Renal and urologic tuberculosis

Generally, TB affect the kidney & urologic system through mycobacterial seeding of the urogenital tract via heamatogenous spread

 

Renal & urologic tuberculosis (T.B.)

 

Lupus vulgaris

Generally, TB affect the kidney & urologic system through mycobacterial seeding of the urogenital tract via heamatogenous spread that can be observed with pulmonary infection or with reactivation or miliary spreading. Less common, renal parenchyma can be involved via interstitial nephritis & or via glomerulonephritis (GN).

TB bacilli can invade the medullary interstitium leading to granuloma formation that may heal with fibrous tissues  formation (with no overt clinical renal disease) or, many years later on, they can break down & rupture into tubular lumen with excreting TB bacilli into the UT >> continuous TB spreading. However, descended spread of infection along the ureter & bladder may induce ureteric stricture, obstructive uropathy, hydronephrosis, & kidney dysfunction. At the begining, renal & urologic TB are symptomless; but pyuria and/or microscopic hematuria can be seen incidentally. Once the pathology has proceeded to involve the UB, Sms of frequency, dysuria, urgency, as well as nocturia can be seen in about 50% of ptns; hematuria with low back pain may develop in one 1/3^rd  of ptns. Systemic manifestations (fever, weight loss) are not common. With TB advanced disease ESRD may develop and, in rare cases, a refractory HT.  

 

Characteristically lab findings may include persistent pyuria (sterile pyuria) + acidic urine with urine culture is persistently negative. Painless macroscopic or microscopic hematuria is persistent in > 90 % of ptns. SCr is often normal with unilateral renal involvement. Increased SCr, however, may be seen with the presence of bilateral renal involvement and/or with interstitial nephritis or GN.  

 

Dgx of renal and/or urologic TB should be expected in ptns with relevant clinical criteria (urine frequency, dysuria, hematuria, and/or pyuria) with relevant epidemiologic environment (previous TB infection/disease, possible TB exposure, and/or past/present resident or travelling to an endemic zones). Dgx of urogenital TB may be established by identification of tubercle bacilli in urine. 3-6 early-morning urine sampling should be examined for urine mycobacterial culture or urine PCR for M. TB. Radiological examination is also required for suspected renal/urologic TB. CT with contrast is preferable if available; in addition to high-resolution US & IVP. Generally, radiological testing concomitant upper + lower UT affection is a robust suggestion of TB. Multiple strictures along the collecting system (fr: kidney pelvis to uretero-vesical junction) can be seen in 60-84 % of ptns.  

 

Genital tuberculosis

 

Male genital tract: TB can affect the prostate, seminal vesicle, vas deferens, epididymis, testicle, Cooper gland, as well as the penis. Epididymitis is the most commonly involved among males with genital TB; it is affected in 10-55 % ptns. Clinical findings include scrotal nodule or epididymal hardening in 50% of ptns, usually bilateral in 34 % of ptns.  Female genital tract: TB infection can affect the fallopian tubes, endometrium, as well as the ovaries but generally sparing the myometrium. Fallopian tubes are involved in 90-100 % of ptns, usually with bilateral affection. Women genital TB is observed clinically as infertility (40-76 %), pelvic/abdominal pain or mass (50 %), as well as menstrual disturbances (25 %).  

 

Dgx of genital TB should be expected with relevant clinical criteria (men: nodular scrotal lesions, prostatic and/or testicular and/or non-healing ulceration of the external genitalia; in ladies: infertility, pelvic/abdominal pain, and/or menstrual disturbances) as well as relevant environmental factors (previous TB, exposure, and/or residents/traveling to zones with endemic TB). Dgx of male genital TB starts with assessing the UT. With absent evidence for urinary involvement, men with suspected genital TB proceed to biopsy of the affected site; biopsy specimen should be sent for histopathology testing, staining with acid-fast bacilli, & mycobacterial culture. In women with suspected genital TB, hysterosalpingo-gram may declare fallopian tube obstruction/constriction and/or uterine adhesions or deformities. Histopathological Dgx may be made via endometrial or fallopian tube biopsy for histology + C&S, or via mycobacterial culture of menstrual fluid. Samples should be sent for histopathologic testing, acid-fast bacilli staining, & mycobacterial culture.  

 

Management

Ptns with urogenital TB should be ttt with anti-T.B. therapy; generally, therapeutic approach is similar to that of pulmonary TB. Ptns with ureteric stricture & hydro nephrotic changes, an early stent placement or percutaneous nephrostomy is beneficial with obstructive uropathy and potentially reversible if provided early.