Genitourinary tuberculosis (GUTB) is defined as the infection of the urinary tract or genitalia most commonly caused by Mycobacterium tuberculosis. GUTB term was coined by Hans Wildbolz in 1937. GUTB comprises 20% of all extrapulmonary tuberculosis. Following pulmonary tuberculosis, 2% to 20% of individuals can develop genitourinary tuberculosis after 5 to 25 years.
An estimated 10 million people got infected with tuberculosis worldwide, out of which 1.5 million people died in 2018, according to the World Health Organization. About one-quarter of the world's population has latent TB. Tuberculosis is curable and preventable. Tuberculosis spreads from person to person through the air droplets.
Renal and Urologic Tuberculosis
Most commonly involves the urinary collecting system (renal pelvis, calyces, ureter, and bladder) and less commonly involves renal parenchyma.
Involves epididymis, testis, urethra, and prostate in the male and Fallopian tube, endometrium, and ovaries in the female.
The most common cause of GUTB is infection with M. tuberculosis. Other less common causes are infection with M. kansasii, M. fortuitum, M. bovis, M. avium-intracellulare (MAI), M. xenopi, and M. celatum.
Few cases of prostatic TB have been reported as a complication of Bacillus Calmette-Guerin (BCG) intravesical instillation therapy for the treatment of superficial bladder tumors. The most common organism isolated was M. bovis.
It is transmitted sexually as the bacteria clears from the body secretions like semen, urine, and genital secretions.
There are cases that reported male to female transmission of GUTB. Infection with Human immunodeficiency virus (HIV), prolonged use of steroids and other immunosuppressive therapies increases the risk of active TB and may indicate the risk of reactivation of dormant foci of infection. In sexually active young men, epididymal TB is most common.
Hematogenous spread of M. tuberculosis from the primary focus may result in TB prostatitis. 10% to 12% of men with primary foci of TB showed the presence of prostatic TB on autopsy in some research studies.
Risk Factors for GUTB
Genitourinary tuberculosis is the second most common form (20% to 40%) of extrapulmonary tuberculosis in developing and third most common in developed countries (2019). Extrapulmonary TB accounts for 15% of the total incidence of 7.0 million cases of TB as in 2018. It is estimated by the Health Organization (WHO) that approximately 9 million people get infected by TB every year, out of which 95% are from developing countries. And, 2 to 3 million people face mortality due to TB each year. Miliary TB is the main culprit form of TB, which leads to spreads the infection to the genital tract in 25% to 60% cases (2017).
It can affect people of all ages but is predominant in males in their fourth and fifth decades. The most common organ affected is the kidney, followed by epididymis, testis, bladder, ureter, and prostate gland. An increased incidence of GUTB is found in people suffering from immunodeficiency like HIV/AIDS.
In GUTB, the kidney is the organs that are most commonly (74%) affected, followed by other organs like testes, epididymis, bladder, ureter, and prostate glands. Isolated organs involvement may also be seen in 5% to 30% of cases.
Inhalation of aerosolized Mycobacterium tuberculosis bacteria results in tuberculosis. The active cases of TB may cough, sneeze, spit or expel while they spit, infectious aerosols of diameter 0.5 to 5 micrometers and can sneeze up to 40,000 droplets.
The mycobacteria replicate in alveolar macrophages and form a Ghon's focus, which remains latent in lung granulomas and lymph nodes.
Genitourinary tuberculosis results from the spread of mycobacterium at the time of primary pulmonary infection or reactivation of old pulmonary infection. Reactivation is common in people suffering from immunodeficiency or those taking steroids. In the case of HIV, the occurrence of GUTB is usually the manifestation of disseminated disease. The infection spreads hematogenously involving kidney forming granulomas (typically bilateral, cortical, and adjacent to the glomeruli), which may either heal forming fibrosis, remain inactive for decades, or break down and rupture into the tubular lumen with excretion of bacilli into the urinary tract. The environment of the medullary region of the kidney is hypertonic, and it impairs the phagocytic functions of the kidney. Descending infection involves ureter and bladder, leading to stricture and fibrosis with subsequent urinary tract obstruction and hydronephrosis. This may also make hypertension in patients with renal TB twice as common as in the general population.
Genital TB may result from hematogenous spread of infection from the kidney or lungs to the prostate and epididymis in the male and fallopian tubes in the female or directly from the local spread of infection through the urinary tract. The female genital tract is affected secondary to intercourse. Testicular involvement is usually due to the direct spread and leads to infertility due to bilateral vasal occlusion. Isolated epididymis involvement due to hematogenous spread is seen in children, while in the case of adults, the direct spread leads to epi-didymo orchitis development. Acute urethritis manifests as a bacterial (mycobacterial)discharge and often results in chronic stricture formation.
Secondary amyloidosis involving a kidney due to TB should be suspected if a patient with tuberculosis develops heavy proteinuria in the nephrotic range. Some pay present with glomerular ischemia and related findings.
Tuberculous interstitial nephritis seems to have idiopathic or immunological epiphenomenon pathophysiology may be indicated if the patient presents with active urine sediment with rapidly progressive renal failure, high leucocyte count in urine sediment, other primary foci of TB elsewhere in the body.
The histopathological finding may depend on the organs involved. The most common findings are:
The clinical presentation of the patient with genitourinary tuberculosis may vary from asymptomatic to non-specific symptoms related to the organ involved. The patient may be from an endemic region or have a prior history of pulmonary tuberculosis.
Patient with GUTB may present with the following symptoms:
Evaluation of the patient with genitourinary tuberculosis requires a detailed history, physical examination, and a combination of laboratory and radiographic studies. The workup plan and findings are explained below.
Common Side Effects of Antitubercular Drugs
Side Effect Management
Prognosis of genitourinary tuberculosis is excellent in young patients, early detected cases, a patient without comorbid conditions, and patients with good medication compliance. Patients with testicular and epididymal TB may require surgery. Early detection and treatment with antitubercular drugs reduce mortality by 2.2%.
Relapse can occur in cases of GUTB after initial urine sterilization. The relapse rate for GUTB without nephrectomy is 6%, while the relapse rate for GUTB with nephrectomy is less than 1%. Therefore, urine mycobacterial culture/PCR should be done every 6 to 12 months for 10 years after the completion of antituberculous therapy in a patient with GUTB without nephrectomy.
The main goal in the treatment of GUTB is early detection and treatment with antitubercular drugs. Patients should strictly follow medication adherence, along with a balanced diet. For non-compliant patients, directly observed therapy (DOT) should be used where patients are given medications under the direct care of health care workers.
Patients should be given appropriate knowledge about the side effects of antitubercular drugs and should return immediately if any side effects develop.
Mycobacteria usually clear approximately 4 weeks after appropriate medications are started. Inform patients that genitourinary tuberculosis (GUTB) may cause sterility in females, and consider genital TB in a male sex partner if the female has persistent, swollen, painful inguinal lymph nodes and no obvious source of infection.
Genitourinary tuberculosis is becoming a major public health problem in the developing world. Patients from the endemic region with clinical symptoms of GUTB should be tested without delay. Early detection, patient education, and long-term monitoring are key to eradicate GUTB. Managing cases of GUTB involves multiple interprofessional team approach that includes an infectious disease expert, a urologist, a gynecologist, radiologist, public health nurse or clinician, and a pharmacist. The role of clinicians is important in early detection and patient education about medication compliance and side effects. They also have an important role to play in patients who develop complications. The pharmacist has a key role to give medication under supervision to non-compliant patients.
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