Genitourinary Tuberculosis- Causes, Symptoms, and Management

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.