Genitourinary Tuberculosis

Renal Tuberculosis

Asymptomatic renal cortical foci may occur during all forms of tuberculosis. An
autopsy study of pulmonary tuberculosis revealed unsuspected renal foci in 73% of
cases, usually bilateral; 25% of miliary cases have positive urine cultures.[219] Cortical
foci tend to be stable unless they penetrate to the medulla, where local factors favor
accelerated infection. Most patients have evidence of concomitant extragenitourinary
disease, usually pulmonary and most frequently inactive. In normal hosts, the interval
between infection and active renal disease is usually years and sometimes decades.
Local symptoms predominate, and advanced tissue destruction may occur long before
the diagnosis is made. This is mostly a disease of middle-aged adults.

The clinical features in two large series of cases are presented in Table 248–12 .[220][221]
Although sterile pyuria is typical of renal tuberculosis, positive cultures for routine
bacterial pathogens may lead to misdiagnosis, sometimes for years. The intravenous
pyelogram is usually abnormal. Early findings are nonspecific, but later changes may be
more suggestive, including papillary necrosis, ureteral strictures, “pipe stem” changes,
“corkscrewing,” “beading,” hydronephrosis, gross parenchymal cavitation, and
autonephrectomy. Focal calcification is particularly suggestive. The clinical disease is
usually unilateral, although microscopic changes are probably always bilateral. Culture
of three morning urine specimens for mycobacteria establishes the diagnosis in 80% to
90% of cases. When a renal abnormality is present but urine cultures are negative,
cytologic studies and culture of material obtained by fine-needle biopsy may be
diagnostic.

Table 248-12   -- Clinical Features of Renal Tuberculosis in Two Series of Patients

Study
Clinical Features Simon et al.[220] Christensen [221]
Number of patients 102 78
Primarily genitourinary symptoms 61% 71%
Back and flank pain 27% 10%
Dysuria, frequency 31% 34%
Constitutional symptoms 33% 14%
Abnormal urine, no symptoms 5% 20%
Abnormal urinalysis 66% 93%
Abnormal intravenous pyelogram 68% 93%
Tuberculin positive 88% 95%
Abnormal chest roentgenogram 75% 66%
Active pulmonary tuberculosis 38% 7%
Other old or active extrapulmonary disease 5% 20%
 Study
[220]
Clinical Features Simon et al. Christensen [221]
Urine culture positive 80% 90%
 For tuberculosis
 For routine pathogens 45% 12%
Epididymitis, orchitis 19% 17%
Chronic prostatis 6% 6%

Chemotherapy with drug regimens containing INH and RMP as for pulmonary
tuberculosis is recommended. Ureteral cicatrization and obstruction may occur during
healing, and the urologic literature recommends frequent pyelograms during therapy,
corticosteroid therapy if obstruction develops, and ureteral reimplantation if the
obstruction does not resolve.[222] However, obstruction did not develop among 102
treated cases reported by Christensen.[221] Surgery has rarely been required in most
recent series.

Hypertension is not a feature of renal tuberculosis, and renal function is usually

preserved. However, a rare condition called tuberculous interstitial nephritis may cause
renal failure.[223] It is characterized by interstitial granulomas and normal-sized kidneys,
usually in the presence of active extrarenal tuberculosis. Acid-fast bacilli have been
seen but not cultured from renal biopsy specimens, and renal dysfunction responds to
corticosteroid therapy but not antituberculous chemotherapy alone. It is unclear that
tuberculous interstitial nephritis is actually caused by tuberculous infection.

Genitourinary Tuberculosis in Acquired Immunodeficiency Syndrome

In a study of 79 HIV-positive patients with tuberculosis, 77% had positive urine

cultures, usually as an incidental finding. Only two had male genital involvement, none
had symptoms of renal disease, and in only 4% was the genitourinary tract the only
apparent site of tuberculosis.[191]