1. Urologic Tuberculosis
Xu Ha
Department of Urology, Tongji Hospital

2. Tuberculosis (TB) Pathogen — Mycobacterium tuberculosis
Infected — one third of world's population
Organism — lung first, through bloodstream to other
Probability — exposure, size, and infectivity
Initial infection — most controlled and no clinical illness
Clinical disease — multiplication of dormant bacilli

3. Genitourinary TB Account for 10% of tuberculosis cases
Most 20 to 40 years old
Male VS female — 2:1
Very uncommon in children
Spread of organism to kidney through blood
Other parts become involved by direct extension

4. Pathologic Features Kidney Caseating granuloma Caseous abscess
Fibrosis
Calcification
Papillary necrosis
Calyceal stem or UPJ obstruction
Autonephrectomy
Caseating granuloma

5. Fibrosis

6. Caseous abscess, Fibrosis and Calcification

7. Ureter with calcification and stricture formation
Pathologic Features
Ureter
Mucosa or submucosa tubercular nodule
Stricture formation
Granuloma
Fibrosis
Ureter with calcification and stricture formation

8. Pathologic Features Bladder Ureteral orifice inflamed and edematous
Ureteral orifice obstruction
Tuberculous ulcers
Tuberculous inflammation
Bladder wall fibrosis and contraction

9. Acutely inflamed ureteric orifice Tuberculous bullous granulations

10. Tuberculous golf-hole ureter
severely withdrawn
Acute tuberculous ulcer

11. Acute tuberculous cystitis
with ulceration
Healed tuberculous lesion

12. Clinical Manifestations
The diagnosis of genitourinary TB should be considered in a patient presenting with vague, longstanding urinary symptoms for which there is no obvious cause!

13. Clinical Manifestations
SPECIFIC - Genitourinary tract
Lower urinary tract – 50 to 80 %
Burning , frequency , urgency , urge incontinence
Dysuria , hematuria
Suprapubic pain / perineal discomfort
Decreased stream , straining, ineffective voiding
Slough in urine

14. Clinical Manifestations
Upper urinary tract symptoms
Pain - kidney and ureter region
Gross hematuria- 10 %
Genital – Male
Hematospermia - 10 %
Azoospermia
S/S of chronic
epididymorchitis
Genital – Female
Menstrual irregularities
Pelvic pain syndrome
Infertility – 18 %

15. Clinical Manifestations
Other systems
Respiratory % patients
Gastrointestinal %
Lymphoreticular
Constitutional to 15 %
Evening rise of temperature
Weight loss
Anorexia

16. Diagnosis Laboratory Urinalysis and Culture
Acidic urine , sterile pyuria , microscopic hematuria
Guide for further investigation, especially in pauci-symptomatic patients
Fastidious / slow growth – difficult to culture – at least three, but preferably five

17. Diagnosis Laboratory Purified Protein Derivative
(PPD, Tuberculin Test, Mantoux Test)
If Positive – supports the diagnosis
If Negative – can not exclude extrapulmonary TB
Response – HIV, Immunocompromised , Post-transplant pts

18. Diagnosis Laboratory Nucleic Acid Amplification (NAA) Testing—PCR
Multiple sample
Sensitivity from 87% to 95% (VS culture)
Specificity from 92% to 99.8% (VS culture)
Resistance mutations

19. Diagnosis Radiography Plain Radiograph
Positive findings up to 50% on chest radiograph
Calcifications in 30% to 50% case on KUB

20. Diagnosis Radiography Intravenous Urography (IVU)
Traditional gold standard tool
Replaced by CT in many institutions
Early signs: calyceal erosion and papillary irregularity
Most common: hydrocalycosis, hydronephrosis, orhydroureter

21. Diagnosis Radiography Intravenous Urography (IVU)— kidney
Calyx distortion
Calyx fibration
Calyx occlusion
Calyceal destruction
Parenchymal destruction

22. Diagnosis Radiography Intravenous Urography (IVU)— ureter
Dilatation above UVJ stricture
Rigid fibration
Multiple strictures

23. Diagnosis Radiography Intravenous Urography (IVU)— bladder
Small and contracted (thimble bladder)
Irregular with filling defects
Asymmetry

24. parenchymal destruction
Occluded calyx
Severe calyceal and 
parenchymal destruction

25. Stricture at the distal left ureter
 Contraction of the bladder left side 

26. Diagnosis Radiography Three-dimensional reconstructed images
Computed Tomography (CT)
Three-dimensional reconstructed images
At least the equal of IVU in identification
Findings with not specific

27. Computed Tomography (CT) Calyceal abnormalities
Hydronephrosis or hydroureter
Autonephrectomy
Amputated infundibulum
Urinary tract calcifications
Renal parenchymal cavities
Hydronephrotic in right kidney
End-stage nonfunctioning atrophic left kidney with calcification.

28. Diagnosis Endoscopy Cystoscopy and Biopsy
Rarely indicated in diagnosis
Must under general anesthesia
Assessing the disease extent or the response to
chemotherapy
No Biopsy advised before medical therapy

29. Treatment Successful treatment Early diagnosis
Prompt initiation of adequate drug
Rest and nutrition
Urgical treatment for advanced cases

30. Treatment Medical Treatment Multidrug treatment
Initial 6-month regimens of rifampicin, INH,
pyrazinamide, and ethambutol
Administered in one dose
Dosage, toxicity, drug interactions

31. Antituberculous Drugs
Treatment
Antituberculous Drugs

32. Antituberculous Drugs
Treatment
Antituberculous Drugs

33. Treatment Surgical Therapy Adjuvant to medical therapy
Focus on organ preservation and reconstruction
At least 4 to 6 weeks medical therapy before
Excision of diseased tissue and reconstructive

34. Treatment Surgical Therapy Excision of diseased Nephrectomy
Partial Nephrectomy
Abscess Drainage

35. Treatment Surgical Therapy Indications for nephrectomy
A nonfunctioning kidney with or without calcification
Extensive disease involving the whole kidney, together with
hypertension and UPJ obstruction
Coexisting renal carcinoma

36. Treatment Surgical Therapy Reconstructive Surgery Ureteral strictures
Augmentation cystoplasty
Urinary conduit diversion
Orthotopic neobladder

37. Summary
Part of general tuberculosis caused by Mycobacterium tuberculosis
Vague, longstanding urinary symptoms with no obvious cause
Urinalysis and culture and radiography for diagnosis
Basilic medical treatment
Adjuvant surgical therapy

38. THANK YOU