Genitourinary Tuberculosis

CT REF: Grainger 4^th edition p. 1547/1490

See APPENDIX-63 for list of “Investigations of choice”

• Early renal TB-IVP is most sensitive imaging modality
• Advanced renal TB – CT > IVP > USG ( order of sensitivity)

The most sensitive imaging modality to detect early renal tuberculosis is intravenous urography.

Earliest urographic findings in renal TB is irregular calyceal contour which occur secondary to papillitis.

Characteristic urographic finding in renal TB is ‘phantom calyx’ which refers to an obstructed, nonfunctional calyx proximal to an infundibular stricture.

Early signs of ureteral TB includes dilation, ulceration and mucosal irregularity.

Ref: Diagnosis of Genitourinary Disease By Martin I. Resnick, 2nd Edition, Pages 289-90

The classic renal manifestation of TB is the presence of microscopic pyuria with a sterile urine culture or STERILE PYURIA.

Urine culture is the gold standard for diagnosis.

Ref: CMDT 2008 Edition, Page  815.

A i.e. Intravenous urography

Ans. is ‘b’ i.e. hematogenous 

• Genitourinary tuberculosis is always secondary to pulmonary infection, though in many cases, the primary focus has healed or is quiescent.
• Infection occurs via the hematogenous route.
• Most common genitourinary tuberculosis site is kidney

Ans. is ‘a’ i.e. Intravenous urography 

• In early renal tuberculosis, the only radiological abnormality may be irregularity or destruction of one or more papillae and the most sensitive modality to detect it is IUV as it can show detailed calyceal anatomy.

Advanced changes are:‑

1. Calcification – this may occur in any part of the genitourinary tract, most commonly in the kidney, next in the ureter.
2. Cavities
3. Fibrosis leading to obstruction

• fibrotic strictures of the pelvis or ureters lead to hydronephrosis
• strictures of the calyceal neck lead to hydro calyces (or hydrocalycosis)

      d) Bladder changes

• bladder wall may appear thickened and trabeculated and bladder may be small, contracted. – in later stages, VUR may develop
• Computed tomography shows advanced changes well, but is less sensitive in the early stages as it cannot show detailed calyceal anatomy.

Answer is ‘a’ i.e. Sterile pyuria is consistent finding

“Sterile pyuria is the rule” – CSDT 13/e p928

But about 15-20% of patients with tuberculosis have secondary pyogenic infection, obscuring the clue – sterile pyuria.

• The tubercle bacilli can be identified on AFB staining of 24 hr urine specimen or the first morning urine sample collected on 3 successive days.” AFB staining is positive in about 60% of cases – Smith’ Urology
• Most common site of genitourinary tuberculosis is – kidney
• Commonest cause of pyelonephritis is —> E. coli

Ans. is ‘c’ i.e., Sterile pyuria 

Ans. is ‘a’ i.e., Increased frequency 

Answer is ‘d’ i.e. Whitish efflux from the ureteric holes.

• Tubercle bacilli (M. tuberculosis) may invade one or more organs of the genitourinary tract and cause chronic granulomatous infection.
• Complications
• Scarring with stricture formation is one of the most typical lesions of tuberculosis and most commonly affects juxta vesical portion of the ureter.
• Inflammation of bladder mucosa in early stages → tubercle formation (seen endoscopically as white or yellow raised nodules surrounded by a halo of hyperemia) → Mural fibrosis (Thimble bladder)

Cystoscopy in Tuberculosis-

• The earliest sign is pallor around the ureteric orifice.
• Other features are tubercular ulcer and golf hole ureteric orifice.

Intravenous urography (IVU)- is the most useful test.

• Progression of the disease will cause the “moth-eaten” appearance of the calyces and lost calyx due to infundibular stenosis.
• Subsequently, tiny white translucent tubercles develop all over. Gradually these tubercles enlarge and may ulcerate (but do not cause bladder perforation) and these tubercles lend ‘cobblestone’ appearance on cystoscopy.

Ans is `a’ i.e. Kidney 

“The kidney and possibly the prostate are the primary sites of tuberculous infection in the genitourinary tract. All other genitourinary organs become involved by either ascent (prostate to bladder) or descent (kidney to bladder, prostate to epididymis).” – Smith’s Urology

Also Know:

Pyuria without bacteriuria (or sterile pyuria) is associated with genitourinary tuberculosis

Answer is B (Sterile Pyuria):

The most common clinical presentation of Urological Tuberculosis is Sterile Pyuria.

‘The most common clinical presentation of urological tuberculosis is sterile pyuria and painless hematuria – Textbook of Pulmonary and Critical Care Medicine

`Renal Tuberculosis is probably underdiagnosed because it is frequently asymptomatic Many cases are diagnosed as a result of routine detection of sterile pyuria. The development of symptoms reflects a more advanced stage of disease’ – Oxford Textbook of Medicine

Classical Renal Tuberculosis

Early Clinical Features:

• Symptoms of cystitis;
• Microscopic or macroscopic hematuria;
• Pyuria with negative bacterial culture (`sterile pyuria’);
• Constitutional symptoms.

Late Clinical Features:

• Nephrolithiasis and ureteral colic;
• Intractable frequency and urgency;
• Refractory hypertension;
• Renal insufficiency due to obstructive nephropathy.

Ans. A i.e. Renal pyramid

• Granulomas at renal pyramid –> enlarge (tubercular abscess) –> burst into PC system and pus discharge in urine (sterile pyuria) 

Ans. D: Tuberculosis

The most common finding in tuberculous cystitis is reduced bladder capacity.

Typically, tuberculous cystitis manifests as a shrunken bladder with wall thickening.

Occasionally, filling defects due to multiple granulomas may also be seen. In advanced disease, the bladder may be diminutive and irregular (thimble bladder).

Advanced bladder involvement may be complicated by vesicoureteral reflux due to fibrosis involving the ureteral orifice. Calcification of the bladder wall is rarely seen.

Ans. C^. tuberculosis of urinary bladder

TB of urinary system:

• Cystoscopy shows that early TB of the bladder commences around the ureteric orifice or trigone
• The earliest evidence is pallor of the mucosa due to submucus edema
• Subsequently tubercles may be seen as cobblestone appearance
• Long standing cases, there is much fibrosis and the capacity of the bladder is gretly reduced (thimble bladder)
• Rigid, wide mouthed ureter (golf hole ureter)

Ans. Intravenous urography

intravenous urography remains the primary modality used to image patients with renal, ureteric, and bladder tuberculosis, findings of urinary tuberculosis are also detectable using ultrasonography, computed tomography scanning, or magnetic resonance imaging

Ans. Intravenous urography