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Genitourinary Tuberculosis- Causes, Symptoms, and Management

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Genitourinary tuberculosis refers to infection of the genitalia or urinary tract by Mycobacterium tuberculosis. Read the below article to know more.

Written by

Dr. Kavya

Published At November 11, 2022
Reviewed AtDecember 15, 2022

Introduction

Tuberculosis is one of the major causes of mortality worldwide. Extrapulmonary manifestations account for 45 % of tuberculosis cases, out of which 40 % of cases affect the urogenital tract. Genitourinary tuberculosis refers to infection of the genitalia or urinary tract by Mycobacterium tuberculosis. Hans Wildbolz gave the term genitourinary tuberculosis in 1937.

Genitourinary tuberculosis affects the bladder, ureters, urethra, or kidneys. In males, it affects the scrotum penis, testes, vas deferens, or epididymis. In females, it affects the vagina, cervix, uterus, vulva, ovaries, or fallopian tubes. Urinary tract tuberculosis is more common than genital tuberculosis. Genitourinary tuberculosis, if left untreated, leads to complications such as renal failure, ureteric strictures, and infertility.

What Is the Etiology of Genitourinary Tuberculosis?

M.tuberculosis causes genitourinary tuberculosis along with other cases of tuberculosis. In rare cases, the disease is caused by the Mycobacterium tuberculosis complex, including Mycobacterium africanum, Mycobacterium pinnipedii, Mycobacterium bovis, Mycobacterium microti, tuberculosis vaccine Bacillus Calmette Guerin (BCG), and Mycobacterium caprae.

During the initial spread, bacteria transmit through the hematogenous spread, causing genitourinary tuberculosis. These bacteria remain in the genitourinary tract in a dormant stage and cause an active infection during immunosuppression. Lymphatic spread and sexual transmission are the other routes of spread. Reactivation is seen in cases of low body mass index, diabetes, concurrent cancers, advancing age, immunosuppression, and kidney failure. There is a 15 % rate of reactivation.

What Is the Epidemiology of Genitourinary Tuberculosis?

Around 20 % of pulmonary tuberculosis cases are genitourinary tuberculosis. Genitourinary tuberculosis is 10 % lesser in developed countries, and the incidence is 15 to 20 % in developing countries. However, developing countries report around 90 % of cases of genitourinary tuberculosis.

What Is the Pathogenesis of Genitourinary Tuberculosis?

The primary infection occurs through inhalation or ingestion of the Mycobacterium tuberculosis complex. The multiplication of the bacilli occurs in the gut or lungs, triggering an immune response. The immune response can lead to the elimination of the bacilli or may cause primary granuloma formation (Ghon's focus), which is the containment of the bacilli. The slow response of the infection leads to a primary infection of clinical genitourinary tuberculosis. Individuals with innate immunity are naturally resistant to genitourinary tuberculosis. Primary tuberculosis lesions in susceptible individuals are found in the tonsils, lungs, intestines, or other organs.

What Are the Symptoms and Clinical Presentation of Genitourinary Tuberculosis?

The clinical presentation depends on symptomatic to nonspecific symptoms based on the organ involved, high prevalence region, and history of pulmonary tuberculosis. The symptoms include night sweats, fever, anorexia, and weight loss.

  • Renal Tuberculosis: It is the most common among genitourinary tuberculosis. The diagnosis is usually delayed leading to complications such as end-stage kidney failure. End-stage kidney failure occurs due to extensive involvement of renal parenchyma and subsequent obstructive nephropathy.

  • Bladder Tuberculosis: This occurs secondary to renal tuberculosis as the bacilli enter the urine, which enters the urinary bladder. It is also caused by the retrograde spread of tuberculosis bacilli from genital tuberculosis through lymphatic or hematogenous seeding. Individuals with bladder tuberculosis have recurrent urinary tract infections that do not respond to antibiotic therapy. In bladder tuberculosis, inflammation and stricture formation lead to hydroureteronephrosis, causing kidney failure.

  • Ureteric Tuberculosis: The most commonly affected site is the lower third of the ureters, followed by the ureteropelvic junction. Ureteric tuberculosis is often seen in association with renal tuberculosis. Signs and symptoms include hematuria, abdominal pain, inflammation, and stricture formation leading to hydroureteronephrosis, causing kidney failure.

  • Prostatic Tuberculosis: Hematogenous spread from the primary focus causes prostatic tuberculosis. Individuals are asymptomatic during the initial phase of infection. However, symptoms such as dysuria, pollakiuria, acute or chronic pelvic pain, sexual dysfunction, or nocturia appear in the later stages of prostatic tuberculosis.

  • Scrotal Tuberculosis: There is unilateral or bilateral involvement in tuberculosis epididymo-orchitis with signs of painful or painless scrotal swellings. There is the destruction of vas deferens and epididymis causing oligospermia or azoospermia.

  • Penile Tuberculosis: The signs and symptoms include swellings (multiple or single) or ulcers on the penis, which may or may not be painful.

  • Ovarian and Fallopian Tube Tuberculosis: Individuals may present with abdominal pain. Most of the cases are asymptomatic and diagnosed while seeking infertility treatment.

  • Uterine Tuberculosis: Individuals experience irregular menstrual bleeding, vaginal discharge, abdominal masses, abdominal pain, and dysmenorrhea.

  • Tuberculosis of the Vulva, Vagina, and Cervix: Symptoms depend on the site of the lesion. They include post-coital bleeding, dyspareunia, pelvic pain, and infertility.

What Is the Differential Diagnosis for Genitourinary Tuberculosis?

The differential diagnosis for genitourinary tuberculosis includes:

  • Urethritis.

  • Epidimytis.

  • Urinary tract infections.

  • Prostatitis.

  • Malignancy (testicular tumor, renal cell carcinoma).

  • Chronic pyelonephritis.

  • Bacillus calamette gurein cystitis.

  • Hydrocele.

  • Spermatocele.

  • Urethral stricture.

  • Infertility.

What Are the Treatment Options for Genitourinary Tuberculosis?

Medical Management:

Treatment for genitourinary tuberculosis is similar to pulmonary tuberculosis. It involves a four-drug regimen for six months.

For the first two months:

  1. Rifampicin.

  2. Isoniazid.

  3. Ethambutol.

  4. Pyrazinamide.

For four months:

  1. Isoniazid.

  2. Rifampicin.

Individuals with HIV co-infection, bone infiltration, and kidney abscess require prolonged treatment. For example, multidrug-resistant tuberculosis is treated with Bedaquiline, fluoroquinolones, Delaminid, and aminoglycosides for 18 to 24 months.

Surgical Management:

  • Stenting or percutaneous nephrostomy is the treatment of choice for genitourinary tuberculosis complications such as hydronephrosis and ureteral stricture.

  • Nephrectomy is the treatment of choice for individuals with co-existing renal cell carcinoma, non-functioning kidneys, and extensive kidney disease.

Drug Toxicity and Its Management:

The common side effects include:

  1. Ethambutol: Optic neuropathy.

  2. Pyrazinamide: Painful joints caused due to hyperuricemia.

  3. Rifampicin: Arthralgias and dark-colored urine (orange or red).

  4. Isoniazid: Toxic neuropathy, headache, and hepatitis.

Side Effect Management:

Isoniazid, Rifampicin, and Pyrazinamide cause hepatotoxicity. A liver function test is suggested every two months. If the liver function shows abnormal results, the offending drugs are stopped immediately. Isoniazid and Ethambutol cause peripheral neuropathy, which Pyridoxine can treat. Ethambutol causes optic atrophy. A regular eye examination is advised for individuals on Ethambutol.

What Are the Complications of Genitourinary Tuberculosis?

The complications involve:

  • Vaginal tuberculosis ulcers.

  • Tuberculous interstitial nephritis.

  • Reduced bladder capacity.

  • Prostatic abscess.

  • Infertility.

  • Chronic renal failure.

  • Renal hypertension.

  • Fistula.

  • Strictures.

  • Superadded infections.

Conclusion

Genitourinary tuberculosis is a significant public health problem. It is an infection of the genitalia or urinary tract by Mycobacterium tuberculosis. Early diagnosis, patient education, and appropriate and prompt antitubercular treatment are essential for its eradication.

Frequently Asked Questions

1.

What Is Mycobacterium Tuberculosis Infection?

Mycobacterium tuberculosis is a bacteria that causes a serious infection, tuberculosis or TB. Tuberculosis is a chronic infectious disease that can be life-threatening if not treated. The bacteria most commonly spread through droplets when a person sneezes or coughs. The bacteria most commonly attacks the lungs but can spread to or attack other body parts such as the spine, kidney, genitourinary tract, and brain.

2.

How Does Mycobacterium Tuberculosis Spread?

Mycobacterium tuberculosis is a bacteria that can spread from one person to another through air or droplet spread. The bacteria are expelled into the air when an infected person speaks, coughs, or sings. Those who breathe in these bacteria can become infected with Mycobacterium tuberculosis and develop tuberculosis.

3.

Which Is the Most Common Site of Infection Caused by Mycobacterium Tuberculosis?

The most common site of active tuberculosis infection is the lungs, especially the upper part of the lungs. As a result, these are usually spread by the droplets as the infected person coughs or speaks. The tuberculosis bacteria multiply and spread through the bloodstream and the lymphatic system to other parts of the lungs and body sites such as the bone, kidneys, genitourinary system, and the brain.

4.

Can Tuberculosis Affect the Genitourinary System?

Yes, tuberculosis can affect the genitourinary tract (the genital organs and the urinary tract). The tuberculosis bacteria usually spread through the blood from the primary site (usually the lungs) and lodge in the urinary tract or the genital organs, causing an active tuberculosis disease involving the kidneys, ureter, bladder, and genital organs. In rare scenarios, the primary site of infection can be the genitourinary tract. The symptoms of genitourinary tuberculosis usually resemble urinary tract infections, leading to delayed diagnosis.

5.

Is Genitourinary Tuberculosis Curable?

Yes, genitourinary tuberculosis is treatable. It is usually treated with the drug regimen used to treat lung tuberculosis. Some patients may require longer treatment or other medications to cure tuberculosis. Early stenting and percutaneous nephrostomy may be necessary in complicated cases with ureteric strictures and hydronephrosis.

6.

How Do Doctors Check for Genitourinary Tuberculosis?

Genitourinary tuberculosis is usually diagnosed after months to years as the symptoms resemble common urinary tract infections. A detailed history, examination, and investigations (radiographic and laboratory tests) are essential to come to a diagnosis. The gold-standard method to diagnose genitourinary tuberculosis is to demonstrate the presence of the TB bacteria in the patient's samples.

7.

How Is Genitourinary Tuberculosis Treated?

Genitourinary tuberculosis is treated similarly to lung tuberculosis. The drugs Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, and Isoniazid are used to treat tuberculosis. The drug regimen is usually given for six months. It may be administered for a longer duration in some patients with co-morbidities. Surgical management is necessary for patients with ureteric stricture and hydronephrosis (unilateral or bilateral). The surgical interventions include percutaneous nephrostomy and early ureteral stenting.

8.

What Is the Life Expectancy of Patients With Genitourinary Tuberculosis?

Genitourinary tuberculosis is a treatable infection that rarely is life-threatening when diagnosed early. However, in case of delayed diagnosis, immediate stenting, an anti-tuberculosis drug regimen, and careful monitoring of the patient’s response is essential to determine the prognosis. In case of complications such as renal and ureteric strictures and kidney shrinkage, appropriate management can help the patient live a long life.

9.

Who Is Most at Risk for Genitourinary Tuberculosis?

Patients with uncontrolled active tuberculosis of the lung, without treatment initiation, and immunocompromised patients with lung tuberculosis, are at the highest risk of spread of the disease to the genitourinary tract. In addition, the following can increase the reactivation of the latent tuberculosis infection:
 - Diabetes.
 - Advanced age. 
 - Low body mass index (BMI).
 - Cancers.
 - Immunosuppressive state such as HIV infection.
 - Kidney failure.

10.

How Does the Tuberculosis Bacteria Damage the Genitourinary Tract?

In a patient with active tuberculosis, the bacteria multiply, spread through the blood, and attack the lungs, lymph nodes, genitourinary tract, brain, skin, bones, and spine. Thus, weakening multiple organs of the body. In the genitourinary tract, these can cause fibrosis, which leads to loss of kidney function, bladder and kidney shrinkage, and ureteric strictures that can lead to reduced quality of life, chronic kidney disease, and kidney failure.
Source Article IclonSourcesSource Article Arrow
Dr. Samer Sameer Juma Ali Altawil
Dr. Samer Sameer Juma Ali Altawil

Urology

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