1、Genitourinary Tuberculosis,TB - introduction,A disease observed in humans for over 7000 years ( Myers, 1952 ) A common disease in Egypt around 1000 BC ( Morse et al, 1964 ),TB - introduction,Almost one fourth of the deaths in England in 1700s were caused by TB( Colby, 1954 )Globally, TB is the most
2、common opportunistic infection in AIDS patients ( Pape et al, 1983 ; WHO, 1997 ; Perlman et al, 1999 ).,From TB to GxUinary TB,Genitourinary TB is “metastatic from” rather than “secondary to ” primary lung TB infection. ( Medlar, 1926 )Primary site of bloodstream dissemination Urinary system: kidney
3、 Genital system: epididymis,Genitourinary TB - introduction,10 million/y new TB cases 10% of the new cases are extrapulmonary TB, 20% of these are Gxurinary TB 200,000 new cases of Gxurinary TB Serious urological problem Nonspecific irritative voiding symptoms, insidious onset diagnosed late remains
4、 a major health problem in developing countries,(Scand J Infect Dis. 2002) (Renal Failure. 2005),Development of Gxuinary TB,The initial infection occurs in the renal cortex where the bacilli can remain dormant ( lying asleep ) within granulomas for decades. This dormant infection then becomes activa
5、ted due to failure of the local immune response.,Development of Gxuinary TB,The primary site for infection of the genital tract is often the epididymis in men and the fallopian tubes in women, also by hematogenous spread. Similar to urinary disease, the infection then spreads to adjacent organs by d
6、irect extension.,Age and sex distributions,Among 174 TB predominantly male 102 male patients (58.7%) and 72 females (41.3%) age distribution 019 y, 3.5%; 2039 y, 47.7%; 40 59 y, 33.3%; 50 y, 15.5%,(Scand J Infect Dis. 2002),Symptoms,Most often: frequent painless micturition. Urgency is uncommon. The
7、 urine is classically characterized by a sterile pyuria; however, up to 20% of patients do not have any leukocytes in the urine ( Gow, 1976 ). Commonly, the symptoms are intermittent.,Symptoms,Overt hematuria is present in only 10% of patients, but microscopic hematuria is present in up to 50%. Rena
8、l or suprapubic pain is a rare presenting symptom and usually means extensive involvement of the kidney and bladder. Ureteral colic is uncommon and occurs only if a small flake of calcification or a clot passes down the ureter.,Symptoms,(Scand J Infect Dis. 2002),Pollakiuria: Rarely used term for ex
9、traordinary urinary frequency. Origin: G. Pollakis, often, + ouron, urine,Haemoptysis: The expectoration of blood or of blood stained sputum. Origin: Gr. Ptyein = to spit,Physical findings,CVA tenderness m/c less common Fever (usually low-grade) palpable kidney Hypertension tenderness in the suprapu
10、bic region thickened epididymis urethral stricture scrotal fistula Scoliosis vesicovaginal fistula,(Scand J Infect Dis. 2002),CVA: costovertebral angle,scoliosis: an abnormal lateral curve to the vertebral column,Laboratory findings,Urine AFB (+) : 127 (72.9%) concentrated sediments from 24-h urine
11、specimens retrieved on 3 consecutive days Urine culture (+) : 110 (63.2%) Repeated culture from first voided (morning) urine sample Acid urinary pH : 100 (57.4%) Secondary infection with E. coli : 31%Urine AFB (-) & Urine culture (-) : 42 (24.1%) 34 had been strongly suspected as having tuberculosis
12、 from pathologic examinations of tissue specimens after surgical intervention or endoscopic bladder biopsies,(Scand J Infect Dis. 2002),AFB: acid fast bacilli,(Renal Failure. 2005),Sedimentiation: the phenomenon of sediment or gravel accumulating Cavernous: Anatomy Filled with cavities or hollow are
13、as,Ultrasonographic finding,only 5% of patients who have active tuberculosis will have cavitary lesions in the urinary tract Early findings by intravenous urography. cavities appear as small irregularities of the minor calyces - moth-eaten. extends from the calyces into the underlying renal parenchy
14、ma Calcifications ureteral strictures rigid, irregular, pipestem ureter Granulomatous mass lesions in the renal parenchyma can be seen as masses of mixed echogenicity Mucosal thickening of the renal pelvis and ureter and hydronephrosis bladder changes such as mucosal thickening and reduced capacity,
15、A.Hypoechoic areas (arrows) in the renal cortex suggestive of lobar caseation B.C. with dense peripheral calcification,Caseation: necrosis with conversion of damaged tissue into a soft cheesy substance From Latin c seus, cheese.,CT finding,Retrograde ureteropyelogram,A, Extensive tuberculosis of the
16、 kidney and ureter with calcification and stricture formation. B, Acutely inflamed ureteric orifice. C, Tuberculous bullous granulations. D, Acute tuberculous ulcer. E, Tuberculous golf-hole ureter. F, Tuberculous golf-hole ureter, severely withdrawn. G, Healed tuberculous lesion. H, Acute tuberculo
17、us cystitis with ulceration.,Pathologic Evaluation,Treatment,All patients were given triple-drug chemotherapy rifampicin, isoniazid and ethambutol Rifampicin and isoniazid were given for 12 months ethambutol was stopped after 3 months 30 (17.5%) additional surgical interventions Nephrectomy m/c,(Sca
18、nd J Infect Dis. 2002),Follow-up,Average interval between the original treatment and relapse was 5.3 y (mean follow-up period was 10 y) should be followed up for 5 y. After 12 months of anti-tuberculosis treatment, the relapse rate was 19% therapy should be continued for at least 12 months,Recurrent
19、 cystitis is also a warning sign of urinary TB. If the cause is not confirmed and the symptoms persist or recur, investigation should be conducted repeatedly, because M. tuberculosis may be difficult to isolate from the urine.,Keep in mind,Keep in mind,Urologists should always consider the diagnosis of genitourinary TB in a patient presenting with vague, longstanding urinary symptoms for which there is no obvious cause ( Garcia-Rodriguez et al, 1994 ). The symptoms and signs of genitourinary TB vary in both intensity and duration.,Thanks,
