INT J TUBERC LUNG DIS 19(12):1441–1447
Q 2015 The Union
http://dx.doi.org/10.5588/ijtld.14.0888
Computerised tomography and intravenous pyelography in
urinary tuberculosis: a retrospective descriptive study
Y. Wang,* J-P. Wu,† G-C. Qin,* D-Y. Li,* Z-P. Zhou,* X. Dou,* B. Zhu,* H-Q. Guo†
Departments of *Radiology, and †Urology, the Affiliated Nanjing Drum Tower Hospital of Nanjing University
Medical School, Nanjing, China
OBJECTIVE: To assess the radiological findings of
urinary tuberculosis (TB) in patients from multiple
centres to improve understanding of this disease among
urologists and radiologists.
M A T E R I A L S A N D M E T H O D S : A total of 192 consecu-
tive patients (98 males and 94 females) with urinary TB
underwent computed tomography; 28 of the 192 also
underwent contrast agent-enhanced intravenous pyelog-
raphy of the kidney, ureter and bladder (KUB/IVP).
R E S U LT S : The most common finding was hydrone-
phrosis, observed in 79.1% of the patients, with
THE URINARY SYSTEM is one of the most
common sites of extra-pulmonary tuberculosis
(TB).1,2 As urinary TB has various clinical charac-
teristics and is often misdiagnosed,3 the early
diagnosis of the condition would be helpful in
rescuing kidney function.4,5 Minimal attention has
been devoted to the diagnosis of urinary TB using
imaging techniques, and a systematic approach to its
clinical diagnosis has not yet been established.2,6
With recent improvements in imaging technology,
imaging findings could be used to support the
diagnosis of urinary TB.7 Characteristic kidney,
ureter and bladder signs as observed using intrave-
nous pyelography (kidney, ureter, bladder/intrave-
nous pyelography [KUB/IVP]) and computed
tomography (CT) are useful in identifying urinary
TB.7 However, radiographic findings of early uri-
nary TB are often non-specific and are of limited
diagnostic value.8–10 No systematic descriptions of
urinary TB based on imaging characteristics in large
samples have been reported.
We performed a retrospective study of a large
sample of patients with urinary TB to more
precisely evaluate urinary TB and promote a better
WY, JPW, QG, LD, ZZP and XD are co-first authors.
Correspondence to: Hongqian Guo, Department of Urology, the Affiliated Nanjing Drum Tower Hospital of Nanjing
University Medical School, 321 Zhongshan Road, Nanjing 210008, China. Tel: (þ86) 025 8310 6666. Fax: (þ86) 025 8331
7016. e-mail: guohongqiang2014@163.com
Article submitted 25 November 2014. Final version accepted 18 June 2015.
SUMMARY
81.4% of the destructive renal lesions identified in the
medulla. The numbers of lesions in the dorsal medulla
and the lower pole of the renal medulla were greater
than those in the ventral, middle and upper poles (P ¼
0.0361).
C O N C L U S I O N : Hydronephrosis is a frequently ob-
served radiological finding among patients with urinary
TB. Most TB lesions were observed in the renal medulla,
especially the dorsal and lower poles of the medulla.
K E Y W O R D S : radiological features; urinary TB; imag-
ing
understanding of this disease among urologists and
radiologists.
MATERIALS AND METHODS
Institutional review board approval was obtained for
this retrospective study at all participating sites; the
need for informed consent was waived as the study
was based on patient records.
Patient population
This retrospective analysis was based on patient data
collected from five hospitals: four in Jiangsu Province
and one in Zhejiang Province, China. Between
January 2007 and April 2014, a total of 192
consecutive urinary TB patients who had undergone
contrast-enhanced KUB/IVP, CT or both were con-
sidered for inclusion in the study. Exclusion criteria
included upper urinary tract tumours or stones and a
history of urinary tract trauma. Participation of
hospitals in the study was voluntary. The final
selection reflected a good mixture of centres located
in both Nanjing and Ningbo, including academic and
general hospitals as well as small and large centres
with dedicated radiology departments.
Patients were selected using a database search of
medical records. A final 192 patients formed the basis
1442 The International Journal of Tuberculosis and Lung Disease
of this report. A total of 98 males and 94 females,
ranging in age from 16 to 92 years (mean 46.3 years
6 standard deviation [SD] 16.6) were enrolled in the
study. Urinary TB was confirmed in all 192 patients
and diagnosed using urine acid-fast staining or
culture (n ¼ 103) or by histological examination of
surgical specimens (n ¼ 89). All of the patients
underwent surgery after imaging.
Imaging techniques
KUB/IVP images
KUB/IVP was performed on 28 patients using the
kVp, mA and geometrical parameter values of the
standard protocol provided with the simulated digital
diagnostic X-ray system (Philips Healthcare, Eind-
hoven, The Netherlands). All of the KUB/IVP studies
were recorded using a picture archiving and commu-
nication system (PACS) recorder for subsequent over-
reading. With the patient in the prone position, both
kidneys were visualised on KUB. The clinical history
and KUB findings were interpreted, and a prospective
diagnosis was made and recorded. IVP was then
performed on all of the patients. A 100-ml IV bolus of
non-ionic contrast material (Omnipaque 350; GE
Healthcare, Milwaukee, WI, USA) was administered
followed by radiography at 1, 5, 10, 15 and 20 min.
Post-void and delayed films were obtained if indicat-
ed.
CT images
All CT examinations were performed using a 16- and
64-slice GE CT system (GE Healthcare) or a 16- and
64-slice Philips CT system (Philips Healthcare). All
scans were performed using a helical technique, and
images were obtained using the following parameters:
a single breath-hold; 1.25 or 1.75 mm collimation,
gantry rotation speed of 0.5 s, a pitch of 1.0, 1.25 or
1.5 mm reconstruction; 120 kVp; 250 mA; a 512 3
512 matrix; and a display field-of-view of 25 cm. The
non-ionic contrast agent iohexol (Omnipaque 350)
was injected with a power injector at a rate of 3.0 ml/s
through the marginal vein using a 20-gauge needle at
a dose of 1.0 ml/kg. CT was started 30 s after the
injection. Axial images were reconstructed using the
standard algorithm. Image quality was assessed
paying particular attention to visualisation of the
renal parenchyma, ureter and bladder with medias-
tinal window settings (window width, 400 H;
window level, 65 H).
All 192 patients were examined using CT, 28 of
whom were also examined using KUB/IVP. The KUB/
IVP and CT findings were reviewed by two radiolo-
gists. To determine the accuracy of the KUB/IVP and
CT diagnoses, a consensus interpretation of the
imaging findings was accepted. We assessed the
presence and frequency of certain findings on KUB/
IVP and CT, including indirect manifestations (hy-
dronephrosis, poorly staining kidney and autoneph-
rectomy) and direct manifestations (renal swelling,
destructive lesions and repair manifestations). The
frequency of each finding on KUB/IVP and CT was
recorded.
KUB/IVP and CT image analysis
All KUB/IVP and CT images were independently
reviewed in a random order by two radiologists (YW
and BZ), with respectively 10 and 32 years of
experience. The observers were notified of the
locations of the lesions but were blinded to all other
information. Three image sets were reviewed as
follows: KUB/IVP images alone, thin-slice CT images
alone and KUB/IVP plus thin-slice CT images. First,
the KUB/IVP images alone and the thin-slice CT
images alone were interpreted, in that order; the
KUB/IVP plus thin-slice CT images were then
evaluated after an interval of 2 weeks.
Statistical analysis
KUB/IVP and CT findings were compared using the
McNemar test as appropriate, and P values of ,0.05
were considered statistically significant. The KUB/
IVP and CT study patterns with multiple findings
were further analysed. Multiple findings on KUB/IVP
or CT were classified as the presence of a single
imaging finding at multiple locations or the presence
of multiple co-existing imaging findings.
RESULTS
Image quality analysis
KUB/IVP findings
The most common findings on KUB/IVP were
hydrocalycosis, hydronephrosis or hydroureter due
to stricture in 54.8% of the patients (15/28 patients),
autonephrectomy in 18.7% (5/28 patients) and
urinary tract calcifications in 26.3% (7/28 patients)
(Figure 1A). Interobserver agreement between the
two readers on a per-patient basis showed a j value of
0.75, representing substantial agreement.
CT findings
The frequency of imaging findings on CT in the 192
patients is given in the Table. Hydrocalycosis,
hydronephrosis or hydroureter due to stricture was
the most common finding in 79.1% of the patients
(151/192 patients) (Figure 1B), followed by paren-
chymal scarring in 67.6% (130/192 patients), renal
swelling in 54.8% (105/192 patients) (Figure 1C),
and thickening of the renal pelvis, ureter and bladder
walls in 23.1% (44/192 patients) (Figure 1D). In
long-standing TB with atrophy of the renal paren-
chyma, normal kidney morphology is lost (Figure
1C). A total of 92.0% (177/192) of renal TB cases
involved a single kidney (Figure 1A, B; Figure 2A, C,
D; and Figure 3A, B). Renal TB in the right or left
kidney was found at a rate of respectively 51.2% (91/
 Features of urinary TB on CT 1443

Figure 1 Hydronephrosis and hydroureter in a 42-year-old man (A and B) and hydronephrosis, swelling, atrophy and a thickened
urinary tract wall in a 71-year-old man (C and D). A) The marked left hydronephrosis and hydroureter are revealed by IVP imaging
(white arrow). B) The marked left hydroureter (white arrow) and necrotic tissue are shown on abdominal axial-enhanced CT. C)
Bilateral hydronephrosis (arrow and arrowhead), left renal swelling and right atrophy are shown on CT imaging. The renal medulla
lesion in the lower pole is clear (arrowhead). D) The axial-enhanced CT image shows circumferential ureteral wall thickening (arrow).
IVP ¼ intravenous pyelography; CT ¼computed tomography.

177) and 48.8% (86/177) (P ¼ 0.6102; Table). Only
8.0% (15/192) of renal TB cases were bilateral
(Figure 1C).
In our study, 89.1% (171/192) of the patients
presented with poorly staining kidneys in the cortico-
medullary and parenchymal phases. Characteristic
early washout during the arterial and early cortico-
medullary phases served as differential criteria
against other inflammatory lesions (Figure 2A).
Calcifications were noted in patients with healed or
chronic TB (Figure 2). Renal calcifications in renal
parenchyma were identified on CT in 123 cases. The
final outcome of inadequately treated TB is dystro-
phic calcification involving both kidneys, known as
‘putty kidney’ (Figure 2D).
Our results showed that 81.4% (156/192) of the
destructive renal lesions of end-stage renal TB were
identified in the medulla (Figure 1B and C and Figure
2A). Destructive forms of circular or quasi-circular
abscess cavities with diameters ranging from 0.8 to
3.4 cm could be detected on CT. However, some
details of the features of these lesions could be easily
overlooked on KUB/IVP images. The number of
major lesions in the dorsal medulla was larger than
that in the ventral medulla, and these lesions
accounted for respectively 68.2% (393/576) and
31.8% (183/576) of the total number of lesions (P
, 0.05; Figure 3A). The number of major lesions in
the lower pole of the renal medulla was greater than
in the middle and upper poles, and these lesions
accounted for respectively 50.5% (291/576), 36.7%
(211/576) and 12.8% (74/576) of the total lesions (P
, 0.05; Figure 3B, Table).
When the renal pelvis and ureter showed TB
involvement, hydronephrosis was considered to be
severe. The involved segments showed wall thicken-
1444 The International Journal of Tuberculosis and Lung Disease

Table Imaging findings on computed tomography ing and enhancement on CT (Figure 1D). Multiple
Imaging finding n/N (%) strictures were commonly observed in the ureters on
CT images. Our results show a rate of ureteral
Indirect manifestations
Hydronephrosis 152/192 (79.1) calcification of 26.3% (50/192); renal calcification
Poorly staining kidney 129/192 (67.6) was the most common form in 58.8% (113/192) of
Autonephrectomy 36/192 (18.7)
patients (Figure 2C and D).
Direct manifestations
Renal swelling 146/192 (76.2)
Location of destructive lesions
Left kidney 98/192 (48.8)
DISCUSSION
Right kidney 94/192 (51.2)
Renal medulla 156/192 (81.4) KUB/IVP and CT are the two most commonly used
Upper 24/192 (12.8) methods for urinary TB imaging.7 The accuracy of
Middle 70/192 (36.7)
Lower 97/192 (50.5)
KUB/IVP in the diagnosis of urinary TB is 88%.11
Dorsal 131/192 (68.2) The earliest urographic change occurs in the minor
Ventral 61/192 (31.8) calyces, with subtle initial signs such as minimal
Repair manifestation calyceal dilatation.12 As the disease progresses, the
Nephrotic 130/192 (67.6)
Renal calcification 112/192 (58.8) calyceal outline becomes more irregular, fuzzy and
Ureteral calcification 50/192 (26.3) ragged, subsequently becoming feathery and ‘moth-
eaten’ in appearance. Although calyceal erosion has
been described as the first KUB/IVP sign in renal

Figure 2 Comparison of destructive lesion in a 40-year-old woman (A and B) and pathological repair in a 70-year-old woman (C)
and a 58-year-old woman (D). A) Focal hypoperfusion of the right kidney was observed on axial-enhanced CT (white arrow). B) The
low-power photomicrograph (haematoxylin-eosin staining; original magnification, 40x) shows renal TB with focal-caseating
granulomas, glomerular hyalinisation and sheets of chronic interstitial inflammation. C) The non-enhanced image reveals the presence
of small areas of calcification in the left kidney (arrow). D) The non-enhanced image depicts dense calcification replacing the right
kidney (arrow). CT ¼ computed tomography.

Figure 3 Accurate renal parenchymal cavities on oblique-enhanced CT in a 62-year-old woman (A) and a 47-year-old man (B). A)
The contrast-enhanced image shows that the caseous necrosis in the dorsal medulla is larger than that in the ventral medulla (arrows).
B) The contrast-enhanced image shows that the large caseous necrosis in the lower pole is much larger than those in the middle and
upper poles of the renal medulla (arrow). CT ¼computed tomography.
TB,12 in the authors’ opinion early papillary necrosis
may be the first detectable sign in practice.
From 2007 to 2014, the primary morphological
changes in patients with renal TB were hydronephro-
sis (79.1%) and renal swelling (76.2%) (Figure 2A,
Table). Hydronephrosis is considered to be severe
when the renal pelvis and ureter are involved. Wall
thickening and post-contrast enhancement can be
observed in the involved segment of the collecting
system.13 The progression of urinary TB can be
described according to its initial haematogenous
dissemination, reactivation and destructive spread,
which can be correlated with the pathogenesis of
inflammation, tissue swelling significantly earlier
than tissue atrophy and scar formation.14 During
the late phase of renal TB, histopathological exam-
ination revealed varying degrees of mixed inflamma-
tory cell infiltration and tissue necrosis (Figure 2B).
Engin et al. and Das et al. reported that localised
tissue oedema and vasoconstriction caused by active
inflammation result in focal hypoperfusion, as
observed on contrast-enhanced CT.15,16
In our patients, we found that most of the renal TB
cases had single kidney involvement. Similar results
were also reported by Ballesteros et al. and Chowd-
hury.17,18 One possible reason why TB would affect
only one kidney is the possible trapping of Mycobac-
terium tuberculosis in periglomerular capillaries
Features of urinary TB on CT 1445
during the early stage of renal TB. We estimate that
as this process progresses, survival may be ensured by
as yet unidentified compensatory mechanisms. Addi-
tional investigations into this area are therefore
needed.
In addition to the repair characteristics of the
involved kidney, another common manifestation of
urinary TB is uneven renal parenchymal calcifica-
tions.7 Triangular ring-like calcifications characteris-
tic of papillary necrosis may be noted within the
collecting system and in the lower pole of the kidney
(Figure 2). These results may be explained by the fact
that TB is a chronic inflammatory infectious disease
caused by interactions between tissue injury and
repair mechanisms. Muttarak et al. have reported
that calcification is detectable in a large number of
cases (40–70%);19 this varies in appearance depend-
ing upon the stage and severity of the disease, from
punctate areas to amorphous areas to thin rims
surrounding low-attenuation areas of focal cortical
inflammation. Calcification may also be noted in
patients with healed or chronic TB.15,20
During the early stages of urinary TB, a few calices
are involved, and only papillary necrosis or calyceal
deformity are depicted on imaging studies.21 Our
results showed that most of the destructive renal
lesions of TB are located in the medulla (Table). In
TB cases, papillary necrosis results not only from
1446 The International Journal of Tuberculosis and Lung Disease
ischaemia, which is the basis of change in most cases
of renal papillary necrosis, but also as a result of
direct tissue destruction. Medullary cavitation with
communication with the collecting system has been
described as a frequent finding by Kollins et al.22
This cavitation may involve one or more papillae
unilaterally or bilaterally, and it can vary in
appearance from small and smooth to large and
irregular;22 however, the incidence rate has not been
reported. Currently, the central type of necrosis in
TB cases most likely occurs due to ischaemia.
Ischaemic papillary necrosis in renal TB could be
caused by a small granuloma eroding or impinging
upon adjacent vessels.23 However, these possibilities
will require further study. According to our CT
imaging, embryology and immunology findings, we
propose some possible explanations. Considering
that the concentration of prostaglandin (PG) E2 in
the renal medulla is approximately 10–100 times
higher than that in the renal cortex and the finding
that PGE2 is immunosuppressive,24–26 we propose
that PGE2 might play an important role in regulating
the incidence of renal medulla TB. This hypothesis
will require further testing.
Our results collected over 8 years showed that the
numbers of renal TB lesions in the dorsal medulla and
lower pole of the renal medulla are greater than those
in the ventral medulla and middle and upper poles of
the renal medulla (Figure 3). Gurski & Baker
reported that a chronic renal abscess might have the
appearance of a well-circumscribed multiseptated
cystic renal mass or a cystic renal neoplasm.27
However, to our knowledge, no previous reports
have described the presence of renal TB lesions in the
renal medulla. The combination of collinear vari-
ables, such as a sedentary lifestyle, being bedridden,
the effect of gravity and the distribution of blood flow
in the kidneys, with multivariate and role-related
factors can lead to the development of a cheese-like
substance in the lower pole of the renal medulla and
dorsal renal medulla.
Our study had several limitations. First, the
population size was not consistent over the years and
only a few samples were observed in 2007. This was
due to the fact that the population came from hospitals
and that PACS had not been implemented in all
hospitals at the same time. The second limitation stems
from the use of cases from different hospitals. There
are no standards to define the appropriate technical
requirements for each type of urinary TB.
In conclusion, the study characterises and classifies
the most frequent radiological presentations of
urinary TB. Renal TB lesions are most likely to be
observed in the dorsal medulla and lower pole of the
renal medulla with kidney swelling. This knowledge
could facilitate the identification of patients with
clinical suspicion of urinary TB, and it enhances our
understanding of this disease.
Acknowledgements
Financial support for the study came from the National Natural
Science Foundation of China, Beijing (Grant no. 81400702), and
the Medical Technology Development Project of Nanjing, Nanjing,
China (Grant nos. YKK13062). The authors wish to thank X
Zheng for his commenets.
Conflicts of interest: none declared.
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O B J E C T I F : Evaluer les constatations radiologiques de
la tuberculose (TB) urinaire chez des patients dans de
nombreux centres pour promouvoir une meilleure
compréhension de la maladie par les urologistes et les
radiologistes.
M A T E R I A L S E T M É T H O D E : Un total de 192 patients
consécutifs (98 hommes et 94 femmes) atteints de TB
urinaire a eu un balayage tomodensitométrie, et 28
autres sur les 192 ont eu un examen avec produit de
contraste du rein, de l’uretère, de la vessie avec
myélographie (KUB/IVP).
R É S U LT A T S : L’hydronéphrose a été la constatation la
O B J E T I V O: Evaluar los hallazgos radiográficos en los
casos de tuberculosis (TB) urinaria en varios centros,
con el propósito de mejorar la comprensión de esta
enfermedad por parte de los urólogos y los radiólogos.
P A C I E N T E S Y M É T O D O S: Se practicó una tomografı́a
axial computarizada a 192 pacientes consecutivos (98
hombres y 94 mujeres) con diagnóstico de TB urinaria;
además, en 28 de los 192 pacientes se llevó a cabo una
pielografı́a intravenosa con contraste y realce del riñón,
el uréter y la vejiga (KUB/IVP).
R E S U L T A D O S: El hallazgo más frecuente fue la
Features of urinary TB on CT i
RESUME
plus fréquente faite chez 79,1% des patients. De plus,
81,4% des lésions destructives rénales ont été identifiées
dans la medulla. Le nombre de lésions dans la medulla
dorsale et le pôle inférieur de la medulla rénale a été plus
élevé que dans les pôles ventral, moyen et supérieur (P ¼
0,0361).
C O N C L U S I O N : L’hydronéphrose est une constatation
radiologique très fr équemment observ ée chez les
patients qui ont une TB urinaire. De plus, la majorité
des lésions TB ont été observées dans la medulla rénale,
surtout dans son pôle dorsal et inférieur.
RESUMEN
hidronefrosis, presente en el 79,1% de los pacientes.
Además, el 81,4% de las lesiones destructivas del
parénquima renal se localizó en la médula. Las lesiones
de la médula dorsal y el polo inferior de la médula renal
fueron más numerosas que las lesiones ventrales, medias
o del polo superior (P ¼ 0,0361).
C O N C L U S I Ó N: La hidronefrosis es la anomalı́a
radiográfica observada con mayor frecuencia en los
pacientes con TB urinaria. La mayor parte de las lesiones
tuberculosas se observó en la médula renal, sobre todo
en su parte dorsal y el polo inferior.