Dr. Ajay Anand
Genitourinary Tuberculosis (GUTB) can present in various ways which include irritative voiding symptoms as increased frequency of micturition, constitutional symptoms, sterile pyuria, hematuria(blood in urine), renal insufficiency, calcification, renal mass, miscellaneous (UTI, fistulae, scrotal mass etc.).
GUTB often involves multiple sites in the genitourinary tract. Most common sites include bladder (thimble bladder), kidneys (Calcification, Hydronephrosis, and Non-Functioning Kidney), ureters (Vesicoureteric reflux, stricture, dilation). Some degree of renal insufficiency is seen in ¼ of patients with GUTB. Other sites affected by GUTB include prostate, epididymis, seminal vesicles and urethra. Complex lesions involving 3 or more sites can also be seen.
Figure – Tubercular bladder showing decreasing capacity and finally thimble bladder (very small capacity bladder)
Diagnostic Investigations for GUTB can be non-specific and specific.
Non-specific investigations include:-
Raised ESR
Anemia
Sterile acid pyuria (presence of pus cells in urine without any growth of organisms in urine culture)
Radiological Imaging
Cystoscopy
Specific investigations for GUTB comprise of:-
Urine culture for Mycobacterium tuberculosis (MTB)
Bladder biopsy
FNAC
Urine PCR for MTB
Guidelines for renal tuberculosis include:-
Stage 1 – Parenchymatous renal disease without radiological alterations
(Chemotherapy)
Stage 2 – Locally confined destruction
(Conservative)
Stage 3 – Destruction of at least two calices, alteration of at least two-thirds of the renal parenchyma or both / Nonfunctional kidney on radionuclide renal scans.
(Ablative)
Reconstructive procedures for kidney include pyeloplasty, ureterocalyceal anastomosis, and partial nephrectomy.
Management options for ureteral stenosis because of GUTB can be:-
Corticosteroids
Ureteric dilatation/Double J stenting
Ureteroscopy
Balloon dilatation/ Endoincision
Reconstructive surgery
Reconstructive ureteral procedures include reimplantation, ileal replacement, Boari flap, strictureplasty
Guidelines for bladder tuberculosis include:-
Stage 1: Bladder Capacity > 150 ml
* ATT/Hydrostatic distention
* Stage 2: Bladder Capacity 30-150 ml
* Augmentation
Stage 3: Bladder Capacity < 30 ml
* Orthotopic neobladder
* It is worth noting that renal failure is not a contraindication to reconstruction in GUTB. Reconstruction may delay the need for renal replacement therapy (RRT).
Incidence of GUTB has not changed considerably. Diagnosis is often delayed because of late presentation. High index of suspicion is necessary for early diagnosis. Combination of antitubercular drug therapy and judicious surgery achieves satisfactory results in majority of cases. Short course and DOTS chemotherapy is effective. Early cases may not require surgical intervention. Reconstructive surgery is possible in a large number of cases and Ablative surgery in selected cases. Renal failure can be avoided by timely intervention and effective management.
(The author is presently working as consultant urologist in Super specialty Hospital, GMC, and Jammu).
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