Treatment of TB requires administration of several drugs for at least 6–12 months, and in special cases – to 18–24 months leading to high costs, side-effects and the emergence of drug-resistant strains associated with patient non-compliance.

The management of the patients with TB is challenging in several respects:

We have a number of very strong anti-TB drugs – but results are often poor. Why? Particularly, because of peculiarities of TB infection determine a special approach to the chemotherapy of urogenital tuberculosis.

First, we cannot treat “UGTB” – we have to define special therapy for each form of UGTB, alike for urinary tract infections (UTI), which combine diseases from urethritis and cystitis till urosepsis – and each form should be treated differently.

Second, the beginning of the ChT immediately compels Mtb to reduce its replication, and slow- or non-replicating bacteria in hypoxic granulomas are phenotypically tolerant towards antibiotics (Raffetseder et al. 2014). Even small doses of anti-TB drugs, including amicacin and fluoroquinolones, which are widely used in general urology, make living conditions unpleasant for Mtb and its transfers into dormant form – insensitive to antimycobacterials. It is one more reason for the long time anti-TB treatment – we try to catch the moment of the replication of mycobacteria, when they are sensible to the action of anti-TB drugs. The problem is – we cannot predict this moment. It may be in one day, in one week, in one month and even in one year.

There are two exits from this problem:

Third, drugs poor penetrate fibrous wall of a cavern and its concentration in caseous mass is low, insufficient for destroying of Mtb. To overcome this obstacle we can via address delivery of anti-TB drugs.

And finally, healing of TB is occurs via forming fibrosis. It is a good outcome for pulmonary TB – but not for UGTB, where we receive “desirable fibrosis in undesirable place”. Sequels of UGTB, such as stricture of ureter or urethra, shrinkage of bladder etc. may be more serious than proper TB inflammation. Inappropriate management of UGTB patient results in loss of organ, even if TB is cured. The example of post-tuberculous hydronephrosis due to post-tuberculosis stricture of ureter is shown on Fig. 5.1.

Regimen of the ChT for UGTB strongly depends on the form of the disease; nevertheless there are two very important points: (1) Choice of optimal drugs; and (2) Choice of optimal administration of the drugs.

Not all anti-TB drugs are suitable for all forms of UGTB. Standard scheme recommended by WHO (isoniazid + rifampicin + pyrazinamide + streptomycin/ethambutol) is good for simple non-complicated cases only. For example, kidney TB 1 stage, when there are some granulomas without destruction of parenchyma. Streptomycin is not optimal for complicated forms of UGTB, when urinary tract is involved, as it lead to redundant fibrosis and forming of strictures. Ethambutol is not optimal in kidney TB 2–4 stages, when hematuria is common symptom, as it provokes hematuria. As well ethambutol poor penetrates prostatic tissue and cannot provide sufficient concentration in the site of inflammation in patients with prostate TB.

Thus, streptomycin and kanamycin are not recommended for UGTB; among fluoroquinolones ofloxacin or levofloxacin only are suitable for UGTB therapy. Moxifloxacin and sparfloxacin are respiratory fluoroquinolones, so they are good for PTB, but not optimal for UGTB.

PAS is highly recommended for UGTB with involvement of pelvic organs, amoxicillin/clavulonat should be prescribed together with meropenem or imipenem, as they potentiate anti-TB effect. Cycloserin is highly recommended, if the patient has comorbidity of UGTB and non-specific UTI. Patient with comorbidity of UGTB and HIV and receiving anti-retrovirus therapy should be treated with rifabutin instead of rifampicin. Rifampicin and streptomycin are contraindicated for patients after organ transplantation. Amikacin as well as streptomycin and kanamycin are contraindicated for UTTB patients.

Optimal anti-TB drugs for UGTB are:

Of course, we can use any other anti-TB drug – but with precaution. There is no any data on using new anti-TB drugs bedaquilin and perhlozon in UGTB patients, so we cannot recommend its yet.

Simplest and cheapest way of administration of anti-TB drugs is intake per os. It is suitable when you have many patients and a few personnel and finances. But it is not optimal. UGTB is local form of TB, and address delivery of drugs is preferable. It may be achieved by using liposomal forms, by lymphotropic, including rectal, or intravenous administration.

Again, the main principles of anti-TB chemotherapy are: continuity, controllability, succession of the treatment. The patient has to take at least four anti-TB drugs simultaneously during at least 2 months (intensive phase) followed by phase continuation for at least 6 months with at least two anti-TB drugs, depending on the form of UGTB. Of course compliance is low and some patients try to avoid receiving these drugs. When they receive pills – nurse cannot be exact sure they swallow its. When she introduce drugs intramuscular, intravenous, or rectal – she fully control the therapy. Neglecting of these principles leads to development of drug-resistance of Mtb and relapse of TB.

The etiotropic therapy for UGTB differs from the therapy of PTB. Depending on the form of UGTB 5 regimes of chemotherapy are defined:

Every regime includes the phase of intensive therapy followed by the continuation phase (see Table 5.1).