eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Tuberculosis of the Genitourinary System

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

Introduction

Background

The genitourinary system is a common site of extrapulmonary tuberculosis (TB). Genitourinary tuberculosis (GUTB) may involve the kidneys, ureter, bladder, or genital organs. Clinical symptoms usually develop 10-15 years after the primary infection. Only about a quarter of patients with GUTB have a known history of TB; about half of these patients have normal chest radiography findings.

Pathophysiology

Mycobacterium tuberculosis bacilli are inhaled through the lungs to the alveoli, where they are phagocytosed by polymorphonuclear leukocytes and macrophages. Although most bacilli are initially contained, some are carried to the region's lymph nodes. Eventually, the thoracic duct may deliver mycobacteria to the venous blood; this may result in seeding of different organs, including the kidneys.

Multiple granuloma form at the site of metastatic foci. In the kidneys, they are typically bilateral, cortical, and adjacent to the glomeruli and may remain inactive for decades.

Although both kidneys are seeded, clinically significant disease, which is caused by capillary rupture and delivery of proliferating bacilli into the proximal tubules, usually develops in only one kidney. The medullary hypertonic environment impairs the phagocytic function.

Growing granuloma may erode into the calyceal system, spreading the bacilli to the renal pelvis, ureters, bladder, and other genitourinary organs. Depending on the status of the patient's defense mechanisms, fibrosis and strictures may develop with chronic abscess formation. Extensive lesions can result in nonfunctioning kidneys. Hypertension in persons with renal TB is twice as common as it is in the general population.

Ureteral TB is an extension of the disease from the kidneys, generally to the ureterovesical junction. It only rarely affects the middle third of the ureter. Ureteral TB often causes ureteral strictures and, sometimes, hydronephrosis. Occasionally, severe cases can cause stricture of virtually the entire ureter. Ureteral TB develops in about half of all patients with renal TB.

Bladder TB is secondary to renal TB and usually starts at the ureteral orifice. It initially manifests as superficial inflammation with bullous edema and granulation. Fibrosis of the ureteral orifice can lead to stricture formation with hydronephrosis or scarification (ie, golf-hole appearance) with vesicoureteral reflux. Severe cases involve the entire bladder wall, where deep layers of muscle are eventually replaced by fibrous tissue, thus producing a thick fibrous bladder. Tubercles are rare in the bladder; if present, they usually appear at the ureteral orifice. Malignancy should be considered with any isolated tubercles away from the ureteral orifices.

The higher frequency of isolated epididymal TB lesions in children favors the possibility of hematological spread of infection, while adults seem to develop tuberculous epididymoorchitis caused by direct spread from the urinary tract.1 The formation of a draining sinus is uncommon in developed countries, but epididymal induration and beading of the vas are common.

Involvement of the testis is usually due to direct extension. Infertility may result from bilateral vasal obstruction. Nodular beading of the vas is a characteristic physical finding. Orchitis and the resulting testicular swelling can be difficult to differentiate from other mass lesions of the testes.

Prostatic TB is also spread hematogenously, but involvement is rare. The affected prostate is nodular and not tender to palpation. Eighty-five percent of patients also have renal TB. Severe cases may cavitate and form a perineal sinus, although this development is rare. Decreased semen volume may indicate extensive prostatic disease or ejaculatory duct obstruction.2

Patients with genital and urethral TB present with a superficial tuberculous ulcer on the penis or in the female genital tract secondary to mycobacteria exposure during intercourse. The penile ulcer may cause cavernositis that extends to the urethra. This form of TB may involve the uterus and fallopian tubes, causing strictures. Consider malignancy if genital ulcers are present. Urethral TB is secondary to genital TB. Acute urethritis manifests as mycobacterial discharge and often results in chronic stricture formation.

Frequency

United States

GUTB comprises approximately 6% of extrapulmonary cases of TB (217 of 3438 cases in 1999). Individuals infected with HIV account for about 50% of the total population with TB, and 70% of patients with AIDS and TB had extrapulmonary disease, accounting for an overall incidence of 2.3%.

International

GUTB in developing countries comprises approximately 15-20% of extrapulmonary cases of TB.

Mortality/Morbidity

  • Worldwide, 10 million people per year contract TB, and 3 million per year die from TB.

Race

  • The incidence is highest in persons emigrating from Mexico or from Asian, Middle Eastern, African, and South American countries.

Sex

  • The male-to-female ratio is 5:3.

Age

  • The most common age at presentation is 30-45 years.
  • Recently, the frequency of TB notably increased among persons aged 45-55 years and in those older than 70 years. This increase is primarily in developed countries.
  • Rare but documented cases in the 5- to 12-year-old age group have been reported.

Clinical

History

The presentation is often vague, and physicians must have a high degree of awareness to make the diagnosis.

  • Symptoms are generally chronic, intermittent, and nonspecific. Genitourinary tuberculosis (GUTB) often manifests as repeated urinary tract infections that do not respond to the usual antibiotics.
  • Persons with GUTB rarely display the typical symptoms of TB.
    • The most common symptoms of GUTB, in descending order of frequency, include increased frequency of urination (during the day initially but at night later in the disease course), dysuria, frank pain, suprapubic pain, blood or pus in the urine, and fever.
    • Urinary urgency is relatively uncommon unless the bladder is extensively involved.
    • Patients with GUTB may present with a painful testicular swelling, perianal sinus, or genital ulcer.
    • Asymptomatic patients are not uncommon. Unexplained infertility in both men and women is sometimes attributable to GUTB.3 Also, physicians have diagnosed endometrial TB while seeking the cause of congenital TB in the newborn.

Physical

  • While the hallmark of GUTB is sterile pyuria, up to 20% of patients develop a secondary coliform infection.
  • Gross hematuria occurs in 10% of cases and is usually total and painless. Microscopic hematuria is present in 50% of cases.
  • Tender testicular or epididymal swelling, beading of the spermatic cord, and epididymocutaneous sinus formations may develop.

Causes

  • The most common pathogen associated with TB is M tuberculosis.
  • Uncommonly implicated pathogens include the following:
    • Mycobacterium kansasii
    • Mycobacterium fortuitum
    • Mycobacterium bovis
    • Mycobacterium avium-intracellulare
    • Mycobacterium xenopi
    • Mycobacterium celatum

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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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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