6  Genitourinary Diseases
Briony K. Varda, Alan B. Retik
KEY FEATURES
• Intrinsic renal disease must be differentiated from
extrinsic disease affecting the genitourinary tract;
urinalysis with microscopy and renal/bladder ultrasound
can facilitate diagnosis even in remote environments.
• Regardless of the setting, urinary tract infection (UTI) is
one of the most common genitourinary problems in
both children and adults; antimicrobial resistance
patterns should be considered before treatment, and
recurrent or recalcitrant infections warrant further
evaluation of the genitourinary tract.
• Communicable infections of the genitourinary tract seen
more commonly in tropical regions include
schistosomiasis (hematuria), tuberculosis (sterile pyuria
and delayed stricture disease), filariasis (chyluria and
filarial hydroceles), Echinococcus (renal hydatid cysts),
untreated Neisseria gonorrhoeae (urethral stricture
disease), and HIV/AIDS (prostatic abscesses,
nephropathy, and opportunistic infections of the external
genitalia and inguinal region).
• Trauma may affect any part of the genitourinary tract
and includes injuries from motor vehicle accidents and
violence (blunt and penetrating), as well as obstetric
injury leading to vesicovaginal fistula disease.
• Sickle cell disease has a greater prevalence in tropical
regions and can cause nephropathy, papillary necrosis
with hematuria, priapism, and a rare but lethal form of
renal cancer.
• Genitourinary problems related to metabolic diseases
and diseases of aging are becoming more prevalent as
people live longer and assume elements of the
Westernized lifestyle; in parallel, congenital anomalies of
the genitourinary tract will be increasingly identified as
diagnostic technology becomes more widely available
and infant mortality declines.
This chapter focuses on genitourinary (GU) diseases that occur
commonly in tropical regions. These are divided into those with
etiologies related to endemic infectious diseases and those with
non-infectious causes (Table 6.1).
The chapter addresses pathology affecting structural aspects
of the kidneys, collecting system, ureters, bladder, prostate, urethra,
and external genitalia. However, intrinsic renal disease (Table 6.2)
may present with similar signs as urologic conditions, including
hematuria, hypertension, and acute renal failure. In many cases,
the underlying etiology can be differentiated with a renal/bladder
ultrasound and urine microscopy. Table 6.3 summarizes normal
renal ultrasound findings and those typical of obstructive uropathy
or intrinsic renal disease. Additional information about red cell
morphology on urine microscopy can distinguish intrinsic renal
disease from urologic abnormalities. A history of recent upper
respiratory tract or gastrointestinal infection, new medications,
use of herbal remedies, a family history of kidney disease or sickle
44
cell, or a known HIV infection may further help distinguish intrinsic
renal disease.
COMMUNICABLE DISEASES AFFECTING THE
GENITOURINARY TRACT
Bacterial Cystitis and Pyelonephritis
Urinary tract infections (UTIs) occur in approximately 3% of
children,1 whereas rates are much higher among sexually active2
and post-menopausal women, with >50% experiencing at least
one UTI in her lifetime.3 In contrast, men experience a 14% risk
of UTI in their lifetime, with elderly males (>85 years old) the
most frequently affected.4 Boys less than 6 months old also have
a heightened risk of febrile UTIs, but the incidence dramatically
decreases by age 1. Circumcision has been associated with a
decreased risk of UTI in boys, but is primarily recommended
after a first UTI in the setting of a known anatomic abnormality.5
In older men, UTIs should raise the suspicion of a functional
abnormality (such as poor bladder emptying associated with benign
prostatic hyperplasia) or bladder stones.
Acute bacterial cystitis is more common than pyelonephritis.
Causes of UTIs include colonization by uropathogens from fecal
flora and entry into the bladder with ascension to the kidneys in
the case of pyelonephritis. The most commonly seen uropathogens
include Escherichia coli, Klebsiella, Enterobacter, Enterococcus, and
Staphylococcus saprophyticus. Pseudomonal infections are harbingers
of GU pathology, and urea-splitting organisms may be associated
with struvite stones. Candidal UTIs are uncommon, except in
infants and immunocompromised individuals. Contamination of
the urine with Candida is quite common and does not represent
a true infection in the majority of cases.
Symptoms of acute bacterial cystitis are urinary frequency,
urgency, dysuria, and/or supra-pubic or low back pain. In the
absence of vaginal discharge, these symptoms are highly predictive
of true infection in women. Pyelonephritis is characterized by a
triad of findings: fever (>101°F), flank pain, and evidence of UTI
on urinalysis. The workup of a suspected UTI starts with a uri-
nalysis. A urine dipstick may be positive for leukocyte esterase,
blood, and nitrites, and a urine microscopy will yield pyuria (>5
WBCs/hpf) with associated microscopic hematuria (>3–5 RBCs/
hpf) and bacteria. A urine culture is the gold standard for diagnosing
a UTI, as well as identifying the causative bacteria and its antibiotic
susceptibility.
Recommendations for management of UTIs are summa-
rized in Table 6.4. Acute bacterial cystitis among post-pubertal
women is considered an “uncomplicated” infection and typically
requires only a short course of oral antibiotics. In young men
with signs and symptoms of UTI, suspicion for a chlamydial
or gonorrheal infection should be high, with testing performed
and empiric treatment initiated. A true UTI in a young male is
rare and raises the suspicion of an anatomic problem; functional
problems affecting bladder emptying should be considered in
older males with a UTI. It may take several days for a patient
with pyelonephritis to defervesce even with adequate treatment.
In patients who do not improve, the correct antibiotic choice
should be ensured and consideration given to ultrasound for
evaluation of abscesses (e.g., renal or prostatic) or obstructive
processes.
 CHAPTER 6  Genitourinary Diseases 45

TABLE 6.1  Genitourinary Diseases Commonly Seen in Tropical TABLE 6.3  Common Renal Ultrasound Signs in Normal Kidneys,
Regions Obstructive Nephropathy, and Intrinsic Renal Disease 6
Communicable Non-communicable NORMAL
Parasitic Congenital anomalies Renal size appropriate for age
Schistosomiasis Hypospadias Differential renal length not greater than 2-cm
Filariasis Undescended testicles Left kidney typically slightly larger than the right
Hydatid disease Hernias/hydroceles Cortical echogenicity less than the liver
Malaria Hydronephrosis Cortex more echogenic than the medullary pyramids
Bacterial Genetic Renal hilum highly echogenic (due to sinus fat)
Neisseria gonorrhoeae Sickle cell disease Renal pelvis imperceptible or slitlike with anechoic center
Tuberculosis Metabolic Ureters imperceptible
Uropathogens (e.g., Urolithiasis Uniform arterial and venous flow seen with Doppler
Escherichia coli) Trauma
OBSTRUCTIVE UROPATHY
Viral Vesicovaginal fistula
HIV Urethral stricture Enlarged kidney or ureter
BK virus Diseases of aging Dilation of renal pelvis or calyces
Benign prostatic hypertrophy Dilated pelvis and calyces communicate
Underactive bladder Hydroureter
Pelvic organ prolapse +
Prostate cancer Hyperechoic cortex
Loss of cortico-medullary differentiation
Cortical thinning
INTRINSIC RENAL DISEASE
TABLE 6.2  Examples of Intrinsic Renal Disease Commonly Seen in No collecting system dilation
Tropical Regions +
Cortex hyperechoic
Acute renal failure
Loss of cortico-medullary differentiation
Hemolytic uremic syndrome
Small size for age
Malaria acute kidney injury (MAKI)
Small size compared with contralateral kidney
Post-infectious glomerulonephritis
Multiple cortical cysts
Chronic kidney disease
No evidence of cyst communication
Diabetic nephropathy
HIV nephropathy
Sickle cell nephropathy
Focal segmental glomerulosclerosis
Medication-induced renal injury spontaneous regression; however, approximately 10% develop
Toxin-induced renal injury chronic urinary tract involvement.8
Because mature worms migrate to the pelvic venous plexus,
the distal ureters and bladder are affected. The prostate and seminal
vesicles (Fig. 6.1B) may also be infected; however, the kidneys
Xanthogranulomatous pyelonephritis and emphysematous and genitalia are usually spared. Ova deposited in the submucosal
pyelonephritis are two types of complicated renal infections. veins of the bladder trigger an immune reaction leading to the
Xanthogranulomatous pyelonephritis is typically associated with formation of perioval granulomas. This can lead to ischemic mucosal
a central renal stone resulting in chronic and recurrent infections. lesions, cystitis cystica, calcifications in the bladder wall (Fig. 6.1A),
Patients may have prolonged waxing and waning constitutional fibrosis, and squamous metaplasia and can be associated with lower
symptoms, but ultimately can become septic. In untreated cases, urinary tract symptoms (urinary frequency, urgency, and incon-
nephrocutaneous fistulae will develop, particularly with past tinence). In severe cases, the patient can develop a poorly compliant,
attempts at percutaneous decompression or stone-related obstruc- low-capacity bladder associated with vesicoureteral reflux and renal
tion.6 If focal, IV antibiotic treatment may be successful, but damage (Fig. 6.1D). A fibrotic, thickened bladder can also cause
definitive management of a diffuse process is nephrectomy. ureterovesical obstruction or bladder outlet obstruction. Ureteral
Emphysematous pyelonephritis is a gaseous infection of the kidney scarring can lead to stricture (Fig. 6.1C).
strongly associated with diabetes mellitus. Imaging suggests a Chronic inflammation with squamous metaplasia puts patients
gaseous infection and may show areas of necrosis with fluid col- at an increased risk for developing bladder cancer. Bilharzial-
lections. When greater than a third of the kidney is affected, the related bladder cancer is most often squamous cell carcinoma
mortality rate reaches 70%.7 Urgent nephrectomy is the manage- (SCC; 54%–77%), though transitional cell carcinoma (TCC)
ment of choice in these cases. or adenocarcinoma (AC) can also occur. Bilharzial-associated
bladder cancer has a similar natural history and prognosis to that
of classic TCC, with a 5-year incidence of distant metastases in
Schistosomiasis 23% (15% SCC, 39% TCC, and 58% AC). After cystectomy,
According to the World Health Organization, an estimated 200 loco-regional recurrence occurs in 5% to 31% of patients.
million people in 74 countries have schistosomiasis. Schistosoma Intravesical bacillus Calmette–Guerin (BCG) therapy, which
haematobium is specifically associated with GU involvement. is typically used for high-grade non-muscle invasive bladder
It is endemic to sub-Saharan Africa, Egypt, and the Arabian cancer (NMIBC) caused by TCC, works poorly in SCC and
Peninsula. AC. Therefore high-grade NMIBC with or without carcinoma
Patients with schistosomal infections may present with lower in situ and any muscle-invasive bladder cancer requires early
urinary tract symptoms and hematuria. Diagnosis is made by cystectomy.9
demonstrating ova on urine microscopy. Treatment is with pra- Many of the GU manifestations are seen on plain films, as well
ziquantel, which is most effective in killing mature worms. Oral as bladder ultrasound (particularly if there are calcifications or
steroids can be used to lessen the symptoms of the acute infection. urinary tract dilation). In obstruction, either ureteral or bladder
A majority of infected individuals have transient symptoms and neck, patients with concomitant pyelonephritis or acute renal failure
46 PART 1  Clinical Practice in the Tropics

TABLE 6.4  Recommendations for the Management of Urinary Tract Infections

ACUTE BACTERIAL CYSTITIS
Infants (<2 months)* Amoxicillin PO 20–40 mg/kg
Per day divided into 3 doses ×3–5 days
Cephalexin PO 50–100 mg/kg qid
Per day divided into 4 doses ×3–5 days
Children Trimethoprim-sulfamethoxazole PO 6–12 mg/kg trimethoprim Not for use in infants or
30–60 mg/kg sulfamethoxazole patients with G6PD
Per day divided into 2 doses ×3–5 days deficiency
Women, uncomplicated Nitrofurantoin PO 100 mg bid x5 days First line
Trimethoprim-sulfamethoxazole 160/800 mg bid x3 days
Pivmecillinam 400 mg bid 3–7 days
Fosfomycin PO 3 g single dose
Ciprofloxacin PO 500 mg bid ×3 days Second line
Amoxicillin-clavulanate 500 mg bid ×3 days
Older, complicated As above As above, lengthen duration to 5–7 days
PYELONEPHRITIS
Infants & children Ceftriaxone IV 50–75 mg/kg daily ×7–14 days
Ceftazidime IV 100–150 mg/kg
Per day divided into 3 doses ×7–14 days
Gentamicin IV 7.5 mg/kg
Per day divided into 3 doses ×7–14 days
Piperacillin-tazobactam IV 80 mg/kg/dose divided into 3 doses ×7–14
days
Women, low risk Ciprofloxacin PO 500 mg bid ×7 days Only in regions with <10%
(±1 dose 40 mg IV ciprofloxacin) community resistance
(±1 dose 1g IV ceftriaxone)
Older men and high-risk Ceftriaxone IV 1g daily ×7–14 days Transition to PO antibiotics
women Cefepime IV 1–2 g bid ×7–14 days when afebrile >24–48 h
Ceftazidime IV 500 mg bid ×7–14 days
Ciprofloxacin IV 500 mg bid ×7–14 days
Ertapenem IV 1 g IV daily ×7–14 days
Piperacillin-tazobactam IV 3.375–4.5 g qid ×7–14 days
Ampicillin-sulbactam IV 3 g IV q6h ×14 days
*Infants typically present with pyelonephritis; oral antibiotics should be initiated only after clinical improvement following initial parenteral treatment and
bacterial speciation with antibiotic sensitivities.
This does not include adjustments for hepatic or renal insufficiency. All antibiotic regimens should be tailored to urine culture results. In young males,
empiric treatment for chlamydia/gonorrhea should precede empiric management of UTI.
AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; IDSA, Infectious Diseases Society of America; bid, twice daily;
qid, four times daily.
Adapted from the 2010 IDSA Clinical Practice Guidelines, AAFP guidelines for UTIs in Adults, and the 2011 AAP guidelines for UTIs in young children.
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in
women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect
Dis 2011;52(5):e103–20. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB.
Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months.
Pediatrics 2011;128(3):595–610.

need immediate decompression. Ureteral stenting or placement
of a percutaneous nephrostomy tube is ideal for the upper tract,
whereas urethral dilation with Foley catheter placement or a
supra-pubic tube can be used for the lower tract. A patient with
a history of schistosomiasis who develops microscopic or gross
hematuria should be evaluated for bladder cancer—preferably
with urine cytology, cystoscopy, and computed tomography (CT)
urogram (though renal ultrasound is acceptable in resource-limited
settings).
Filariasis
Scrotal and genital involvement secondary to filariasis may be
under-reported due to patient modesty or stigma. Infection is
caused by entry of adult worms into the superficial lymphatics
in the inguinoscrotal (labial) region, resulting in a local inflam-
matory response and ultimately lymphangiectasia. Obstruction of
the local lymphatic drainage leads to lymphatic fluid collections,
skin thickening, and subsequent bacterial skin infections and
further tissue damage. Although many cases are asymptomatic,
over 50% of men with a filarial infection will develop a scrotal
hydrocele.
Preventive chemotherapy with albendazole and ivermectin or
diethylcarbamazine help to prevent the spread of disease but do
little to treat adult worms. For those with chronic filarial hydroceles,
surgical management is necessary by draining the hydrocele fluid
and resecting thickened scrotal skin and underlying tissues.
Depending on severity, the patient may require local split-thickness
skin grafts for adequate coverage. These cases are associated with
poor wound healing and high rates of infection, recurrence, and
hematoma due to the poor quality of the affected tissue.10–12
Nonetheless, management options are limited, and surgery may
be the only possibility of resolving disability.
Tuberculosis
In 2015, there were an estimated 10.4 million new cases of
tuberculosis (TB) in the world, with six countries representing
60% of these cases: India, Indonesia, China, Nigeria, Pakistan,
and South Africa.13
 CHAPTER 6  Genitourinary Diseases 47

Fig. 6.1  Radiologic images of genitourinary manifestations of schistosomiasis. (A) Bladder wall and ureter
calcification. (B) Seminal vesical calcification. Arrowheads indicate the seminal vesicles bilaterally. The arrow
indicates calcification caused by TB. (C) Hydroureteronephrosis related to a distal ureteral stricture.
(D) Hydroureternephrosis related to dilating reflux. (With permission from Shebel HM, Elsayes KM,
Abou El, et al.: Genitourinary schistosomiasis: life cycle and radiologic-pathologic findings. Radiographics
2012;32(4):1031–1046.)

Although extra-pulmonary TB occurs in approximately 20%
of patients, the GU tract is affected in only 4% to 8% of patients
with TB infections.14 It typically presents many years (even decades)
after infection and represents reactivation of dormant disease. As
a result, it is rarely seen in children. The infection may affect any
part of the GU tract, but it is more frequently seen in the epididymis
and the kidney. Infections of the ureters and bladders arise from
infections in the kidney; ureteral TB is most commonly seen in
the distal ureter.15 Less commonly affected are the urethra, prostate,
and testicles.14,15
Chronic, unexplained symptoms of pain or lower urinary tract
symptoms with a history of TB should prompt investigation.
Common findings on urinalysis are pyuria (80%) and microscopic
hematuria (50%)15; detection of acid-fast bacilli is variable.
Confirmation of the diagnosis is based on urine culture or tissue
analysis. For the highest detection, several early morning specimens
48 PART 1  Clinical Practice in the Tropics
should be cultured on Lowenstein–Jensen and pyruvic egg
medium15; if available, polymerase chain reaction (PCR) can be
helpful.14,16 A positive skin tuberculin test can assist with the
diagnosis, but a negative one does not rule out the presence of
extra-pulmonary TB.
Patients with TB epididymitis have concomitant GU tract
abnormality 50% to 75% of the time.15 Plain films will demonstrate
large calcifications, particularly in the kidney. A pathognomonic
finding of TB is the “putty kidney,” which is a large area of
homogeneous, ground glass–like calcification seen on x-ray.17
Ultrasound, intravenous pyelogram (IVP), or CT (with delayed
imaging) may be useful to identify ureteral stricture disease and
any dilatation. Cystoscopy with retrograde pyelography may help
further delineate stricture disease. The European Urologic Associa-
tion recommendations for the evaluation of suspected GU-TB
are shown in Table 6.5.
Medical management parallels that of pulmonary TB and is
summarized in Table 6.6 and in Chapter 43. Multi-drug–resistant
TB should be considered. Surgical management may be necessary
for disease eradication or for the management of chronic symptoms.
Indications for nephrectomy include a poorly functioning kidney
with extensive disease or co-existing hypertension or carcinoma.
Partial nephrectomy may be used for polar lesions. Epididymectomy
may be necessary if refractory to anti-TB agents. Correction of
ureteral strictures depends on the location and length of the
stricture.
Hydatid Disease
Echinococcosis (Echinococcus granulosus), a tapeworm infection of
dogs, is most commonly seen in stockbreeding regions (sheep and
cattle) of North Africa, the Middle East, South America, Australia,
New Zealand, Alaska, and northern China.18,19 Larval infection
TABLE 6.5  EUA Diagnostic Algorithm for the Workup of Suspected
GU-TB
Obtain TB infection history
Assess symptoms
Perform physical examination
Tuberculin skin test
Assess the urinalysis
Radiologic imaging
CT (if available)
Intravenous pyelogram (second option)
Urine cultures with PCR; or tissue cultures with acid-fast stain and/or
PCR
EUA, European Urologic Association.
Adapted from Cek M, Lenk S, Naber KG, et al. EAU guidelines for the
management of genitourinary tuberculosis. European Urology
2005;48(3):353–262. Epub 2005 Mar 16.
TABLE 6.6  Medical Management of Uncomplicated GU-TB
Intensive Phase Maintenance Phase
3 months 3 months
INH, RMP, EMB (or SM) daily INH, RMP twice or thrice per week
2 months 4 months
INH, RMP, PZA, EMB daily INH, RMP twice or thrice per week
EMB, Ethambutol; INH, isoniazid; RMP, rifampin; SM, streptomycin.
Adapted from Cek M, Lenk S, Naber KG, et al. EAU guidelines for the
management of genitourinary tuberculosis. European Urology
2005;48(3):353–362.
in humans typically occurs in the liver and lungs, but in 1% to
5% of cases the kidneys are affected,18–20 resulting in cystic masses
that can rupture into the renal collecting system.
Most patients with renal hydatid disease present with non-
specific symptoms of lumbar or upper abdominal pain, malaise,
and episodic fevers. Less than a third of patients have frank
hydaturia that is marked by the passage of small, white, grapelike
structures.19,21
The initial workup includes urinalysis and renal ultrasonography.
Imaging will reveal a cystic lesion (either simple or multi-loculated;
Fig. 6.2) that can have associated floating debris, daughter cysts,
and hydatid sand. A majority of cysts will be >5 cm in size, with
nearly a third >10 cm.19 The WHO classification for renal ultra-
sound findings is based on signs of active, transitional, and inactive
hydatid disease.22 Serology has a high false-negative rate, with
nearly half of infected individuals testing negative.19
The management of an active renal hydatid cyst is surgical.
Medical management with anti-helminth agents and percutaneous
aspiration is associated with high rates of recurrence. Surgery
entails opening the cyst and removing the endocyst, including the
hydatid membrane and daughter cysts. Thoroughly rinsing the
cavity with saline or a scolicidal agent, such as hydrogen peroxide,
may prevent recurrence.18,19 Spillage of endocyst material carries
the risk of a systemic anaphylactic reaction. The use of albendazole
may reduce the risk of recurrence.23
Neisseria gonorrhoeae and Urethral Stricture
Disease
In the developing world, gonorrhea causes a majority of male
urethral stricture,24–26 with the bulbar urethra most frequently
affected. Urethral narrowing can cause dysuria, frequency, hema-
turia, straining, acute urinary retention, overflow incontinence,
and recurrent UTIs. Severe cases can lead to bilateral upper tract
dilation and obstructive nephropathy. Gonorrheal stricture is most
frequently seen in young and middle-aged men.25
The evaluation for stricture includes questions about sexually
transmitted infections (STIs), trauma, and urinary symptoms. Renal
ultrasound will reveal if there is upper tract dilation and can show
a large-capacity bladder that does not empty after voiding. Diagnosis
can be made with a retrograde urethrogram by injecting contrast
into the penile urethra while taking oblique fluoroscopic images
(Fig. 6.3).
Urethral dilation can be performed via cystoscopy, if available.
However, strictures that recur after dilation should be managed
with definitive reconstructive surgery, as the failure rate increases
with each dilation. Open repair requires surgical experience,
particularly with long or multi-focal strictures, but can be performed
with instruments and sutures common to most operating rooms.
In the event of acute urinary retention, a supra-pubic tube can
be placed as a temporizing measure.
HIV/AIDS
In 2016 there were an estimated 36.9 million people living with
HIV and 940,000 deaths due to AIDS worldwide.27 The majority
of the GU manifestations in HIV infection occur when there are
low CD4 counts and the patient is immunosuppressed. Any dis-
seminated atypical infection (fungal, parasitic, mycobacterial, or
viral) can affect the GU tract.
UTIs are slightly more common among individuals with HIV
and significantly more common among patients with AIDS. In
addition to normal uropathogens, others include Salmonella (which
should be treated and followed by long-term prophylaxis) and
cytomegalovirus (CMV) cystitis, which can be treated with gan-
ciclovir or foscarnet.28
Prostatitis and prostatic abscesses are more common in HIV-
infected patients. They are caused by common uropathogens or

Fig. 6.2  A left renal hydatid cyst (asterisk) on axial CT imaging. (With permission from Ishimitsu DN, Saouaf
R, Kallman C, Balzer BL: Best cases from the AFIP: renal hydatid disease. Radiographics
2010;30(2):334–337.)
Fig. 6.3  Retrograde urethrogram of a 1-cm bulbar urethral stricture.
Salmonella, but atypical organisms can occur in severely
immunocompromised individuals. The signs of a prostatic infection
may include perineal pain, fevers, and bacteremia. Urinalysis and
culture may be equivocal if the patient is taking suppressive
antibiotics such as trimethoprim-sulfamethoxazole. A digital rectal
examination will reveal a tender prostate and in some cases a
fluctuant mass. Definitive diagnosis can be made with transrectal
ultrasound or pelvic contrast-enhanced CT or magnetic resonance
imaging (MRI), where available. Depending on local resources,
the abscess may be unroofed endoscopically.29
Infections in HIV/AIDS patients that affect the external genitalia
and inguinal region include genital ulcer disease (e.g., herpes
CHAPTER 6  Genitourinary Diseases 49
simplex virus, lymphogranuloma venereum, or Haemophilus ducreyi),
condyloma acuminatum, molluscum contagiosum, and Candida
balanitis. Giant condyloma acuminatum, known as a Buschke–
Lowenstein tumor, tends to be locally aggressive and may recur in
immunocompromised patients. Patients with advanced AIDS may
present with genital lesions due to Kaposi’s sarcoma and are
also at an increased risk of penile cancer—particularly when
uncircumcised.
Patients with HIV/AIDS being treated with a protease inhibitor
may be at an increased risk for urolithiasis. Indinavir has been
associated with stone formation in 4% to 13% of cases.30,31
Indinavir stones are radiolucent and may require contrast during
an IVP to help outline them. Atazanavir has also been associ-
ated with urolithiasis32; concomitant liver or renal disease may
potentiate this risk.33 Atazanavir crystals are rodlike and mildly
birefringent under light microscopy, whereas indinavir crystals
may be crystal-like or fan-shaped. Conservative management with
fluids, pain control (in particular non-steroidal anti-inflammatory
drugs [NSAIDs]), and an alpha-blocker will manage most stone
cases. Adequate hydration may help prevent stone formation.
Tenofovir, a nucleotide reverse transcriptase inhibitor, used both
for prevention (pre-exposure prevention or PrEP) and therapy
of HIV, has been associated with renal dysfunction. Renal func-
tion should be screened before use and intermittently while
on therapy.
NON-COMMUNICABLE GENITOURINARY DISEASES
Congenital Abnormalities
The three most common GU congenital abnormalities observed
in the United States and abroad are pre-natal hydronephrosis,
undescended testicles, and penile hypospadias. Pre-natal screening
will improve detection of hydronephrosis, which is present in
approximately 1% of pregnancies. In most children this finding
is benign and will self-resolve. However, some children will have
50 PART 1  Clinical Practice in the Tropics
an underlying anatomic abnormality (e.g., ureteropelvic junction
obstruction, vesicoureteral reflux, ureterovesical junction obstruc-
tion, or posterior urethral valves). Bilateral hydronephrosis in a
male fetus requires immediate post-natal follow-up because it
may indicate posterior urethral valves—a lethal disease if left
untreated. Otherwise, the fetus can be followed post-natally with
an ultrasound between 1 and 2 months after birth. If the baby
develops a febrile UTI, further imaging and prophylactic antibiotics
are recommended. The evaluation and management of antenatal
hydronephrosis is detailed by the American Society of Fetal
Urology.34
Cryptorchidism occurs in 3% of full-term pregnancies
and upwards of 20% to 30% of premature births. Surgical
management, preferably within the first 18 months of life, will
decrease the risk of cancer and improve semen parameters.35 The
presence of intra-abdominal testicles poses a risk of cancer if
uncorrected in post-pubertal patients. Surgical treatment may
also reduce the risk of torsion or trauma to the ectopic testicle.
Ultrasound has a poor sensitivity and specificity for detecting
undescended testicles; typically a physical examination is more
useful. In older or obese children in whom an examination
may be difficult, inguinal-scrotal ultrasound can be considered.
Bilateral cryptorchidism, particularly in association with severe
hypospadias, is a sign of a more serious condition. These patients
should be evaluated for conditions associated with ambiguous
genitalia with a karyotype (in resource-limited settings, a blood
sample may need to be sent to another country for evaluation),
pelvic ultrasound, serum electrolytes, and testosterone. The most
important initial diagnosis to rule out is salt-wasting congenital
adrenal hyperplasia, which can be lethal if untreated. Evaluation
and management of cryptorchidism and ambiguous genitalia are
available.36,37
Penile hypospadias occur in approximately 1/250 births. Surgical
repair is delicate, particularly in more severe cases, which are
associated with a high rate of complications (including urethro-
cutaneous fistulae, dehiscence, and strictures). The condition may
be associated with social stigma and can affect fertility and
urination.38
Genetic Diseases
Sickle cell disease (SCD) has a genetic prevalence of 25% to 50%
in some West African areas. Relative hypoxia in the renal medulla
leads to sickling, with obliteration of the vasa recta, papillary
necrosis, and macroscopic hematuria. Patients with SCD have an
increased susceptibility to bacterial infections, and renal failure is
the cause of death in about 14% of cases. A common GU problem
in men with SCD is priapism—a prolonged painful erection.
Priapism occurs in 3.6% of children and upwards of 42% of adult
men.39 Acute ischemic priapism requires immediate management
with saline irrigation and aspiration, and potentially phenylephrine
injection. In addition, patients with SCD may benefit from
intravenous hydration and supplemental oxygen. Prevention of
stuttering priapism may be achieved with on-demand pseudo-
ephedrine in the SCD population.39
Metabolic Diseases
Dehydration, which is encountered more frequently in tropical
environments due to heat, limited access to clean water, and
increased rates of diarrheal disease, remains one of the strongest
risk factors for kidney stones. However, changes in diet, in particular,
increased salt and carbohydrate intake, compounds underlying
risk factors for stones. Prevention relies on increased fluid consump-
tion and decreased salt intake. In adults with an acute stone <10 mm,
initial management includes fluids, NSAIDs and an alpha-blocker.
Larger stones and infected stones require surgical management,
preferably endourologic surgery, if possible.
Trauma
Trauma to the GU tract from road traffic injuries include renal
contusion or laceration and urethral injury and/or bladder rupture
associated with pelvic fracture. Although most kidney injuries can
be managed with observation, urethral injury may lead to complex,
posterior urethral stricture disease. Penetrating trauma related to
violence typically requires surgical exploration and repair.
Birth trauma can lead to post-partum vesicovaginal fistulas in
areas where obstetric services are inadequate. Many are large,
complex fistulae involving the continence mechanism or adjacent
ureter. Vaginal repair can be performed under spinal anesthesia
by adequately trained staff; however, currently, thousands of women
remain untreated due to lack of personnel and resources.
Diseases of Aging
As people are living longer in tropical regions, GU conditions
related to aging will become more prevalent. Common conditions
include benign prostatic hypertrophy (BPH), underactive bladder,
pelvic organ prolapse, prostate cancer, and other urologic cancers.
To adequately address this growing burden of disease, sub-specialist
training is increasingly important.
REFERENCES
1. Freedman AL, Urologic Diseases in America Project. Urologic diseases
in North America Project: trends in resource utilization for urinary
tract infections in children. J Urol 2005;173(3):949–54.
2. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of
risk factors for symptomatic urinary tract infection in young women.
N Engl J Med 1996;335(7):468–74.
3. Griebling TL. Urologic diseases in America project: trends in resource
use for urinary tract infections in women. J Urol 2005;173(4):
1281–7.
4. Griebling TL. Urologic diseases in America project: trends in resource
use for urinary tract infections in men. J Urol 2005;173(4):1288–94.
5. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention
of urinary tract infection in boys: a systematic review of randomised
trials and observational studies. Arch Dis Child 2005;90(8):853–8.
6. Parsons MA, Harris SC, Grainger RG, et al. Fistula and sinus formation
in xanthogranulomatous pyelonephritis. A clinicopathological review
and report of four cases. Br J Urol 1986;58(5):488–93.
7. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological
classification, management, prognosis, and pathogenesis. Arch Intern
Med 2000;160(6):797–805.
8. Khalaf I, Shokeir A, Shalaby M. Urologic complications of genitourinary
schistosomiasis. World J Urol 2012;30(1):31–8.
9. Zaghloul MS. Bladder cancer and schistosomiasis. J Egypt Natl Canc
Inst 2012;24(4):151–9.
10. Beard JH. Hernia and Hydrocele. Essential Surgery: DCP, vol. 1. 3rd
ed. Washington (DC): The International Bank for Reconstruction and
Development / The World Bank; 2015 Apr 2. [chapter 9].
11. Salako AA, Olabanji JK, Oladele AO, et al. Surgical Reconstruction
of Giant Penoscrotal Lymphoedema in sub-Saharan Africa.Urology
2018;112:181–5.
12. Singh V, Sinha RJ, Sankhwar SN, Kumar V. Reconstructive surgery for
penoscrotal filarial lymphedema: a decade of experience and follow-up.
Urology 2011;77(5):1228–31.
13. World Health Organization. 2015 data on tuberculosis: http://www.
who.int/tb/en/.
14. Lenk S, Schroeder J. Genitourinary tuberculosis. Curr Opin Urol
2001;11(1):93–8.
15. Cek M, Lenk S, Naber KG, et al. EAU guidelines for the management
of genitourinary tuberculosis. Eur Urol 2005;48(3):353–62.
16. Moussa OM, Eraky I, El-Far MA, et al. Rapid diagnosis of genitourinary
tuberculosis by polymerase chain reaction and non-radioactive DNA
hybridization. J Urol 2000;164(2):584–8.
17. Bell DJ, Stanislavsky A, et al. Putty Kidney. Radiopoedia. https://
radiopaedia.org/articles/putty-kidney.
18. Rexiati M, Mutalifu A, Azhati B, et al. Diagnosis and surgical treatment
of renal hydatid disease: a retrospective analysis of 30 cases. PLoS
ONE 2014;9(5):e96602.

19. Horchani A, Nouira Y, Kbaier I, et al. Hydatid cyst of the kidney. A
report of 147 controlled cases. Eur Urol 2000;38(4):461–7.
20. Osman E, Khan Z, Abualsel A, Bhatty T. An undiagnosed giant right
renal hydatid cyst treated laparoscopically: Case report and review
of literature. Urol Ann 2016;8(4):471–3.
21. Shukla S, Singh SK. Pujani M. Multiple disseminated abdominal
hydatidosis presenting with gross hydatiduria: a rare case report.
Indian J Pathol Microbiol 2009;52(2):213–14.
22. World Health Organization Informal Working Group. International
classification of ultrasound images in cystic echinococcosis for
application in clinical and field epidemiological settings. Acta Trop
2003;85:253–61.
23. Arif SH, Shams-Ul-Bari, Wani NA, et al. Albendazole as an adjuvant
to the standard surgical management of hydatid cyst liver. Int J Surg
2008;6(6):448–51.
24. Fenton AS, Morey AF, Aviles R, Garcia C. Anterior urethral strictures:
etiology and characteristics. Urology 2005;65:1055–8.
25. Fall B, Sow Y, Mansouri I, et al. Etiology and current clinical char-
acteristics of male urethral stricture disease: experience from a public
teaching hospital in Senegal. Int Urol Nephrol 2011;43(4):969–74.
26. Lumen N, Hoebeke P, Willemsen P, et al. Etiology of urethral stricture
in the 21st century. J Urol 2009;182:983–7.
27. World Health Organization. HIV/AIDS Fact Sheet. 19th July 2018.
https://www.who.int/en/news-room/fact-sheets/detail/hiv-aids.
28. Heyns CF, Groeneveld AE, Sigarroa NB. Urologic complications of
HIV and AIDS. Nat Clin Pract Urol 2009;6(1):32–43. Erratum in:
Nat Clin Pract Urol. 2010;7(4):178.
CHAPTER 6  Genitourinary Diseases 51
29. Heyns CF, Fisher M. The urological management of the patient with
acquired immunodeficiency syndrome. BJU Int 2005;95(5):709–16. 6
30. Wu DS, Stoller ML. Indinavir urolithiasis. Curr Opin Urol
2000;10(6):557–61.
31. Saltel E, Angel JB, Futter NG, et al. Increased prevalence and analysis
of risk factors for indinavir nephrolithiasis. J Urol 2000;164(6):1895–7.
32. Izzedine H, Lescure FX, Bonnet F. HIV medication-based urolithiasis.
Clin Kidney J 2014;7(2):121–6.
33. Chan-Tack KM, Truffa MM, Struble KA, et al. Atazanavir-associated
nephrolithiasis: cases from the US Food and Drug Administration’s
Adverse Event Reporting System. AIDS 2007;21:1215–18.
34. Nguyen HT, Herndon CD, Cooper C, et al. The Society for Fetal
Urology consensus statement on the evaluation and management of
antenatal hydronephrosis. J Pediatr Urol 2010;6(3):212–31.
35. Pastuszak AW, Lipshultz LI. AUA guideline on the diagnosis and
treatment of cryptorchidism. J Urol 2014;192(2):346–9.
36. Kolon TF, Herndon CD, Baker LA, et al. American Urological Assoca-
tion. Evaluation and treatment of cryptorchidism: AUA guideline. J
Urol 2014;192(2):337–45.
37. Lambert SM, Vilain EJ, Kolon TF. A practical approach to
ambiguous genitalia in the newborn period. Urol Clin North Am
2010;37(2):195–205.
38. Metzler IS, Nguyen HT, Hagander L, et al. Surgical outcomes
and cultural perceptions in international hypospadias care. J Urol
2014;192(2):524–9.
39. Salonia A, Eardley I, Giuliano F, et al. European Association of Urology
guidelines on priapism. Eur Urol 2014;65(2):480–9.