephrostomy
 Pyeloureteroplasty*
 Ureterocalycostomy
 Pyeloplasty
 Ileal replacement
2-Multiple strictures or total stricture of the urethra
 Ileal replacement of the ureter
 Diversion
 Permanent ureterostomy
 Ureterosigmoidostomy
 Nephrostomy

42. 3-Urinary bladder tuberculosis
• Antituberculosis treatment
• Bladder neck incision
• Hydraulic dilatation
• Augmentation
1- Small capacity bladder [30 to 150 ml]
• Ileal patch
• Ileocystoplasty
• Ileocaecoplasty
• Sigmoidcolocystoplasty
2-Thimble bladder [10 to 30 ml]
Cystectomy + orthotopic neobladder

43. 4-Tuberculosis of urethra
• Endoscopic dilatation
• Internal urethroplasty
• Staged urethroplasty
• Meatoplasty
5-Genital tuberculosis
• Epididymectomy
• Orchiectomy
• Excision of fistula
• Partial penectomy

44. MONITORING FOR TUBERCULOSIS RELAPSE
• GU TB patients may relapse at a higher rate than pulmonary TB patients, in 6.3% to
22% of cases even after 12 months of medical therapy
• Pulmonary TB patients are usually followed for 2 years after completing treatment;
for GU TB patients, some investigators have recommended 10 years of follow-up,
because the average time of relapse was 5.3 years

45. PREGNANCY AND LACTATION
Women of childbearing age should be advised to avoid pregnancy while being treated
for active TB. If the diagnosis is discovered during pregnancy, prompt therapy should
be initiated because the risk to the fetus from TB outweighs the risk of adverse drug
effects. Treatment consists of INH, ethambutol, rifampin, and pyridoxine, for 9
months. Pyrazinamide is avoided because the effects on the fetus are unknown.
Postpartum, women may breastfeed their infants because drug concentrations in
breast milk are too low to cause toxicity.

46. HUMAN IMMUNODEFICIENCY VIRUS INFECTION
• HIV infection increases the risk of active TB 30-fold. With HIV and TB coinfection,
each disease accelerates the other. All TB patients should be tested for HIV. Among
HIV-positive persons in the world, almost 25% of deaths are due to TB (WHO,
2013). This is reminiscent of TB mortality rates in 18th- and 19th-century Europe.
• GU TB may be more common in HIV-positive patients. In a small study in India, GU
TB was found postmortem in 49% of AIDS patients
• TB treatment in HIV-positive patients should not be delayed. Treatment guidelines
are similar to those for persons without HIV infection

47. Thank you