328

Practical Urology: EssEntial PrinciPlEs and PracticE

intervention to promote complete clearance of

Clinical Manifestations

all infection. Open or percutaneous drainage of

abscesses, nephrectomy, adrenalectomy, tran-

The clinical manifestations of genitourinary TB

surethral resection of the prostate (TURP),

are a vast and vague collection of symptoms

orchiectomy and biopsies for tissue diagnosis

that depend on the organ of involvement. TB

are a few of the surgical interventions that might

can involve nearly all urologic organs as they

adjunct pharmacotherapy. In addition, patients

course from the mid-abdomen to the pelvis and

with disseminated infections are often immu-

perineum (Table 24.3). Though it is often

nocompromised and critically ill with a multi-

asymptomatic,it can present with constitutional

tude of comorbid conditions, this can further

symptoms (37%), hematuria (51%), irritative

complicate management.5,10

voiding symptoms (76%), and recurrent urinary

tract infections (22%). Pulmonary manifesta-

Tuberculosis

tions may be absent in as many as 20–30% of

patients.33

Genitourinary TB can spread hematogenously

The incidence of Tuberculosis (TB) has been on

to the adrenal glands with abscess and necrosis

the rise since the introduction of HIV in the

of the adrenals results in the clinical manifesta-

1980s and persistence of other immunocompro-

tions of Addison’s disease. Corticotrophin stim-

mised conditions, combined with increased

ulation testing will confirm the diagnosis with a

immigration and the upsurge of drug resistant

low response. In addition, bilateral adrenal cal-

strains of TB.30

cifications may be present by radiographic

Tuberculosis typically manifests as pulmo-

analysis.30

nary conditions, but can present in a multi-

Renal tuberculosis has also been shown to

tude of ways at a variety of sites, giving it the

result from direct metastatic hematologic seed-

title “The Great Mimic.” Genitourinary TB

ing of M. tuberculosis to the glomeruli.An acute,

makes up nearly 30% of all the extrapulmo-

then chronic inflammatory reaction occurs

nary sites of manifestation.31 The great variety

resulting in granuloma formation and caseaous

of clinical symptoms, combined with the prev-

necrosis. This inflammation will spread to the

alence of immunocompromised states requires

renal medulla and papilla with resultant necro-

a thorough knowledge of the possible presen-

sis. Papillary sloughing can result in intermit-

tations of TB, as well as the presence of a high

tent renal colic. As extension continues in the

degree of suspicion, and a low threshold to

renal pelvis, ulceration and calcification with

culture.

stone formation occur. Calyceal infundibular

Tuberculosis is caused by the aerobic organ-

stenosis can occur in multiple calyces with resul-

ism Mycobacterium tuberculosis. This slow

tant obstruction.34 Renal and calyceal abscess

growing organism can exist within the host

can develop (Fig. 24.2).35 Overall, renal function

phagocyte, lying indolent for many years before

can be compromised by a combination of

reactivating during a time of host immunocom-

destruction of renal parenchyma and obstruc-

promise. TB is spread by human droplet expo-

tive uropathy, resulting in elevated creatinine

sure and Primary TB may present simply as a

and renal failure in over 40% of patients.30

self-limited pneumonia-like illness. As the

Classic CT finding reveal renal punctuate or

inflammatory process subsides and healing

curvilinear calcifications, with concurrent

begins, fibrosis and calcification may result in

deformation and blunting of calyces.36

scar formation or strictures.10

Manifestations of TB in the ureters include

Populations at increased risk of manifesting

inflammation and fibrosis with resultant stric-

genitourinary TB include patients with any con-

ture disease. Continuous or segmental strictures

dition that creates an immunosuppressed state.

may be seen anywhere along the course of the

This includes patients with chronic renal failure,

ureter. Chronic inflammation at the ureteral ori-

diabetics, HIV+ patients, particularly those with

fices can result in a “golf hole” appearance, and

low CD4 counts, organ transplantation recipi-

resultant ureterocoele.10

ents receiving immunosuppressive therapies

Bladder involvement is typically a sequela of

and IV drug abusers.32 Recent immigrants and

renal tuberculosis. It can be asymptomatic, but

health care workers are also at risk.

more commonly presents with irritative voiding

Genitourinary tuberculosis can present as

Ultrasound can be helpful when elucidating

male infertility with obstructive azoospermia

abnormalities in the prostate, seminal vesicles,

from fibrosis and scarring of the epididymal

orscrotum.Findingsofcalcifications,hypoechoic

and ejaculatory ducts, or leukocytospermia.

irregular testicular masses, irregular epididy-

Physical examination will reveal hardened pros-

mal-testicular margins, hyperechogenicity of

tatic nodules, epididymal dilation, and thick-

epididymis, and atrophy or swelling of the semi-

ened seminal vesicles.

nal vesicles are suggestive of TB.42

The intravesical administration of the inac-

Recently, molecular techniques have been

tive bacilli Calmette-Guerin tuberculosis strain

making advances in rapid, specific diagnosis of

for superficial bladder cancer is most commonly

tuberculosis. Polymerase chain reaction has a

associated with local, mild side effects. Systemic

demonstrated 94% sensitivity in known TB pos-

sepsis is a rare complication of this common

itive patients.32

treatment, characterized by fevers, rigors,

hypotension, mental status changes, coagulopa-

thy,and acute lung injury.This serious side effect

has significant morbidity and mortality and

Treatment

requires aggressive antituberculin therapy.40

Antituberculosis chemotherapy is the mainstay

of all genitourinary tuberculosis (Table 24.2).

Diagnosis

Recently, an increase in resistant strains of TB, as

well as the long duration of chemotherapeutic

While TB’s manifestations are often vague and

regimens necessitate aggressive treatment and

nonspecific, the clinical genitourinary clinical

active follow-up with patient reinforcement and

manifestations will be resistant to standard meth-

counseling and often directly observed adminis-

ods of treatment and antimicrobial therapies.

tration.Initially,the patient is treated for 2 months

Diagnosis often starts with a cutaneous puri-

with a four drug combination of isoniazid,pyrazi-

fied protein derivative (PPD) skin test, with the

namide, rifampin, and ethambutol. At the confir-

injection of purified protein derivative. Results

mation of culture sensitive lack of resistance,

must be interpreted cautiously, as a false-positive

ethambutol may be discontinued. Liver enzymes

is seen in patients previously vaccinated against

must be closely monitored during therapy.

TB, and false-negatives can be seen with severely

Patients must be advised to refrain from unpro-

blunted immune responses.30

tected sexual activity for 4–6 weeks during initial

The diagnosis of TB can often be made from

treatment, due to the risks of sexual transmission

urine analysis and culture. Initially, pyuria with

of tuberculosis.Completion therapy must be con-

acidic urine and the absence of typical patho-

tinued for a total of 6–9 months.33

gens with urine culture should prompt special

In addition to chemotherapeutic regimens,

cultures for tuberculosis. These take as long as 8

aggressive drainage of all abscesses, debride-

weeks in a specific culture medium.32 In addi-

ment of infected tissue, and diversion in the

tion, drained abscess or tissue cultures may

presence of urinary obstruction, many of the

reveal tuberculosis.

long-term sequelae of genitourinary TB require

Histologic

specimens

may retrospectively

definitive surgical management. Ureteral stric-

cinch the diagnosis with the presence of acid-

ture might require reimplantation, boari flap,

fast bacilli as well as caseating granulomas or

or ileal interposition to relieve obstruction.

Langhans giant cells.30

Bladder contractures can be augmented. Urethral

Radiographic findings, while generally non-

strictures may be treated by endoscopic incision

specific, can suggest the diagnosis of genitouri-

or urethroplasty. Seminal vesicle tuberculosis

nary TB. CT remains the most accurate method

may require abscess drainage, while scrotal

of delineating gross abnormalities commonly

tuberculosis can necessitate epididymectomy or

seen with tuberculosis.36 Classically, CT will

orchiectomy.33 Infertility due to obstruction

reveal the presence of renal or caliceal abscesses,

might be relieved by microsurgical vasovasos-

blunted calyces, infundibular stenosis, renal

tomy or vasoepididymostomy.In advanced cases,

curvilinear or punctate calcifications, ureteral

testicular biopsy with sperm extraction and

stricture, and calcifications or abscesses of the

intracytoplasmic sperm injection (ICSI) can

vas deferens,

prostate,

or seminal vesicles.41

restore fertile potential.43