Urogenital Tuberculosis – Definition and Classification




(1)
Research TB Institute, Novosibirsk Medical University, Novosibirsk, Russia

 



Abstract

To improve the approach to diagnose and management of urogenital tuberculosis (UGTB) we need clear and unique classification. UGTB remains an important problem, especially in developing countries, it is often overlooked disease. As any other infections, UGTB should be cured by antibacterial therapy, but because of late diagnosis it may often require surgery.

Scientific literature dedicated to this problem was critically analyzed and juxtaposed with own more than 30-years experience in TB-urology.

The conception, terms, definition were consolidated in one system; classification stage by stage as well as complication are presented. Classification of any disease includes dispersion on forms and stages and exact definition for each stage. Clinical features and symptoms significantly varied between different forms and stages of UGTB. The simple diagnostic algorithm was done.

UGTB is multivariant disease, and standard unified approach to it is impossible. Clear definition as well as unique classification is necessary for real estimation of epidemiology and optimization therapy. Join term “UGTB” has insufficient information in order to estimate therapy, surgery and prognosis – as well as to evaluate the epidemiology.


Keywords
Urogenital tuberculosisClassificationKidney tuberculosisBladder tuberculosisMale genital tuberculosis



3.1 Introduction


In 2012, the largest number of new TB cases occurred in Asia, accounting for 60 % of new cases globally (WHO 2014). UGTB is frequent form of TB, but it is a mostly overlooked disease. Despite major efforts to increase case detection, an estimated one third of new TB cases are still being missed each year, and the unavailability of a rapid, low-cost, accurate diagnostic assay that can be used at the point of care is a major hindrance (WHO 2014). There are a very few multicenter randomized studies on UGTB because of absence of unique approach to definition, diagnosis, therapy and management of this disease.


3.2 Terms and Definitions


The first note of UGTB was made by Porter in 1894; in 1937 Wildbolz suggested the term genitourinary TB. However, the term UGTB is more correct, because kidney TB (KTB), which is usually primary, is diagnosed more often than genital TB.



  • Urogenital tuberculosis (UGTB) – infectious inflammation of any urogenital organ – isolated or in combination (kidney and/or male or female genitals), – caused by Mtb or M. bovis.


  • Genital tuberculosis (GTB) – infectious inflammation of the female or male genitals – accordingly female genital tuberculosis (FGTB) or male genital tuberculosis (MGTB) caused by Mtb or M. bovis.


  • Kidney tuberculosis (KTB) – infectious inflammation of kidney parenchyma, caused by Mtb or M. bovis.


  • Urinary tract tuberculosis (UTTB) – infectious-allergic inflammation of calyx, pelvic and upper and lower urinary tract caused by Mtb or M. bovis, always secondary to kidney TB and should be considered as a complication of kidney TB.


  • Generalized urogenital tuberculosis (gUGTB) – generalized tuberculosis of the kidney and the male or female genitals, respectively.


3.3 Classifications of UGTB


UGTB includes many forms of TB with its own clinical features requiring specific therapy and management. Therefore correct clinical classification and staging are important for optimal management and therapy. UGTB can be subclassified into the following entities: kidney tuberculosis and genital tuberculosis.


3.3.1 Kidney Tuberculosis


There are four stages to be considered for Kidney tuberculosis:



  • Stage 1: TB of kidney parenchyma (non-destructive form, KTB-1).


  • Stage 2: TB papillitis (small-destructive form, KTB-2).


  • Stage 3: Cavernous kidney TB (destructive form, KTB-3).


  • Stage 4: Polycavernous kidney TB (widespread-destructive form, KTB-4).

Complications of kidney TB are chronic renal failure, fistula, high blood pressure.


3.3.2 Urinary Tract TB






  • TB of ureter.


  • TB of the bladder is divided into four stages (Kulchavenya 2010):



    • Stage 1 – tubercle-infiltrative;


    • Stage 2 – erosive-ulcerous;


    • Stage 3 – spastic cystitis, which in fact means overactive bladder;


    • Stage 4 – contracted bladder up to full obliteration.

    There is one more form of bladder TB, the iatrogenic BCG-induced bladder TB, which develops as a complication of BCG therapy for bladder cancer.


  • TB of urethra.


3.3.3 Male Genital Tuberculosis (MGTB)






  • TB epididymitis (Uni- or bilateral)


  • TB orchiepididymitis (Uni- or bilateral)


  • TB of the prostate (infiltrative or cavernous forms)


  • TB of seminal vesicles


  • TB of the penis




  • Complications of MGTB are strictures, fistula, infertility, sexual dysfunction.


  • Female genital tuberculosis (FGTB) (is not included in this book).


  • Generalized urogenital tuberculosis (gUGTB): simultaneous lesion of the kidney and the genital organs; gUGTB is always considered as a complicated TB.


3.4 Clinical Features


Clinical features of UGTB have no specific signs, are instable and depend on many factors; this is one of the reasons for late diagnosis.

Comparison of clinical features of UGTB was conducted between 1st group, which were ill in benefit antibacterial era and 2nd group which were ill in novo days.

Current trends of UGTB have shown a change of clinical features: torpid, latent, obscure course predominates; while in the 1st group 35 % of patients had an acute onset of UGTB. Flank pain and haematuria were diagnosed significantly more often novo days. The frequency of pyuria and dysuria was the same, as well as renal colic. In the 1st group mycobacteriuria was found in 85 %, in 2nd group this symptom has decreased up to 44 %, mostly because of widespread using of antibiotics.


3.4.1 Clinical Features of Kidney TB


As whole KTB patients complain of flank pain (up to 80 %) and/or dysuria (up to 54 %). If the urinary tract is involved, then renal colic (24 %) and gross-hematuria (up to 20 %) are possible. Prostate TB manifests by perineal pain and dysuria, and in half of the cases by hemospermia. TB orchiepididymitis always starts from epididymitis, isolated TB orchitis does not exist. Oedema and swelling of the scrotal organs and pain are most often the first symptoms. In 68 % there is an acute debut of the disease. Nevertheless, in 32–40 % the disease has a chronic or asymptomatic course (Figueiredo and Lucon 2008; Lenk and Schroeder 2001; Miyake and Fujisawa 2011; Carrillo-Esper et al. 2010).



  • KTB-1 has minimal lesion without destruction, full recovery is possible by anti-TB drugs. Intravenous urography (IVU) is normal. Urinalysis in children is often normal, but in adults low level leucocyturia may be found. Usually patients have no complaints and are diagnosed by chance. KTB-1 is complicated very rarely. Prognosis is good, usually outcome is full recovery. With inappropriate therapy KTB-1 may progress to destructive form. KTB-1 should be confirmed by bacteriology in any case. Usually Mtb in KTB-1 patients are sensitive to anti-Tb drugs. Mtb detection in urine is always necessary for diagnosing kidney TB stage 1, but may not always be revealed in other forms of UGTB.

If biopsy was performed – single granulomas may be found (Figs 3.1, and 3.2). Very important point – positive result of pathohistological investigation confirm diagnosis “tuberculosis”, but negative result doesn’t exclude it, as granulomas are localized sporadically, and zone of TB inflammation may be missed.

A327448_1_En_3_Fig1_HTML.jpg


Fig. 3.1
Kidney TB. Perivascular epithelioid-cell granuloma. ×200. Hematoxylin and eosin


A327448_1_En_3_Fig2_HTML.jpg


Fig. 3.2
Kidney TB. Large epithelioid-cell granuloma. ×100. Hematoxylin and eosin




  • KTB-2 is subject to conservative therapy, but if KTB-2 is complicated by urinary tract TB, than reconstructive surgery is indicated. Prognosis is good; usual outcome is recovery with fibrous deformation and post-tuberculous pyelonephritis. With inappropriate therapy KTB-2 may progress to the next stage. Mtb is not detected in all cases and may be resistant.

Pathohistological findings – granulomas with necrosis (Fig 3.3).

A327448_1_En_3_Fig3_HTML.jpg


Fig. 3.3
Kidney TB. Large and small epithelioid granulomata with central caseous necrosis. ×100. van Gieson




  • KTB-3 has two ways of pathogenesis, from TB of parenchyma or from papillitis. The first way means development of a sub-cortical cavern without connection to the collecting system. The clinical manifestation of a sub-cortical cavern is similar to a renal carbuncle, thus the diagnosis is usually made after the operation. The second way is the destruction of the papilla until a cavern is developed. Complications develop in more than half of the patients. Full recovery by anti-TB drugs is impossible, surgery is generally indicated. The best outcome is the formation of a sterile cyst; a negative outcome is further destruction upto polycavernous TB.

Pathohistological findings–interstitial proliferative inflammation, fibrosis of the stroma and of some glomeruli, cavern with typical three-layered wall.



  • KTB-4 means several caverns in the kidney; nevertheless overall renal function may be sufficient. KTB-4 may result in fistulas due to pyonephrosis. Self-recovery is also possible, when a stricture of the ureter locks the kidney and caseation in the caverns is impregnated by calcium, the so-called auto-amputation of the kidney. KTB-4 is almost always complicated; very often the contralateral kidney is involved. Recovery with anti-TB drugs only is impossible; surgery is necessary, basically nephrectomy. Diagnosis is confirmed by UVI and multi-slice computer tomogram, pathohistological findings may reveal caseous, fibrosis, sever inflammation (Figs 3.4, and 3.5). Removed kidney with TB 4th stage is shown on Fig 3.6.

    A327448_1_En_3_Fig4_HTML.jpg


    Fig. 3.4
    Kidney TB 4th stage with huge caseous destruction


    A327448_1_En_3_Fig5_HTML.jpg


    Fig. 3.5
    Kidney TB 4th stage – cavern with typical three-layered wall


    A327448_1_En_3_Fig6_HTML.jpg


    Fig.3.6
    Nephrectomy due to kidney TB 4th stage – many huge caverns


3.4.2 Clinical Features of Urinary Tract TB


Urinary tract TB is a specific complication of KTB and so is always secondary to KTB. Urinary tract TB with any localization first appears as an oedema; the next stages are infiltration, ulceration and fibrosis.

Jul 5, 2017 | Posted by in UROLOGY | Comments Off on Urogenital Tuberculosis – Definition and Classification

Full access? Get Clinical Tree

Get Clinical Tree app for offline access