Genito urinary TB

Genito urinary TB

GENITO URINARY TUBERCULOSIS 


INCIDENCE:
15 To 20% of Tuberculosis patients have Genito Urinary TB as the prime focus. Tuberculosis is the most common opportunistic infection in AIDS patients.

DEVELOPMENT OF DISEASE:
All Tuberculous infections are acquired infections from the inhalation of droplet nuclei which reach the pulmonary alveoli.

Upto 50% of the active disease occurs within two years of infection.

The development of the disease depends on interactions between the pathogen and immune response of the patients. The organism evokes a humoral and cellular response and the latter response determines the outcome of the infections.

a) Renal TB is caused by the activation of a previous blood – borne metsetatic renal infection from the lungs.

The organisms settle near the blood vessels close to the glomeruli and a caseating granuloma develops consisting of langhans
giant cells surrounded by lymphocytes and fibro blasts.

The healing process results in fibrosis and the classical calcified lesion is seen. Fibrous tissue can cause a stricture in the
calyceal stem and PUJ.

b) Tuberculosis of the ureter and bladder are always secondary to renal infections. The most common site is the uretero-vesical
junction and rarely the whole ureter is involved.

c) Bladder lesionstart around the ureteric orifice with inflamed odematous mucosa with occasional TB ulcer. Fibrosis
around the ureteric orifice leads to stricture.

d) TB of the prostrate, testis and epidydimis are spread by blood-borne infections. The globus minor of the epidydimis which is highly vascular is the most commonly affected site and from here the infection spreads to the testis. TB of the prostrate, urethra and penis are rare.

DIAGNOSIS:
1) High suspicion of the disease in cases of vague long standing unexplained urinary symptoms is needed.
2) Common symptoms are frequent, painless urination mainly during night to start with later on during the day time also.
3) The urine is usually sterile but it is loaded with pus cells. Microscopic hematuria is seen in 50% of the cases.
4)  Recurrent cystitis may come.

INVESTIGATIONS:
1) Urine examination shows sterile pyuria. Early morning urine specimen is sent for special culture. 
2) X- RAYS: Plain x-ray KUBU may show calcified lesions in the renal or urteric region.
3)             IVU: shows   A. Calyceal diverticulum
B. Infundibular stenosis
C. Cut-off calyces
D. PUJ stricture
E. Ureteric stricture
F. Small capacity bladder with evidence of cystitis

 4) CYSTOSCOPY: 
Cystoscopy is carried out to assess the bladder mucosa, bladder capacity and biopsy of any TB lesion which will confirm the
diagnosis.

MEDICAL MANAGEMENT: PRIMARY DRUGS USED:

1. PAS
2. INH
3. RIFAMPICIN
4. ETHAMBUTAL

SURGICAL MANAGEMENT: The indications for nephrectomy are:

1. Non-functioning kidney with or without calcifications.
2. Extensive disease involving the whole kidney with PUJ obstruction and occasional hypertension.

Partial neprectomy is indicated if there is a polar lesion.
Epididymal lesions not responding to chemotherapy are excised,
Testicular TB rarely needs orchidectomy

RECONSTRUCTIVE SURGERY:
Ureteric stricture can be managed with either dilations or D.J.stenting or occasionally with psoas hitch or BOARI flap from the bladder. Rarely whole ureter may require replacement with small bowel. Contracted bladder needs augmentation cystoplasty using either small bowel or caecum.


Dr. R. Jayachandran
Consultant Urologist
Email : [email protected]

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