Property of Department of Urology, Faculty of Medicine, University of Zagazig, Egypt

2. Genitourinary
Tuberculosis
Lecturer Of Urology
Zagazig University

3.  Akhenaton, aAkhenaton, a
Pharaoh of thePharaoh of the
eighteentheighteenth
dynasty of Egypt,dynasty of Egypt,
and his wifeand his wife
Nefertiti both areNefertiti both are
believed to havebelieved to have
died fromdied from
tuberculosis.tuberculosis.
 Evidence indicatesEvidence indicates
that hospitals forthat hospitals for
tuberculosistuberculosis
existed in Egyptexisted in Egypt
as early as 1500as early as 1500
BCEBCE
TB's History

4. TB's HistoryTB's History
 Proof of TB has been found in 4 000Proof of TB has been found in 4 000
year old mummies.year old mummies.
Tuberculosis was alsoTuberculosis was also
knownknown
consumptionconsumption fromfrom
Hippocrates through theHippocrates through the
18th century18th century
The white deathThe white death
The great white plagueThe great white plague
The robber of youthThe robber of youth
The graveyard coughThe graveyard cough
During the 18th and 19th centuries tuberculosis
was epidemic in Europe and caused millions of
deaths, particularly in the poorer classes of
society.

5.  Robert KochRobert Koch discovered indiscovered in March 24th March 24th 1882 that1882 that
TB was caused by a bacteria.TB was caused by a bacteria.
 March 24th has becomeMarch 24th has become “World Tuberculosis Day.”“World Tuberculosis Day.”
 19201920 – BCG vaccine– BCG vaccine
 1944 –1944 –Streptomycin.Streptomycin.
 19701970 – first outbreak of– first outbreak of MDR-TBMDR-TB in USA.in USA.
 20052005-- XDR-TBXDR-TB (KwaZulu-Natal, South Africa)(KwaZulu-Natal, South Africa)

6. EPIDEMIOLOGYEPIDEMIOLOGY
 One third of world’s populationOne third of world’s population (WHO,1997)(WHO,1997)
 8-10 million new cases/year8-10 million new cases/year
 One of top 10 (2 million deaths)cause ofOne of top 10 (2 million deaths)cause of
deathdeath (Bleed,D et al 2000)(Bleed,D et al 2000)
 75% in the developing countries.75% in the developing countries.
 Genitourinary TB 15-20% in those countriesGenitourinary TB 15-20% in those countries
and in 1.2% of cases in USand in 1.2% of cases in US ((NYCDH,2000)NYCDH,2000)
 The most common opportunistic inf.in AIDSThe most common opportunistic inf.in AIDS
(Perlman et al,1999)(Perlman et al,1999)

8. TRANSMISSION OF M.T.TRANSMISSION OF M.T.
 Droplet InfectionDroplet Infection
 Factors determine likelihood of inf.:Factors determine likelihood of inf.:

9. MYCOBACTRIAMYCOBACTRIA
• Small non-Small non-
motile non motile non
sporing bacillisporing bacilli
• Thick cell wall Thick cell wall
formed of 4 formed of 4
layerslayers
• Strictly aerobicStrictly aerobic
• Lipid 40-50% Lipid 40-50%
of its weightof its weight

11. PATHOGENESISPATHOGENESIS
 Primary pulmonary infectionPrimary pulmonary infection
 Inflammatory reactionInflammatory reaction
 Little resistanceLittle resistance  MultiplicationMultiplication
 SpreadSpread  lymphatic then bloodlymphatic then blood
 Immune response within 4weeksImmune response within 4weeks
 Most individuals control 1ry infectionMost individuals control 1ry infection
 Dormant Bacilli wait appropriateDormant Bacilli wait appropriate
circumstances.circumstances.

12. Host immunity Org. virulence
Infection aborted Infection established

13.  The kidney, epididymis The kidney, epididymis in men, andin men, and
fallopian tubesfallopian tubes in women are thein women are the
primary landing sites for hematogenousprimary landing sites for hematogenous
spread of TB.spread of TB.
 The prostate The prostate is also considered one ofis also considered one of
the sites for hematogenous spread,the sites for hematogenous spread,
though its involvement with TB bacilli inthough its involvement with TB bacilli in
urine is more common.urine is more common.
 Other genitourinary organs are involvedOther genitourinary organs are involved
byby direct, endoluminal, or lymphaticdirect, endoluminal, or lymphatic
spreadspread from these sites.from these sites.

14. PATHOLOGYPATHOLOGY
KIDNEYKIDNEY

16. Healing by
fibrosis and
scarring

18. Photographs of a cut gross specimen show the earlyPhotographs of a cut gross specimen show the early
necrosis of the medullary tip (black spot innecrosis of the medullary tip (black spot in aa). Once). Once
devitalized, the papilla sloughs off, leaving a defectdevitalized, the papilla sloughs off, leaving a defect
(cavity in(cavity in bb))

19. Pathology: GrossPathology: Gross
Renal tuberculosis. Photograph of a cut gross specimen shows
multiple, predominantly peripheral, white tuberculous
granulomas throughout the kidney.

21. PATHOLOGYPATHOLOGY.cont.cont
 URETERURETER
*Extension from kidney*Extension from kidney
*UVJ, UPJ, Mid.ureter,Whole*UVJ, UPJ, Mid.ureter,Whole
ureterureter
*Mucosal granuloma*Mucosal granuloma
*Ureteritis stricture*Ureteritis stricture
*Saw-toothed, beaded, cork-*Saw-toothed, beaded, cork-
screw short, aperistaltic, pipe-screw short, aperistaltic, pipe-
stemstem

23. PATHOLOGYPATHOLOGY.cont.cont
BLADDERBLADDER

24. Descending infection to bladderDescending infection to bladder
HealingHealing
small, contracted bladder with greatly thickened wallssmall, contracted bladder with greatly thickened walls
(thimble bladder)(thimble bladder)
three functional consequencesthree functional consequences
-small bladder capacity-small bladder capacity
-incomplete emptying with sec. bacterial infection-incomplete emptying with sec. bacterial infection
-vesicoureteral reflux (Golf hole)-vesicoureteral reflux (Golf hole)

28. PATHOLOGYPATHOLOGY.cont.cont
 URETHRAURETHRA
*Spread from genital tract*Spread from genital tract
*Acute : urethral discharge*Acute : urethral discharge
epididymis & prostateepididymis & prostate
*Chronic :stricture*Chronic :stricture

29. PATHOLOGYPATHOLOGY.cont.cont
EpididymisEpididymis
* Posterior sinus* Posterior sinus
* Scrotal swelling* Scrotal swelling
* Beaded vas* Beaded vas

32. CLINICAL PICTURECLINICAL PICTURE
 Age 20-40Age 20-40
 M:F 2 :1M:F 2 :1
 General :General :
-Fever 37-80%-Fever 37-80%
-Anaemia & mild leucocytosis10%-Anaemia & mild leucocytosis10%
-Leucopenia & leukomoid reaction-Leucopenia & leukomoid reaction
(Nancy E. et al,2000)(Nancy E. et al,2000)

33. CLINICAL PICTURECLINICAL PICTURE ..contcont
 UROLOGICALUROLOGICAL
 Non-SpecificNon-Specific
 Intermittent & long standing.Intermittent & long standing.
 vague.vague.
 Minimal not reflecting severe disease.Minimal not reflecting severe disease.
 Frequent painless mict & urgency.Frequent painless mict & urgency.
 Flank or suprapubic painFlank or suprapubic pain
 Ureteral colicUreteral colic
 Hematuria 10% overt & 50%Hematuria 10% overt & 50%
microscopic.microscopic.

34.  Three other major complications of renal tuberculosis:Three other major complications of renal tuberculosis:
hypertensionhypertension (RAS axis mediated)(RAS axis mediated)
super-infection (12 to 50%)super-infection (12 to 50%)
nephrolithiasis (7 to 18%)nephrolithiasis (7 to 18%)
 In 1940, Nesbit and Ratliff reported that hypertensionIn 1940, Nesbit and Ratliff reported that hypertension
could be cured by the removal of a tuberculous kidney,could be cured by the removal of a tuberculous kidney,

35. URINE EXAMINATIONURINE EXAMINATION
 Sterile pyuriaSterile pyuria
 3 or 5 consecutive morning samples3 or 5 consecutive morning samples
 SedimentationSedimentation
 Preferably immediate examination, ifPreferably immediate examination, if
delay unavoidable sample must bedelay unavoidable sample must be
refrigerated, not froze.refrigerated, not froze.
 Z-N stainingZ-N staining
 Culture:Culture:
 *Lowenstein-Jensen Medium*Lowenstein-Jensen Medium
 *Pyruvic egg medium*Pyruvic egg medium

36. Sterile PyuriaSterile Pyuria
 Tuberculosis of the urinary tractTuberculosis of the urinary tract
 Chlamydia trachomatis, Mycoplasma, orChlamydia trachomatis, Mycoplasma, or
Ureaplasma infectionUreaplasma infection
 Chemically induced cystitisChemically induced cystitis
 Renal calculiRenal calculi
 ProstatitisProstatitis
 Coliform (or other pathogen) urinary tractColiform (or other pathogen) urinary tract
infection but antibiotic inhibiting growthinfection but antibiotic inhibiting growth
 WBC from outside urinary tract, e.g. fromWBC from outside urinary tract, e.g. from
foreskin or vulvaforeskin or vulva
 Renal parenchymal causes as acuteRenal parenchymal causes as acute
tubulointerstitial nephritis, glomerular diseasetubulointerstitial nephritis, glomerular disease

37. Urine ExamUrine Exam.. Cont.Cont.
 Liquid culturesLiquid cultures
*Radiometric (BACTEC 460)*Radiometric (BACTEC 460)
(Piersimoni et al, 2001)(Piersimoni et al, 2001)
*Non-radiometric :*Non-radiometric :
(BACTEC 9000, MGIT 960)(BACTEC 9000, MGIT 960)
(Bemer P. et el,2002)(Bemer P. et el,2002)

38. Double stranded target DNA
DNA denatured Two DNA targets for PCR
Primers bind to target DNA Double stranded DNA duplicate
PCR
amplification
cycle
POLYMERASE CHAIN REACTION

39. Double stranded target DNA
DNA denatured Two DNA targets for LCR
Primers bind to target DNA Double stranded DNA duplicate
LGASE CHAIN
REACTION
LIGASE CHAIN REACTION

40. Tuberculin TestTuberculin Test
 Intradermal injection of purifiedIntradermal injection of purified
protein derivative indurationprotein derivative induration
 Criteria for tuberculin positivityCriteria for tuberculin positivity
 Reaction ≥ 5mm of indurationReaction ≥ 5mm of induration
 Reaction ≥ 10mm of indurationReaction ≥ 10mm of induration
 Reaction ≥ 15mm of indurationReaction ≥ 15mm of induration
(CDC,2000)(CDC,2000)
 +ve reaction does not mean activity+ve reaction does not mean activity

41. Five millimeters or more of indurationFive millimeters or more of induration ::
Considered positive inConsidered positive in persons with the highestpersons with the highest
likelihood of developing active disease.likelihood of developing active disease.
These include:These include:
1.1. Patients with HIV infectionPatients with HIV infection
2.2. Organ transplantsOrgan transplants
3.3. ImmunosuppressionImmunosuppression
4.4. Close contact with persons having activeClose contact with persons having active
tuberculosis cases or radiographic findings consistenttuberculosis cases or radiographic findings consistent
with old tuberculosis.with old tuberculosis.

42. Ten millimeters or more of induration:Ten millimeters or more of induration:
considered positive in those who do not meet theconsidered positive in those who do not meet the
preceding criteria but who are at high risk forpreceding criteria but who are at high risk for
tuberculosis.tuberculosis.
These include:These include:
1.1. HIV-negative injection drug usersHIV-negative injection drug users
2.2. Residents and employees of high-risk congregateResidents and employees of high-risk congregate
settings, such as prisons, nursing homessettings, such as prisons, nursing homes
3.3. Laboratory personnel dealing with mycobacterialLaboratory personnel dealing with mycobacterial
samplessamples
4.4. Persons with high-risk medical conditions,Persons with high-risk medical conditions,
including diabetes, chronic renal failureincluding diabetes, chronic renal failure
Fifteen millimeters or more of induration isFifteen millimeters or more of induration is
considered positive in anyone.considered positive in anyone.

43. RADIOGRAPHYRADIOGRAPHY
 Plain RadiographyPlain Radiography
•• KUB: CalcificationKUB: Calcification
- Renal parenchyma- Renal parenchyma. (Leung TK,2003). (Leung TK,2003)
- Ureteral calcification intraluminal- Ureteral calcification intraluminal
(Hartman et al, 1997)(Hartman et al, 1997)
- Bladder calcification rare- Bladder calcification rare
(Ali Nawaz,2002)(Ali Nawaz,2002)
•• Chest & spineChest & spine

44. RADIOGRAPHYRADIOGRAPHY cont.cont.
 INTRAVENOUS UROGRAPHYINTRAVENOUS UROGRAPHY
•• Moth eaten calyx, hydrocalycosis,Moth eaten calyx, hydrocalycosis,
amputated calyx, hydronephrosis,amputated calyx, hydronephrosis,
parenchymal cavity, mass, autonephrecparenchymal cavity, mass, autonephrec
•• Strictures infundibular,UPJ,UVJStrictures infundibular,UPJ,UVJ
•• Thimble bladderThimble bladder
•• Dynamic study with image intensifiedDynamic study with image intensified
endoscopyendoscopy (Warren D. et al, 2002)(Warren D. et al, 2002)

46. Classic lobar pattern of calcification, which is pathognomonic of end-stage
renal tuberculosis, with Ureteral calcification , which is fainter in upper
parts.
The occurrence of any upper ureteral calcification (however, faint) along with any
other renal calcification is a good pointer of renal TB.

48. A.lower infundibular and
renal pelvic
scarring,papillary
necrosis
B.papillary necrosis in the
upper group of calyces,
Healing forniceal papillary
necrosis in a lower calyx
C.multiple parenchymal cavities with areas of
papillary necrosis

49. o The cephalic
retraction of the
inferior medial margin
of the renal pelvis at
the ureteropelvic
junction (UPJ), or the
"hiked up renal pelvis,
is another suggestive
urographic change.
.

50. Intravenous urogram
revealing cicatrization that
has resulted in obliteration
of the renal pelvis, multiple
infundibular strictures
(white arrows) and uneven
caliectasis. Note non-
visualization of the middle
group of calyces–the
“phantom calyx” (black
arrows) and a cavity
communicating with a lower
calyx (arrowheads)>> due
to selective non excretion of
calyes

51. Intravenous urogram revealing a (R) ureteric stricture (white arrow) with
ureteric calcification (black arrowheads), pseudo-calculi (black arrow),
and irregular calcification in the parenchyma (circled area)
*dense calcification may mimic calculi ‘pseudo calculi’*‑ ‑

52. (A) Intravenous urogram revealing a non-functioning (L) kidney and a small
capacity urinary bladder. (B) Intravenous urogram revealing non-functioning
(R) kidney. (L) Renal pelvic and upper infundibular scarring (white
arrowheads), resulting in uneven caliectasis. A (L) lower ureteric stricture
(arrow) and small capacity bladder (black arrowheads) are also noted

55. Parenchymal granulomas (black arrows) in the (L)
kidney with uneven caliectasis and ureterectasis
accompanied by urothelial thickening (white arrow).

56. oTubercular renal abscesses are seen as hypodense areas of
10 40 HU with mild peripheral enhancement.‑

57. (A)CT revealing caseous TB cavity (arrow) in the upper pole of the (L)
kidney. (B)CT revealing a cavity (white arrowheads)communicating
with a dilated pelvi calyceal system (PCS)
Inflammatory granulomatous and caseating masses show enhancement.

58. (A) Non-contrast CT image showing fine cortical calcification in the (L)
kidney (white arrow). (B and C) non-contrast CT image showing
punctate calcification [arrows in (B) and soft (caseous) parenchymal
calcification arrowheads in (C)].
(D and E) axial CT revealing the lobar pattern of calcification
(arrowheads)

59. Pelvicalyceal system (PCS) and ureteral
involvement
 Focal or diffuse caliectasis unaccompanied by renal pelvic dilatation.
 Urothelial thickening.
 Multifocal strictures lead to uneven caliectasis.
 Hydronephrosis
 Multiple ureteral strictures

60. With long standing renal TB, progressive parenchymal atrophy‑
and hydronephrosis lead to a loss of normal morphology, and
the appearance mimics multiple thin walled cysts or,‑
occasionally, a multiloculated cyst

61. Two goalsTwo goals
Clinical ManagementClinical Management
conservation of tissue
and function
antimycobacterial cure.

62. DrugDrug Daily DoseDaily Dose Intr. DoseIntr. Dose
IsoniazidIsoniazid 5mg/kg5mg/kg 10mg/kg10mg/kg
RifampicinRifampicin 10mg/kg10mg/kg 10mg/kg10mg/kg
PyrizinamidePyrizinamide 25mg/kg25mg/kg 35mg/kg35mg/kg
EthambutolEthambutol 15mg/kg15mg/kg 25mg/kg25mg/kg
StreptomycinStreptomycin 15mg/kg15mg/kg 15mg/kg daily15mg/kg daily
 Streptomycin- max. dose 750 mg in pts. <40 yrs ageStreptomycin- max. dose 750 mg in pts. <40 yrs age

63. Longer courses of ATT rangingLonger courses of ATT ranging from 9 months tofrom 9 months to
2 years2 years are useful in patients:are useful in patients:
 Who do not tolerate PyrazinamideWho do not tolerate Pyrazinamide
 Those responding slowly to standard regimenThose responding slowly to standard regimen
 Those with miliary and CNS diseaseThose with miliary and CNS disease
 Children with multiple site involvementChildren with multiple site involvement
Longer courses of ATTLonger courses of ATT

64. After 2 month of therapy-After 2 month of therapy-
3 urine cultures3 urine cultures
If negative- continue therapyIf negative- continue therapy
At the end of therapyAt the end of therapy
3 consecutive negative samples3 consecutive negative samples
Repeated after 3 months and at 1 year.Repeated after 3 months and at 1 year.
Treatment monitoringTreatment monitoring

65. SURGERYSURGERY
 NEPHRECTOMYNEPHRECTOMY
 PARTIAL NEPHRECTOMYPARTIAL NEPHRECTOMY
 NEPHROURETERECTOMYNEPHROURETERECTOMY
 ABSCESS DRAINAGEABSCESS DRAINAGE

66. SURGERYSURGERY

RECONSTRUCTIVE SURGERYRECONSTRUCTIVE SURGERY
UVJ :UVJ : UV reimplantationUV reimplantation
UPJ :UPJ : PyeloplastyPyeloplasty
Contracted bladder:Contracted bladder:
-- Augmentation cystoplastyAugmentation cystoplasty
- Urinary Diversion- Urinary Diversion