5.5. Urinary and genital tract tuberculosis

Urinary tuberculosis is due to spreading of MBT by hematogenic dissemination from the primary infection. Disease usually develops later, 5-15 years after the primary infection. Among the patients with active lung tuberculosis, mainly chronically disseminated, tuberculosis of urinary and genital tract is observed in 20-30% patients , in patients with bones and joints tuberculosis in 10-15 % of cases. More often, combination of the kidney tuberculosis is observed with exudative pleuritis and vertebral tuberculosis. There are indications that extrapulmonary tuberculosis, including genitourinary tuberculosis, more frequently caused at infection of humans of the bovine type MBT (30 %).

Classification of genitourinary tuberculosis.

1. Tuberculosis of the kidney.
   • 1.1. Clinical-rentgenological forms of tuberculosis of the kidney:
     • Tuberculosis of the kidney parenchyma.
     • Tuberculosis pappilitis.
     • Cavity formation.
     • Tubercular pyonephrosis.
     • Post – tubercular pyelonephritis.
   • 1.2. Epidemiological characteristic: MBT +, MBT-.
   • 1.3. A functional condition of a kidney: not broken; lowered; absent.
   • 1.4. The characteristic of tubercular process current: open process; not functional kidney; total scarring of the kidney; segmental scarring; calcification; corrugation.
   • 1.5. Complications: stones, tumour, pyelonephritis, amyloidosis etc.
   • 1.6. Localization (one – two kidney, single kidney; top, average, bottom segment; total damage of a kidney)
2. Tuberculosis of the ureter: ulcerous, scarry, periurethritis.
3. Tuberculosis of the urinary bladder: ulcerous, scarry.
4. Tuberculosis of the urethra ulcerous, scarry.
5. Tuberculosis of the prostate: caseous, focus, cavernous.
6. Tuberculosis of the testis and epididymis.

Tuberculosis of the kidney usually starts in the cortex of the kidney. As it spreads it destroys kidney tissue and forms a cavity. If inflammatory material obstructs the ureter, the backpressure may lead to widespread destruction of the kidney. It spreads also to the bladder (where ulcers may form), and then to prostate, seminal vesicles and epididymis.

The clinical features.

1. Frequent calls for urination.
2. Pain at urination.
3. Flank pain usually dull, sometimes acute (renal colic).
4. Blood in urine. If the disease is mainly in the kidney, with little bladder infection, blood in the urine may be the only symptom. A renal tumor is another possible cause. In some countries bilharziasis is a common cause.
5. Swelling of the epididymis (edema).
6. Pus in the urine. Culture for non-tubercular bacteria will be negative. If a patient has frequent calls for urination and feel pain during urination,has pus in the urine due a negative culture, tuberculosis is the most probable cause.
7. Lumbar abscess in advanced cases.

Diagnosis.

1. Urine: examination for pus and MBT. Smear examination can be misleading. Culture for MBT, is the reliable method but this procedure takes several weeks.
2. X-ray of kidney: the best method is the intravenous pyelogram.
3. X-ray chest: usually there is no abnormality.
4. Tuberculin test: not usually helpful.
5. Blood ureaif available will tell you whether the other kidney is functioning normally.

Management should be carried out under supervision in special institutions.

Tuberculosis of female genital tract.

Etiology. Genital tuberculosis in the female arises because of blood spread after primary infection.
Tuberculosis of female genital tract develops as Fallopian tubes tuberculosis of (salpingitis), tuberculosis of endometrium, ovaries, cervix and vagina.

The clinical features.

1. Infertility is the commonest reason for seeking help. The diagnosis is often made as a result of routine investigation for infertility. This should always include looking for signs of tuberculosis.
2. Lower abdominal or pelvic pain, malaise, disturbance of rhythm of menstruation (including amenorrhoea or bleeding), postmenopausal bleeding.
3. Progression to abscess formation of the fallopian tube. Sometimes with large abdominal masses.
4. Ectopic pregnancy.

Investigations.

1. Pelvic examination: masses, which may be small or large, may be felt over the fallopian tube area.
2. X-ray of genital tract.

Treatment.
Patients improve very well with chemotherapy. Large masses may just fade away. Though the disease is cured when chemotherapy is taken properly, obstruction in the fallopian tube may occur. So the patient may becomes infertile. Because the ovum may not be able to get through the narrowed tube ectopic pregnancy (in the tube, not the uterus) may occur later. Skilled surgical treatment of the blocked tube, can sometimes restore fertility.

Tuberculosis of male genital tract.

The prostate, seminal vesicles and epididymis are involved separately or together. Infection may come from the blood stream or from the kidney through the urinary tract.

Clinical features.
Most often the patient comes up complaining of something wrong with one of his ‘testes’. In fact this is usually the epididymis, not the testis itself. The epididymis enlarges and becomes hard and craggy, usually starting at its upper pole. It is usually only slightly tender. An acute non-tubercular epididymitis is usually very tender and painful. The lesion in the epididymis may break down into an abscess, involve the skin and result in a sinus. In 40 per cent of cases the patient will also have the symptoms and signs of urinary tuberculosis.

Investigations.

1. Urine for evidence of tuberculosis.
2. X-ray of kidney.
3. Tuberculin test is rarely helpful.

Diagnosis.

1. Acute epididymitis: fever, chills, acute pain locally.
2. Tumor: usually smooth and hard. The craggy mass of tuberculosis is usually typical.

Treatment.
Treatment with chemotherapy is normally completely successful if fully followed.