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
| Common Antituberculous Chemotherapeutic Agents | |||
| DRUG | DOSES | SIDE EFFECTS | NOTES |
| Capreomycin | 500-1000mg/dayonce per day for 3 monthsthen twice per week | Nephrotoxicity ototuxicity | Use with caution in elderly |
| Cycloserine | 10-20 mg/kg per day to maximum 500 mg/day | Psychosis | Contraindicated in epileptics |
| Ethambutol | 15 mg/kg per day | Retrobulbar neuritis, color vision changes | Tuberculostatic baseline visual acuity tests |
| Isoniazid (INH) | 5-10 mg/kg per day max 300 mg/day | Peripheral neuritis, hepatitis | Bactericidal, pyridoxin for neuritis |
| Pyrazinamide | 15-30 mg/kg to max 2000 mg/day | Hepatotoxicity, elevates serum uric acid | Monitor Liver function and serum uric acid |
| Para-aminosalicylic acid | 150 mg/kg to max 12 g/day | Hypersensitivity, GI irritation, hepatotoxicity | Tuberculostatic |
| Rifampicin | 10-20 mg/kg per day to maximum 600 mg/day | Hepatotoxicity, hypersensitivity, transient leukopenia, thrombocytopenia | Bactricidal, orange discoloration of urine |
| Streptomycin | 750-1000 mg/day IM for 1 month, then 95 mg/kg twice per week | Nephrotoxicity, ototoxicity | |
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