DR.

ANNIE AGARWAL
23/02/2013
INTRODUCTION
 young to middle-aged adults.

 M/F ratio= 5:3

 Uncommon in children

 Approximately 20-30% of extra-pulmonary infection

 Increase in incidence with HIV epidemic and multi drug

resistant strains

 Important to diagnose as non specific clinical presentation

and progression to renal failure if undiagnosed and
untreated.
 The kidneys are the most
common site of GUTB

 Causative organism :
Mycobacterium
Tuberculosis.

 historyof previous clinical TB

(25%) with a lag time
of 2- 20 years
 SPREAD
 Hematogenous spread - from the
kidneys, the bacilli can spread to the renal
tract, prostate and epididymis.
 Lymphatic spread

 Observed in two settings:

 commonly, as a late manifestation of
earlier clinical or subclinical
pulmonary infection
 rarely, as part of the multiorgan
infection (miliary tuberculosis)

 Rarely primary one—

BCG Tt for Ca bladder
Transplant recipient
CLINICAL FEATURES
 gross / microscopic hematuria
 sterile•pyuria
 Mild proteinuria
 urinary frequency, dysuria, ‘intractable’ UTI
 frequency, urgency, dysuria with involvement of bladder
 back, flank, or abdominal pain. : => extensive renal
disease
 Constitutional symptoms such as fever, weight loss,
fatigue, and anorexia are less common
 haemospermia
 ‘acute epididymo-orchitis’
 Hydrocele,discharging scrotal/perineal sinuses
 Infertility,spontaneous abortion,ectopic pregnancy.
 Menstrual irregularities
 Three other major complications of renal tuberculosis:

hypertension (RAS axis mediated)

super-infection (12 to 50%)
nephrolithiasis (7 to 18%)

 OTHER COMPLICATIONS:
 Perinephric inflammation
 Abscess formation :including psoas abscess
 Fistulae
 Sinus tract into adjacent tissues or viscera.
PATHOGENESIS
 Progressive
involvement of renal
parenchyma

coalescence of
granulomas leading to Seen in advanced renal
unifocal or multifocal tuberculosis Autonephrectomy : end
mass lesions stage d/s
Focal or diffuse
Increase renal length involvement - fibrosis.
Increase thickness of Caseo –
renal substance cavernous type:
Parenchymal surface
Displacement of enlarged sac
scarring over retracted
collecting system. filled with
papillae or pelvis and
dilated/ deformed caseous
calyces. material, +/-
Erosion of pyramid calcification
Cortical / papillary
necrosis Associated calcification Calcified
Caliectasis or calculi shrunken non
Cavity Impaired excretion of functioning of
Deformed calyx contrast kidney
 Following the drainage of a cavity into
the collecting system, there is spread of
infection to other parts of the urinary
tract.

 Stimulation of scirrhous reaction causes

stenosis and obstruction of parts of the
collecting system.
 Common sites of
stricture:

 neck of a calyx –
hydrocalyx, regional
hydrocalycosis

 pelvi – ureteric junction –

generalised dilatation of
pelvicalyceal system.

 lower end of the ureter.

 Imaging
 High dose IVU – traditional gold standard
 CT – new standard
 Pyelography (ante/retrograde) – limited use
 Plain radiographs – important
CXR,spine X-Ray,X-Ray KUB
 US – limited value
 Nuclear Perfusion Scan – function
 MRI – little application
 Plain radiograph of
abdomen
 Renal Size: Small, enlarged or normal

 Presence of scarring or focal bulge

 Calcification

 Calcification of ureter or urinary bladder :

rare

 Evidence of Skeletal Involvement : in hip,

sacroiliac joint, spine, paraspinal abscess

 calcification of lymph nodes, adrenal

gland – 10%
 Calcification : attempt to heal and limit the
pathological processes – 50% - types

Amorphous granular associated

with granulomatous masses-
autonephrectomy
Dense punctate calcification
representing healed tuberculoma.
Chest x ray
 Abnormal in 50 %

 Active pulmonary tuberculosis – 5- 10%

 Sequelae of old tuberculosis of past

infection.
Intravenous urography
 >70% cases- single kidney involved
 IVP (abnormal in 85- 90%) though normal in initial
stages.
 Diagnosis can be made with certainity on urography only if
lesion is ulcerated into calyx.

 Miliary tubercles – involve both the kidneys.

 globally poor renal function

 IVU-
 assess the extent and severity of involvement
 To monitor response to treatment
 To look for complications
 Imaging findings :

Parenchymal scars & Irregularity of the papillary

tips - “moth-eaten” calices

Small cavities in the papillae

communicate with the collecting system

fibrotic reaction develops, stenosis and strictures of

the caliceal infundibula - Infundibular strictures
can lead to localized caliectasis or phantom
calyx.

Scarring of renal pelvis (Kerr kink)

Moth eaten appearance

Earliest abnormality –

an indistinct feathery outline

Irregularity of surface of one

or more papillae or calyces
with normal renal size and
contour.

Fuzzy & irregular calices due

to papillary necrosis.
Normal calices
IVP of 32-year-old woman. A, left renal parenchymal mass (arrows) and left hydroureter due to left
distal ureteral stricture (arrowheads). B, magnification of left kidney shows irregular caliceal
contour as moth-eaten appearance (arrows) of upper calix and multiple cavities (arrowheads) of
lower pole.
Golf ball on a tee

On IVP :

Collecting system shows contrast material

in a large papillary cavity, the “golf ball” (∗).

Blunted calyx, the “tee,” is adjacent

(arrow).
Infundibular stenosis
causing phantom calyx

Phantom calix

Infundibular stenosis
Phantom calyces
Ghost - like

RGP

Decreased nephrographic opacity and nonfilling of the collecting system

elements at the lower pole of left kidney – phantom calyces (ghost : exist, but
not visualised, the same are visualized on RGP).
Hiked up pelvis => pulled up

Cephalic retraction of the inferior medial

margin of the renal pelvis at the
ureteropelvic junction (UPJ)
Kerr kink
 Cortical scarring with
dilatation & distortion of
adjoining calyces coupled
with strictures of the
pelvicaliceal system.

 Cause luminal narrowing

either directly or by causing
kinking of the renal pelvis at
the UPJ.
 If the ulcer or stricture extends to the renal pelvis or the
pelvic ureteral junction, urine outflow obstruction may
occur.

IVUmay show delayed function, clubbed calyces, or

absence of function.

Some show Hydronephrosis - irregular margins and filling

defects owing to caseous debris.

If tuberculous infection extends directly to the rest of the

kidney, the entire kidney becomes a bag of caseous
necrotic pus.

The kidney enlarges initially but subsequently may return to

normal or become atrophic.

infection may extend into peri- / pararenal space + psoas

 Some
nonspecifically
blunt calices in
addition to a track
leading to a cavity
(arrow).
 (A) ‘Cut-off’ upper pole
infundibulum. No filling of
calices in upper pole. Irregular
cavitation in remainder of the
kidney.

 (B) Pathological specimen

showing a fibrotic stricture of
the upper infundibulum (black
arrow) and a caseous
pyonephrosis occupying the
upper pole. Cavitation
elsewhere.
Putty kidney
 Autonephrectomy.

 Diffuse, uniform, extensive

parenchymal
calcifications forming a
cast of the kidney with
autonephrectomy.

 End stage of GuTB.

 Genitourinary tract tuberculosis. Lobar calcification in a large
destroyed right kidney in a patient with renal tuberculosis. Note the
involvement of the right ureter.
URETER
 Almost always secondry to renal tuberculosis – 50% cases.

 Spread of infection by bacilluria.

 ureteral involvement is usually unilateral, bilateral

changes are asymmetric when they occur.

 The most common site of involvement is the lower

third of the ureter.

 Renal damage secondry to ureteral strictures may be more

severe than the effect of original parenchymal involvement.

 Dilatation and stenting of the ureter may restore ureteral

patency and salvage a kidney.
 dilatation resulting from atony
and prolonged bacilluria

beaded or
corkscrew
irregular segments of ureter
appearance.
due to mucosal ulcerations

necrosis of ureteral
musculature is accompanied Terminal
by fibrosis - stricture formation- segment of
50%. the ureter

severe thickening of the wall PIPE

produces a rigid shortened STEM
ureter with narrow lumen URETER
Saw tooth appearance

 Ulcerations causing
mucosal irregularity of
ureter.
Beaded / Corkscrew ureter
 Fusion of multiple strictures
may create a long, irregular
narrowing. Several
nonconfluent strictures can
produce a “beaded” or
“corkscrew” ureter

Mucosal thickening of ureter

Pipe stem ureter
Old pipe stem

 Rigid ureter: irregular

and lacks normal
peristaltic movement,
fibrotic strictures noted.

 Note the distortion,

amputation and
irregularity of the upper
pole calices.
Urinary bladder
 Inv. in later course of d/s in 1/3 rd cases
Tubercular cystitis- edema
of bladder mucosa

Large tuberculomas in
Shrunken & calcification later vesical wall – manifest as
filling defects

Fibrosis in region of trigone Advanced d/s – irregular

produces gaping of the UV contracture with thick walls and
junction resulting in VUR. reduction of bladder capacity –
THIMBLE BLADDER.
 Genitourinary tract tuberculosis. Intravenous urography series in a man with
renal tuberculosis shows marked irregularity of the bladder lumen due to
mucosal edema and ulceration
Thimble bladder
 Diminutive and irregular
urinary bladder –
simulating a thimble.
 IVP film-The lower end of the right ureter demonstrates an irregular caliber
with an irregular stricture at the right vesico-ureteric junction. Note the
asymmetric contraction of the urinary bladder, with marked irregularity due
to edema and ulceration.
 Diffuse reflux
nephropathy with
multiple blunted
calices.
 Left kidney
normal in size.
 Shrunken right
kidney.
Urethral tuberculosis
 Male urethra – uncommon, occurs secondry to
renal infection.

 The periurethral glands of Littre may become

distended with bacteria and leukocytes and may
lead to abscess formation.

 Associated with prostatic abscess or fistula

formation.

 Result in non specific stricture in bulbo-

membranous urethra.
Retrograde pyelography

 Indicated in patients with non functioning

kidney to demonstrate ureteric obstruction
and cavitation in kidney.
 Retrograde ureteropyelography showed an
atrophic right kidney with diffuse caliceal
dilatation, papillary necrosis, and infundibular
narrowing.
 mucosal
irregularities
and erosions of
the ureter.
ultrasonography
 Role of sonography :
 Guidance for interventional procedures of
percutaneouys nephrostomy (PCN)
 Antegrade dilatation of ureteral stricture
 Drainage of perinephric abscess.

 Not a primary modality used for diagnosis:

 Unable to show early calyceal changes.
 No information about status of renal function.
Kidney
 Focal lesion of varying echogenecity.
 Early stages – papillary lesions as areas of hypoechogenicity or
hypoechoic foci with echogenic walls or echogenic non shadowing
lesions.
 Sloughed calyx – echogenic flap separated from normal calyceal wall.
 Large liquefying conglomerate cavities or dilated calyces formed as a
result of infundibular stricture appear as hypoechoic nodules or masses.
 PCS- hydronephrosis or calyectasis.

 The communicating tract from a cavity appears as a sonolucent track

entering the dilated calyx.

 Heterogenous echotexture of the parenchyma or normal appearing

parenchyma may be seen in diffuse involvement.

 May demonstrate hydronephrosis, parenchymal calcification and

perinephric abscess.
  USG
Early findings may be missed

 Sonogram of left kidney shows 1.5-cm hypoechoic nodule (arrowhead) in cortex

Pseudoureterocele

 IVP: cobra head sign,

the lucent halo is
however thick, irregular
and less well defined.

Rao A, Yvette K, Chacko N. Tuberculosis of urinary bladder presenting as

pseudoureterocele. Indian J Med Sci 2005;59:272-3
 Usg is poor in assessing ureter but
shows back pressure changes and
adjacent retroperitoneal disease.

 UB- focal irregular thickening with

reduced capacity.

 Deformed shape and focal abnormalities

better appreciated following distension.
Computed tomography
 Indicated only in patients with strong clinical
suspicion but normal IVU and USG.

 Uses :MDCT:
 Renal and extra renal spread of disease.
 Length of ureteric stricture
 Adjoining retroperitoneal disease
 Associated spinal or solid organ involvement.

 excretory urography is sensitive in the

detection of early urothelial mucosal changes
CT
 identifying renalcalcifications,
 Coalesced cortical granulomas containing either caseous
or calcified material
 Calices that are dilated
 and filled with fluid have an attenuation between 0 and 10
HU;
 debris and caseation, between 10 and 30 HU;
 putty-like calcification, between 50 and 120 HU; and
 calculi, greater than 120 HU.
 Cortical thinning is a common CT finding and may be
either focal or global.
 Parenchymal scarring is readily apparent at CT.
 Fibrotic strictures of the infundibula, renal pelvis, and
ureters may be seen at contrast-enhanced CT and are
highly suggestive of tuberculosis.
 Ureter : thickening of ureteral wall or pelvis
with periureteric inflammation

 Bladder Tuberculosis
 thickened bladder wall (= muscle
hypertrophy + inflammatory tuberculomas)
 filling defects (due to multiple granulomas)
 bladder wall ulcerations
 shrunken bladder - scarred bladder with
diminished capacity - thimble bladder• .
 bladder wall calcifications (rare)
 CT urogram shows severe nonuniform caliectasis and multifocal strictures (arrowheads) involving renal
pelvis and ureter.. Calcification (arrow) is noted in left distal ureter.
 A, Contrast-enhanced CT scan obtained at level of right renal hilum
shows wedge-shaped hypoperfused areas (arrowheads).
 B, CT scan - hypoperfused areas (arrowheads) and focal caliectasis
(arrows)
 (a) Contrast-enhanced excretory-phase CT scan shows dilated
calices and narrowing of the infundibula (arrowheads).
53-year-old man with tuberculosis involving collecting system. Contrast-
enhanced CT scan of left kidney shows uneven caliectasis caused by
varying degrees of stricture at various sites.
 (a) Contrast-enhanced nephrographic-phase CT scan shows dilated
calices and thinning of the renal cortex (arrow). (b) Magnified view
from a contrast-enhanced nephrographic-phase CT scan obtained
caudad to a shows mural enhancement and thickening of the proximal
ureter (arrow).
 Renal Tuberculosis. Coronal reformatted non-enhanced CT scan of the
abdomen and pelvis demonstrates a small, left kidney containing
globular calcifications (white circle) pathognomonic for renal tuberculosis.

CT scan shows dense calcification
replacing right kidney, so-called “putty
kidney.” in NCCT
The left kidney shows large,
dense, oval calcifications.
Low-density areas in the right
kidney probably represent
foci of caseous necrosis.
MRI
 MR urography: evaluate poorly or non
functioning kidney specially obstructive
form for demonstration of ureteric
involvement.

 MR – renal parenchymal changes and

details of PCS
 Used for evaluation of ureteral
peristalsis.
Male Genital Tuberculosis
 seeding from infected urine or via the bloodstream.
 The most common manifestation is tuberculous
prostatitis, less common is epididymo-orchitis

 calcifications in 10% (diabetes more common

cause)

 Tuberculous epididymitis
○ ascending / descending route of infection

 Tuberculous orchitis
○ direct extension from epididymal infection, rarely from
hematogenous spread
Prostatic involvement :
 Plain radiographs-dense calcification within the prostatic bed
 Cavities/ abscesses--discharge into the surrounding tissues sinuses or
fistulae to the perineum or rectum ‘ watering-can perineum.’
 Cystourethrography-
○ early cases - filling of the prostatic ducts without evidence of
cavitation,
○ Advanced cases the ducts may be greatly dilated.
○ Varying degrees of destruction of prostatic parenchyma with
sloughing may produce irregular cavities.

 Tuberculous prostatitis / prostatic abscess: caseation, cavitation

and fibrosis.
○ hypoechoic irregular area in peripheral zone
○ hypoattenuating prostatic lesion
○ hypointense diffuse radiating streaky areas on T2WI (watermelon
sign•
)
○ peripheral enhancement
○ Occasionally fistulous formation
 Prostatic tuberculosis. Contrast-enhanced CT scan shows a well-
defined hypoattenuating lesion within the prostate gland
(arrowhead). Scrotal tuberculosis. US image of a testis shows a
nonspecific focal area of hypoechogenicity, which proved to represent
caseous necrosis secondary to tuberculosis.
Watermelon skin

 Prostatic abscess,
T2-weighted MRI
shows a peripheral
enhancing cystic mass
with radiating, streaky
areas of low signal
intensity.
Female genital tract - TB
 Hematogenous spread.
 Associated wet or dry peritonitis
 strongly associated with infertility in women,
rates of successful pregnancy remain low
even after treatment.

 Salpingitis (94%): mostly bilateral

 Tuboovarian abscess: extension into

extraperitoneal compartment
HSG - GTB
 obstruction and multiple constrictions of the fallopian tubes.
 Rigid pipe-stem tubes
 A clubbed ampula with retort-shaped hydrosalpingx
 Vascular or lymphatic intravasation of contrast
 Small shrunken uterine cavity with filling defects
with adhesions
 Long and dilated cervical canal & dye in cervical
crypts
 Bilateral cornual block
 Punctate opacification of crypts and diverticulae in
lumen of tubes
Flask shaped fallopian
tubes..

 HSG may demonstrate

a flask-shaped dilatation
of the fallopian tubes
due to obstruction at the
fimbria.
Cotton wool plug appearance..

 Focal irregularity and

areas of calcification
occur within the lumen of
the fallopian tubes.
Hydrosalphinx
Bilateral T.O.masses even after
ATT
Tufted appearance..
 Caseous ulceration of the
mucosa of the fallopian tube
produces an irregular contour
of the lumen of the tubes.

 Diverticular cavities may

surround the ampulla and
give a “tuft” like appearance.

 Thick arrow – hydrosalphinx.

Pipe stem
appearance

 Scarring fallopian
tubes.

 Irregular and rigid.

 Filling defect in uterine

cavity – adhesion.
 Beaded appearance..

 Multiple constrictions along the course of fallopian

tube on HSG due to fibrotic strictures.
Beaded appearance more on left
side
Left tube appears as if tubectomy
done also described as look of
sperm head
Both tubes eroded looking. Inner
lining of uterine cavity moth-eaten
appearance
T-shaped uterine cavity

 Scarring results in
a “T” shaped
uterine cavity with
intravasation of
contrast.
Appearance similar to Bilateral
tubal ligation. Elongation and
dilatation of cervical canal
Lymph node calcification
Bilateral cornual block &
intravastion of dye in vessels &
lymphatics.
Intravasation of dye into
myometriums and lymphatics and
left terminal hydrosalpingx
SUMMARY