eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Tuberculosis of the Genitourinary System: Differential Diagnoses & Workup

Author: Mohamed S Soliman, MD, Consulting Staff, Integral Healthcare of Cheraw
Coauthor(s): Klaus-Dieter Lessnau, MD, FCCP, Clinical Assistant Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory, Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital; Aizid Hashmat, MD, Chairman, Department of Urology, Brooklyn Hospital Center
Contributor Information and Disclosures

Updated: Dec 27, 2007

Differential Diagnoses

Renal Cell Carcinoma
Schistosomiasis

Other Problems to Be Considered

Renal malacoplakia
Medullary sponge kidney
Cholesteatoma
Pyonephrosis
Renal echinococcosis
Fungal infection
Bladder cancer
Psoas abscess with calcification
Calyceal diverticula

Workup

Laboratory Studies

  • Tuberculin skin test results are positive in about 90% of patients, but this finding denotes only prior inhalation of mycobacteria rather than active disease.
  • Complete blood cell count, sedimentation rate, serum chemistry, and C-reactive protein studies are helpful to assess the severity of disease, renal function, and response to treatment.
  • Serial early-morning urine collection for acid-fast smear (at least 3) is a specific (89-96%) but less sensitive (approximately 52%) tool.  
  • Serial urine cultures are still considered the criterion standard for evidence of active disease, with sensitivity of 65% and specificity of 100%. Every effort should be made to process the samples immediately after collection. Sending cultures before starting antituberculosis treatment and adjusting therapy according to sensitivity in case of resistance is always recommended. The following methods are available:
    • Solid media: The Lowenstein-Jensen medium yields results in more than 4 weeks.
    • Radiometric media: The BACTEC 460 medium yields results in 2-3 days.
  • The polymerase chain reaction (PCR) test has been extensively studied and has been proven highly sensitive, specific, and rapid.
    • In various studies, data show sensitivity ranging from 87-100% (usually >90%) and specificity from 92-99.8% (usually >95%). Compare this with cultures (37%), bladder biopsies (47%), and intravenous pyelography (IVP) examinations (88%).4
    • Along with an accurate clinical assessment, PCR is the best tool available for avoiding a treatment delay because results are available in only about 6 hours.
    • The following PCR tests are available with near-equivalent quality:
      • Genus-specific 16S rRNA PCR test
      • Species-specific IS6110 PCR test
      • Roche Amplicor MTB PCR test5,6,7
      • Amplified Mycobacterium tuberculosis Direct Detection Test (AMDT)
  • Although not widely used, the following tests are also available:
    • Luciferase and fluorescent techniques: Staining with auramine or rhodamine and examining via fluorescence microscopy can be used to detect low numbers of mycobacteria.
    • High-performance liquid chromatography (HPLC) test: HPLC quickly reveals qualitative and quantitative differences in mycolic acid in cell walls.
    • DNA probe: This probe provides species specification in a few hours.

Imaging Studies

  • Radiography
    • Chest and spine radiographs may show old or active lesions. In 50% of patients, chest radiographic findings are negative.
    • Kidney, ureter, and bladder (KUB) radiographs reveal calcifications in the kidney and ureter in approximately 50% of patients. Calcifications are intraluminal, as opposed to schistosomiasis, which produces intramural calcifications. Calcifications in the bladder are uncommon.
  • Intravenous pyelography and voiding cystography
    • These tests are the standard diagnostic imaging studies for renal TB and have 88-95% sensitivity. They also help define the extent and severity of disease.
    • The earliest radiographically detectable changes are cavitary lesions that progress to the papilla and invade the collecting system, causing calyceal disruption. Findings of infundibular stenosis and multiple ureteral strictures are highly suggestive of renal TB. Later findings may include cortical necrosis, calcifications, and coalesced cavitary lesions with scarring, stricture, sinus, or abscess formation. A small contracted bladder suggests extensive bladder TB.
  • Sonograms may reveal cystic or cavitary lesions, cortical scarring, hydronephrosis, and abscess in kidneys; ultrasonography is very sensitive in testicular TB. Adnexal mass, thickened omentum or peritoneum, peritoneal tubercles, loculated or free fluid in the pelvic cavity, and adhesions are common ultrasonographic findings of female genital TB.
  • In recent years, high-resolution transrectal ultrasonography (TRUS) has become a very useful noninvasive technique in the evaluation of the subfertile man who has severe oligospermia or azoospermia associated with a low-volume ejaculate.8 TRUS can reveal abnormalities in the seminal vesicles and ejaculatory duct and can help assess the status of the prostate. It may show dilatation or fibrosis of epididymis, atrophy, thickening or calcification of seminal vesicles, or prostatitis.
  • Retrograde pyelography is rarely indicated except in patients with renal failure in whom the kidneys cannot excrete contrast and to evaluate stricture in the upper urinary tract. It also helps for sampling urine from individual kidneys for microbiology.
  • CT scanning with contrast
    • This imaging test is a useful adjunct to IVP and is helpful in late or advanced disease for assessing the extent of disease and the indirect functional status of the affected kidney compared with the normal opposite kidney. This study is very sensitive for detecting calcification and thickened walls of the ureter and bladder.
    • Nonvisualization of the affected kidney via excretory urography indicates advanced disease.
  • Angiography is useful when focal lesions mimic a primary renal mass or when partial nephrectomy is planned. Angiography also shows obliterated interlobar arteries and avascular lesions.
  • Renal nuclear scan findings are nonspecific but can be used to assess kidney function and to monitor the effects of therapy.
  • MRI, hysterosalpingography, and image-intensifier endoscopy are sometimes useful to reveal radiographic changes in genitourinary tuberculosis (GUTB).

Other Tests

  • Vasography in association with TRUS may demonstrate mechanical obstruction of the vas deferens.

Procedures

  • Laparoscopy: The discovery of peritoneal tubercles during tubal ligation is not uncommon in developing countries.
  • Consider biopsies of genital ulcers; tubercles in the bladder, especially if scattered away from the ureteric orifice (an uncommon feature of bladder TB); and any lesion with even a slight possibility of malignancy. The yield of biopsy for TB is about 45%.
  • Fine-needle aspiration (FNA) as a minimally invasive technique plays a prime role in the diagnosis of tubercular epididymitis and epididymoorchitis.9 Acid-fast bacilli (AFB) may be detected on FNA smears in up to 60% of these patients.

Histologic Findings

Findings include granuloma with central Langerhans cells surrounded by lymphocytes, fibrocytes, and epithelioid cells, which later progress to central caseous formation and varying degrees of fibrosis and calcification.

More on Tuberculosis of the Genitourinary System

Overview: Tuberculosis of the Genitourinary System
Differential Diagnoses & Workup: Tuberculosis of the Genitourinary System
Treatment & Medication: Tuberculosis of the Genitourinary System
Follow-up: Tuberculosis of the Genitourinary System
Multimedia: Tuberculosis of the Genitourinary System
References
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References

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Further Reading

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Keywords

tuberculosis, genitourinary tuberculosis, urinogenital tuberculosis, urinogenital TB, TB, genitourinary TB, GUTB, renal tuberculosis, renal TB, urethral tuberculosis, urethral TB, bladder tuberculosis, bladder TB, thimble bladder, prostatic tuberculosis, prostatic TB, fallopian tuberculosis, penile tuberculosis, sterile pyuria, Mycobacterium tuberculosis, M tuberculosis, high-resolution transrectal ultrasonography, TRUS, sexually transmitted disease, STD, sexually transmitted infection, STI, ureteral tuberculosis, ureteral TB, epididymal TB, epididymal tuberculosis, tuberculous epididymoorchitis, tuberculous ulcer, endometrial TB, endometrial tuberculosis

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Contributor Information and Disclosures

Author

Mohamed S Soliman, MD, Consulting Staff, Integral Healthcare of Cheraw
Mohamed S Soliman, MD is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Klaus-Dieter Lessnau, MD, FCCP, Clinical Assistant Professor of Medicine, New York University School of Medicine; Medical Director, Pulmonary Physiology Laboratory, Director of Research in Pulmonary Medicine, Department of Medicine, Section of Pulmonary Medicine, Lenox Hill Hospital
Klaus-Dieter Lessnau, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Artificial Internal Organs, American Thoracic Society, Physicians for Social Responsibility, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Aizid Hashmat, MD, Chairman, Department of Urology, Brooklyn Hospital Center
Aizid Hashmat, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Allen Donald Seftel, MD, Department of Urology, Associate Professor, Case Western Reserve University
Allen Donald Seftel, MD is a member of the following medical societies: Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shlomo Raz, MD, Professor, Department of Surgery, Division of Urology, University of California at Los Angeles School of Medicine
Shlomo Raz, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, and California Medical Association
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting

 
 
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