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Renal Tuberculosis​

Genito-urinary Tuberculosis (GUTB) is caused by Mycobacterium tuberculosis, mainly through hematogenous route. It affects young adults and is more common in males.
  1. Pathogenesis and course:
    1. Severity of the infection depends upon, virulence of the organism and host resistance.
    2. It is a slowly progressive disease and primary site is often asymptomatic. The disease starts near the glomerulous, causing caseous breakdown.
    3. The ureter undergoes fibrosis and tends to shorten and straighten leading to loss of sub mucosal tunneling in the bladder and forms golf hole ureteric opening.
    4. Bladder involvement is always secondary to the kidney. Q Vesical irritative symptoms are main presenting feature. Tubercles are formed in the region of ureteric orifice and later on they coalesce and ulcerate.
    5. Healing is through fibrosis and contracture with the development of small bladder (thimble bladder).
    6. Involvement of prostate is rare and is always hematogenous. Prostate may become fibrosed this causes decrease in semen volume.
    7. Involvement of testis is always secondary to epididymis, which is involved through hematogenous route. Tail of epididymis is primary site of involvement, thus a tubercular scrotal fistula is posteriorly located.
  2. Clinical Presentation:
    1. GUTB is considered in any of the following condition:
      1. Chronic cystitis not responding to adequate antibiotic treatment.
      2. Pyuria without bacteriuria.
      3. Gross or microscopic hematuria.
      4. A non-tender enlarged beaded epididymis.
      5. Chronic discharging posteriorly placed discharging sinus.
      6.  A history of present or past tuberculosis elsewhere.
      7. Frequent painless micturation
Sterile pyuria is seen in? (AIPG 2011)
1. Chronic pyelonephritis            
2. Wilms’s tumour               
3. Renal Tuberculosis                         
4. Cystitis
Ans. C. Renal Tuberculosis. (Ref. Harrison's Internal Medicine 17th Ch282. ; Ananthanarayan Microbiology 7th ed. 276) 
  1. Laboratory Findings:
    Investigation of choice for renal TB – Spiral CT but to see for fistula or sinus formation due to TB – MRI is better modality.
    Urinalysis: Persistent pyuria with sterile routine culture; ZN staining for acid-fast bacilli and LJ medium culture should be done, (takes around 4-6 weeks).
    X-ray chest: To rule out pulm. tuberculosis.
    X-ray KUB: May also show enlarged kidney / contracted kidney / calcification or features of perinephric abscess (e.g. obscured renal or psoas shadow).
    IVP: Moth eaten appearance of the involved ulcerated calices.
    Obliteration of one or more calyces.
    Abscess cavity (space occupying lesion), which may or may not
    Communicate with the collecting system.
    Ureteral strictures.
    Non-functioning kidney.
    Cystoscopy: Tubercles; ulcer, Cystitis, Golf hole ureter or contracted bladder.
    Appearance in MRI of prostate TB called watermelon prostate.

Renal: Perinephric nephric abscess, intrarenal abscess, stone formation, CRF and aneuria.
Ureteral: Scarring and stricture formation, hydronephrosis, Pyonephrosis, autonephrectomy, Vesico-ureteral reflux.
Vesical: Contracted bladder, Vesico-ureteral reflux.
Genital: Sterility due to epididymal block, Rupture of epididymal or testicular abscess leading to discharging scrotal sinus.

  1. Treatment:
    1. Four drug ATT (INH, RCIN, ethumbutol/), is required in all.
    2. More than 1 year course or may be even 2 years course is generally requires.
    3. If after 3 months, cultures are still positive and gross involvement of kidney is radiologically evident, Nephrectomy should be considered.
    4. If a vesical ulcer fails to respond on medical treatment, trans-urethral electro-coagulation may be done.
    5. Vesical instillation of chlorpectin (monoxychlorosene) also stimulates healing.
    6. In extremely contracted bladder augmentation cystoplasty is done,
    7. For epididymal involvement treatment is medical and if it fails to respond or abscess or discharging sinus develops epididymectomy should be done.
    8. Perinephric abscess often occurs when kidney is destroyed, abscess should be drained and nephrectomy should be done.
    9. For ureteral stricture, either endoscopic dilatation or surgery is required
    10. For distal ureteral strictures or severely refluxing Vesico-ureteric junction, uretero-neocystostomy should be done.

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