3.7. Genitourinary TB

3.7.1. Urinary tract

Urinary tract disease is more commonly seen in men and those with end-stage renal disease requiring dialysis.⁵⁶^,²⁶⁰ Most often, onset of the disease is insidious, and patients present with asymptomatic sterile pyuria, gross hematuria, frequency and dysuria.^261–264 Back pain or flank pain resembling acute pyelonephritis often reflects calyceal or ureteral obstruction, though renal colic is uncommon. Bladder involvement (with resultant diminished bladder capacity) may present with complaints of an inability to empty the bladder and may be associated with the development of a secondary bacterial bladder infection.

Ultrasonography, CT and MRI are useful diagnostic modalities for the assessment of genitourinary TB.²⁶⁵^,²⁶⁶ Radiologic abnormalities associated with urinary tract TB are distorted or eroded calyces, hydronephrosis, renal parenchymal scarring and calcification (all of which can mimic the changes seen in chronic pyelonephritis).²⁶⁵^,²⁶⁷

In patients with urinary tract disease, urine samples sent for AFB smear, NAAT and culture will confirm the diagnosis in more than 90% of cases. (Table 1 and Chapter 3: Diagnosis of Tuberculosis Disease and Drug-resistant Tuberculosis for details).²³^,54–57,²⁶⁸ Antibiotic therapy with fluoroquinolones, used to treat superimposed bacterial infection, may compromise the laboratory’s ability to recover M. tuberculosis in urine samples and therefore should be stopped more than 48 hours before urine specimens are collected for mycobacteriologic assessment.²⁶⁸ Occasionally, fine needle aspiration (FNA) of the kidney under ultrasound guidance may be indicated if radiologic assessment is suggestive of renal TB and urine mycobacterial cultures are negative.⁵⁷^,⁵⁸

3.7.2. Genital tract

Genital tract TB may follow from a renal focus; the diagnosis of genital TB, therefore, should lead to a search for urinary tract disease. However, disease involving the female genital tract or the seminal vesicles in males is most often due to hematogenous or direct spread from neighboring organs; as such a lack of confirmation of urinary TB should not preclude further investigation in genital tract TB.

3.7.2.1 Female genital tract TB

Any site in the female genital tract may be involved; however, for reasons that are unknown, 90-100% of patients with female genital tract TB have fallopian tube infection, and both tubes are usually involved, with resultant high rates of infertility.^269–271 Female genital tract TB is most commonly diagnosed during a work-up for infertility or during evaluation of abnormal uterine bleeding, pelvic pain or adnexal masses. Other, less common sites of involvement in the female genital tract include cervical or vulvovaginal, which frequently presents as abnormal vaginal bleeding or ulcers.²⁷² The diagnosis of female genital tract TB requires a combination of microbiologic, histologic and radiologic techniques.⁵⁹^,⁶⁰^,²⁷⁰^,²⁷¹^,²⁷³ Findings on hysterosalpingography may suggest TB, although, as with renal TB, imaging is often nonspecific and characteristic findings are typically seen only with more advanced disease.²⁷⁴ Cultures of M. tuberculosis can be obtained from several sources, including menstrual fluid, peritoneal fluid, endometrial biopsy or biopsy of abnormal tissue identified during laparoscopy.⁵⁹^,⁶⁰^,⁶²^,²⁷³^,²⁷⁵ Small studies have examined the role of NAAT testing in diagnosis of female genital tract TB, with high sensitivity in tissue samples.⁶¹ Even with adequate treatment for female genital tract TB, subsequent fertility rates range between 10% and 30%.⁶⁰^,²⁷⁶^,²⁷⁷ The importance of confirming a diagnosis of TB-related infertility has been highlighted by cases of congenital TB in those in whom the diagnosis has not been identified prior to in-vitro fertilization.²⁷⁸

3.7.2.2 Male genital tract TB

As with the female genital tract, any site of the male genital tract can be involved. Epididymitis/orchitis is the most common presentation.²⁶⁹ Penile and prostatic involvement are rare.²⁶⁹^,²⁷⁹^,²⁸⁰ Male genital tract TB usually presents with scrotal swelling, sometimes with rectal or pelvic pain and less commonly with hydrocele or, in advanced cases, a discharging sinus (“watering can” perineum).²⁶⁹^,²⁷⁹ On examination, the epididymis can be rubbery or nodular, and the prostate can be thickened with hard nodules. Between 50% and 75% of patients have palpable thickening of the vas deferens. Urine and discharge from draining sinuses should be sent for AFB smear, NAAT and culture.^63–66 If this is nondiagnostic, biopsies (FNA or excisional) should be performed for diagnosis.^63–66

3.7.3. Bacillus Calmette-Guérin (BCG) disease

Individuals who have received intravesical administration of BCG for treatment of bladder cancer are at risk of developing localized genitourinary TB (1% of patients) or spinal or disseminated disease (0.4% of patients).^281–287 Men are more likely to develop BCG disease, with a median time to diagnosis of 170 days post-installation.²⁸⁴ Diagnosis can be made with urine mycobacterial sampling for genitourinary disease, and with biopsy sampling of affected organ(s) for disseminated disease.

3.7.4. Genitourinary TB treatment

Standard 6-month anti-TB treatment for drug-susceptible genitourinary TB has demonstrated adequate mycobacterial cure rates in observational studies in male genital TB and urinary TB, and is the suggested regime.²¹^,288–290 There has been one randomized controlled trial in female genital TB comparing 6 months and 9 months of treatment that demonstrated similar treatment outcomes; therefore 6 months is the suggested treatment duration.²⁹¹ Given the drug-susceptibility profile of BCG mycobacterium (with sensitivity to INH and RMP and resistance to pyrazinamide), individuals with disease caused by BCG are usually treated with 9 months of INH and RMP.²⁸¹^,²⁸²^,285–287

Recommendations

We conditionally recommend six months of standard anti-TB therapy for treatment of drug-susceptible genitourinary TB (poor evidence).
We conditionally recommend a minimum of nine months of treatment with isoniazid and rifampin for BCG disease, given inherent pyrazinamide resistance (poor evidence).

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