Diagnosis

• Clinical Features and Diagnosis
  • Renal involvement is largely silent, often presenting vague urinary symptoms
  • History taking and high index of suspicion as well as a history of recurrent urinary tract infections that are nonresponsive to common antibiotics
  • Male: the earliest indication may be tuberculous epididymitis or cystitis
  • Female: may present with bladder pain and dysuria
  • Back pain and hematuria are not uncommon
  • A recurrent Escherichia coli infection should serve as a warning sign
• Clinical Findings in Genitourinary Tuberculosis
  • Sterile pyuria
  • Nocturnal painless frequency of micturition
  • History of present or past TB elsewhere in the body
  • Unexplained hematuria
  • Chronic cystitis unresponsive to antibiotics
  • Chronic epididymitis with epididymal nodularity and/or thickened or beaded vas deferens
  • Nodularity of prostate, shrunken "bean bag" prostate
  • Induration of seminal vesicles
  • Dull flank pain and renal colic
  • Chronic draining scrotal sinus
  • Hemospermia (rare)
• Severity of symptoms do not correlate with the degree of urinary tract involvement
• Diagnosis is made by finding M. tuberculosis in the urine or semen
  • Three to five consecutive early morning urines are cultured: repeat if results are negative
  • Acid-fast stains on concentrated urinary sediment from 24-hour specimen may be positive in 50 to 60 percent of cases, but culture corroboration is essential. Once the cultures are positive, the antibiotic sensitivities are performed.
    • Fluorescence microsopy and other modern diagnostic techniques have enhanced the yields
    • DNA probes have allowed clinicians to differentiate between various mycobacterial species and strains
  • A negative tuberculin skin test makes the diagnosis unlikely, but a conversion of previously negative test to positive should raise the index of suspicion
  • Radiographs alone are not sufficient for diagnosis. However, an intravenous urogram may reveal various features of TB and helps rule out obstruction and non functioning unit.
  • Drug-sensitivity testing is essential. Differential diagnosis
  • Chronic nonspecific cystitis or pyelonephritis
  • Acute or chronic nonspecific epididymitis
  • "Urethral syndrome," interstitial cystitis
  • Necrotizing papillitis of one or both kidneys
  • Schistosomiasis

Medical Management

• General considerations:
  • The aim of antituberculous therapy is to treat the active disease promptly and render the patient noninfective in the shortest period of time
  • The size of the bacillary population is related to the extent of the disease
  • Multiple drugs work synergistically against resistant organisms in early treatment
  • Close follow-up of upper tracts is essential during therapy, as asymptomatic uretetal strictures (especially in the lower third) may occur during the healing phase
  • Tuberculous strictures lend themselves to percutaneous or transurethral dilatation techniques
  • Steroids may be beneficial

Surgical Management

• Surgical intervention may play an increasing role with trends toward shorter duration of chemotherapy

Medical Management Subject to Sensitivity Results

• Primary agents: rifampicin, isoniazid, pyrazinamide, and streptomicin
  • Currently, a combination therapy is employed, usually for 4 to 6 months
  • Combination therapy popularized by Gow includes: pyrazinamide, 25 mg/kg daily plus INH, 300 mg daily and rifampin, 450 mg daily for 2 months followed by isoniazid 600 mg and rifampin 900 mg three times weekly for a further 2 months
• Secondary agents: ethambutol, ethionamide, cycloserine, para aminosalycic acid, and capreomicin

Surgical Therapy Subject to Sensitivity Results

• Surgery, when indicated, is performed 4 to 6 weeks after chemotherapy has begun
• Surgical procedures are undertaken to drain perinephric abscess, remove nonfunctioning renal tissue, bypass ureteral strictures, and to augment severely contracted bladders
• Nephrectomy is done for grossly diseased nonfunctioning kidney or diseased kidney with severe secondary hypertension
• Partial nephrectomy is some times undertaken for calcified polar lesion increasing in size
• Reconstructive surgery is performed as necessary

Follow-up

• Patients should be seen at 3, 6, and 12 months after completion of therapy and their urines cultured for acid-fast bacillus (AFB)
• Patients can discharged following a year of disease-free follow up
• Kidney, ureter, and bladder (KUB) x-rays and intravenous urography (IVU) are required to follow the status of calyceal deformities and renal calcifications

References

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