Genitourinary Tuberculosis: A Brief Manual for Urologists on Diagnosis and Treatment from the European Association of Urology Urological Infections Panel

Although tuberculosis (TB) ranks among the most frequent infectious diseases worldwide, one of its extrapulmonary (EP) manifestations, genitourinary (GU) TB, is often underestimated by urologists, particularly in areas such as Europe where TB is not endemic. The aim of this review is to give urologists a concise overview of GUTB as a supplement to the more comprehensive European Association of Urology 2023 update on urological infections guidelines. EPTB can develop in 16% of TB cases. GUTB accounts for 4.6% of EPTB and is often asymptomatic or nonspecific, so it can be confused with other urogenital diseases. GUTB can be highly destructive, leading to failure of urogenital organs. Diagnosis is via microbiological, molecular, and histological testing for urine, genital secretions, or genitourinary tissue, supported by imaging. A 6-mo combinational medical regimen is the first-line treatment for GUTB. However, surgical interventions are also frequently required for the treatment of GUTB complications. Therefore, it is important to keep GUTB in mind for differential diagnosis. PATIENT SUMMARY: We reviewed scientific studies on the occurrence, diagnosis, and treatment of tuberculosis in the genitourinary tract. Our aim is to raise awareness among urologists from countries where this disease does not occur frequently, as urogenital tuberculosis can occur without any symptoms or with unspecific symptoms that can be confused with other diseases.

[History of epidemics in urology in German-speaking countries]

Pandemics are relevant for many fields of medicine from microbiology to economics and epidemiology. Many medical specialties which developed during the 19th century, e. g., urology, have had much impact on diagnostics and therapy, such as during the treatment of tuberculosis and sexually transmitted diseases. For some of them, including urology, treatment of, for example, sexually transmitted diseases, was constitutional and differed between countries.

[Adjunctive technologies in treatment of patients with urogenital tuberculosis]

INTRODUCTION

Currently, the limits of therapeutic efficiency in urogenital tuberculosis have been achieved. The etiological therapy should be supplement by pathogenetic drugs.

AIM

to determine the efficiency of deoxyribonucleate sodium in the complex treatment of patients with urogenital tuberculosis.

MATERIAL AND METHODS

Single-center open-label randomized comparative prospective study was carried out. A total of 62 patients with active urogenital tuberculosis were included. All patients received therapy in accordance with National clinical guidelines for urogenital tuberculosis. In the main group, patients additionally received pathogenetic therapy in form of deoxyribonucleate sodium via intramuscular injection of 75 mg every 48 hours. Whole one-month course consisted of 15 injections. Pathogenetic therapy was started immediately after the choosing of anti- tuberculosis drugs and confirmation of good tolerability. The efficiency of treatment was evaluated after one and three months. The assessed criteria included the intensity of pain and severity of dysuria, signs of inflammation, bacterial isolation and changes in the quality of life.

CONCLUSION

The addition of deoxyribonucleate sodium in the form of intramuscular injections of 75 mg every 48 hours for 1 months resulted in a significant increase in the efficiency of treatment. Quality of life in patients receiving deoxyribonucleate sodium improved twice (from 11.1 to 21.5 points), while in the control group this value was twice as low (from 10.8 to 15.9 points).

[DIAGNOSIS OF UROGENITAL TUBERCULOSIS]

The sequential algorithm of diagnosis of tuberculosis of the urogenital system with emphasis on the identification of the causative agent is presented; the approach to the examination of the patient is described in detail; regimens of ex juvantibus treatment are provided.

[Urinary Tuberculosis: Serious Complications May Occur when Diagnosis is Delayed]

Genitourinary tuberculosis is the third most common form of extrapulmonary tuberculosis, comprising 4 - 17% of extrapulmonary forms. The authors describe the case of a patient with recurrent urinary tract infections, without isolation of an infectious agent and without symptomatic resolution, despite antibiotic treatment. Imaging exams showed left ureteral stenosis with moderate hydronephrosis. The attempt of retrograde catheterization was impossible so we opted for percutaneous nephrostomy to renal relief. Microbiological urine analysis colleted by that way was positive for Mycobacterium tuberculosis complex. The patient started therapy with classical quadruple therapy and underwent nephrostomy for catheter placement. Despite therapeutic measures the patient required nephrectomy due to nonfunctioning kidney. Genitourinary tuberculosis is a diagnosis that should be considered in the presence of a persistent sterile pyuria.

[BASIC CONCEPTS AND CLINICAL MANIFESTATIONS OF UROGENITAL TUBERCULOSIS]

Based on analysis of domestic and international literature and his own long-standing experience the author gives clear-cut and unequivocal definitions ofdifferent forms ofurogenital tuberculosis, its comprehensive classification, which allows guiding a patient management.

[Diagnosis of tuberculosis of bladder]

A comparative analysis of cystoscopic and pathologic patterns in 190 patients hospitalized for differential diagnosis or treatment of genitourinary tuberculosis in 2008-2011 was performed. All patients underwent polyfocal biopsy followed by pathologic examination of biopsy specimens. Furthermore, a comparison of results ofpathomorphological studies of tissue obtained by biopsy and after cystectomy was conducted. Cystoscopy in all patients with tuberculosis of the bladder (TB) revealed the reduced bladder capacity in contrast to patients with other urological diseases. Deformation of orifices, trabecularity and contact bleeding were observed in 66.7 to 94.4% of cases in patients with TB, which were significantly more common than in other diseases. Polymorphism of pathological pattern and the lack of specific changes in the majority of patients with TB were noted; multinucleated Pirogov-Langhans cells were found only in 11.8% of cases, and only in biopsies, whereas in the tissues obtained after cystectomy in same patients, lymphocytic infiltration and fibrosis were observed. The algorithm of diagnosis of tuberculosis of the bladder is suggested.

Genito-urinary tuberculosis in 67 cases: experience from a tertiary core centre in India

Tuberculosis is very much prevalent in developing countries like India. Genito-urinary tuberculosis usually occurs after 5 to 15 years of the primary lung infection. After lymph node involvement,it is the second common form of extrapulmonary tuberculosis. In this retrospective study, case records of 67 patients diagnosed with genito-urinary tuberculosis in our institute were thoroughly reviewed regarding age, sex, the urogenital organ involved by tuberculosis,mode of diagnosis,and treatment given to the patients. Median age of the patients was 38.5 years, males were more commonly involved than females, kidney was the most common organ involved by tuberculosis followed by ureter and urinary bladder.HIV infection was present in a single patient who had developed tuberculous perinephric abscess. Most common mode of diagnosis was by histopathological examination of the organ involved. Hydronephrosis of the involved kidney with echogenic debris in the dilated pelvicalyceal system on ultrasonography and non-visualised kidney on intravenous urogram was the most common findings on imaging studies who underwent nephrectomy. One patient was seen with tuberculosis of the glans penis which is not much common. Surgical intervention was ablative in nature in most of the cases in the form of nephrectomy. Early diagnosis is important and can prevent the anatomical defor- mity and loss of function of the involved organ.

[Tuberculosis in urogenital organs]

Because of the progress in chemotherapy for Mycobacterium tuberculosis, it has become quite rare to diagnose patients with genitourinary tuberculosis. In Japan, however, the incidence of tuberculosis remains comparatively high, particularly in elderly patients, among advanced countries. Furthermore, infectious adverse events associated with intravesical instillation therapy with bacille Calmette-Guérin (BCG), which is one of the most useful agents against non-muscle invasive bladder cancer, are frequently developed. Considering these findings, it is still necessary to be well informed of the diagnosis as well as treatment for genitourinary tuberculosis. In this review, therefore, we would like to summarize the important topics concerning genitourinary tuberculosis, including BCG infection following intravesical instillation therapy for bladder cancer.

Urinary Tuberculosis: Ten Years' Experience

In this study of 26 patients, clinical features diagnosed as urinary tuberculosis in our nephrology and urology clinics between 1993 and 2002 were investigated retrospectively. Fifteen patients (52%) were male, and mean age was 43.5 (18-71). Twenty percent of the patients were asymptomatic. Frequency-dysuria (46%), flank pain (33%), and macroscopic hematuria (12%) were presenting symptoms. Physical examination was not diagnostically helpful in most patients. Hematuria and/or pyuria were detected in 80% of the patients. Eleven patients had positive urine cultures of Mycobacterium tuberculosis (42%), and 7 patients had positive smears (25%). Definitive diagnosis of urinary tuberculosis was established microbiologically in 15 patients (58%) and histopathologically in 11 patients (42%). Tuberculin skin test was positive in 60% of the patients. Eight patients had an abnormal chest roentgenogram. Hydronephrosis (majority bilateral) in 11 patients (42%), contracted bladder in 9 patients (34.6%), and renal calcification in 6 patients (23%) were detected. Two patients also had genital tuberculosis (epididymoorchitis). Although only medical treatment was applied in 13 patients for 9 months, in the rest of the patients medical therapy plus surgical intervention was carried out. End-stage renal failure developed in one patient who died on hemodialysis. Renal functions had decreased moderately in two other patients. In conclusion, the diagnosis of urinary tuberculosis was able to be established after the obstructive complications and functional losses were developed in a fair number of cases. Surgical treatment was carried out in half the patients. Urinary tuberculosis should be taken into consideration because early diagnosis and treatment is very important for the presenting of irreversible sequelae.

[Choice of surgical correction of urodynamics in ureteral tuberculosis]

To determine an optimal choice of surgical correction of urodynamic disorders and time of its conduction in ureteral tuberculosis, we made a retrospective analysis of 271 case histories of primary patients with tuberculosis of the kidneys who had x-ray picture of ureteral lesions, hydro- or ureterohydronephrosis. We used the following methods of this correction: calycoureteroanastomosis (n = 7, 2.5%), plastic reconstruction of the pelvoureteral segment (n = 9, 3.3%), ureteroureterostomy (n = 6, 2.2%), ureterocystostomy (n = 125, 46.1%), ureteroileoplasty (n = 6, 2.2%), ureteroileocystoplasty (n = 12, 4.4%), intestinal cystoplasty with ureteral transplantation (n = 86, 31.7%). Three-four months was an optimal preoperative preparation (treatment with antituberculous drugs). Long-term administration of the drugs (up to 1 year and longer) and late surgical urodynamic correction leads to complete dysfunction of the kidney which may result in removal of this organ (35%). Palliative operations (cystostomy, nephrostomy, ureterostomy, ureterocutanestomy) often invalidate the patients and degrade quality of their life (n = 20, 7.4%). Only high qualification of the surgeon in reconstructive plastic surgery provides good results of medical rehabilitation.

[Clinical aspects, paraclinics and therapeutics of uro-genital tuberculosis]

OBJECTIVE

To specify the clinical, paraclinic and therapeutic aspects of urogenital tuberculosis in the services of Urology and Nephrology of the CHU of the Point G.

PATIENTS AND METHODS

From January 2005 to November 2006, six patients reached of urogenital tuberculosis were seen. The initial evaluation comprised an interrogation in the search of antecedents of urinary extra tuberculosis, a creatinemy, a urogenital echography and an intravenous urography. The research of the bacillus of Koch in the urines was made. A bacteriological examination cyto- of urines (ECBU) was carried out as well as the histological analysis of the fragment S biological and/or the part of exérèse.

RESULTS

The incidence of urogenital tuberculosis was 0.3%. compared to the consulted patients. The principal clinical demonstrations were the lumbar pain (83.33%), the hématurie (33.33%), the pollakiurie (33.33%) and the burns mictionnell be (16.67%). 50% of the patients presented a fever and 33.33% an asthenia. Three (50%) were presented with a renal insufficiency (average creatinemy: 866.7 micromol/l). The bacilluria was present in 50% of the cases. Echography had shown anomalies in 100% of the cases of which most frequent was the urétéro hydronéphrose (2 cases, are 33.33%). The positive diagnosis was related to the bacteriological data (3 times) and histological (3 times). The treatment consisted of a bacillar anti chemotherapy among all patients in association with the surgery (4 cases) and/or of the endo-urologic operations (1 case).

CONCLUSION

The diagnosis of urogenital tuberculosis remains difficult and often late in our context. A surgical or endo-urologic gesture is often necessary to preserve the renal function and to improve the quality of life.

[Case of bladder tuberculosis with onset at the age of nineteen--treatment of urinary tract tuberculosis in accordance with the new Japanese Tuberculosis Treatment Guidelines]

A 24-year-old man experienced gross haematuria and dysuria several times a year from the age of 19, presenting to this Department for the first time at age 21, when he was given standard antibiotic treatment for acute cystitis. Although urinary symptoms persisted, he failed to attend for follow-up. He attended another clinic at the age of 24 with increased urinary frequency. Transrectal ultrasonography revealed thickening of the bladder wall, concavity of the right bladder neck, and nodular changes extending from the left bladder neck to the left bladder wall, so he was referred to this department for further investigation. Mycobacterium tuberculosis was detected in the urine by the referring doctor, so the diagnosis was made of bladder tuberculosis (TB). We treated him with rifampicin (RFP), isoniazid (INH) and pyrazinamide (PZA) triple therapy for 2 months, followed by RFP and INH dual therapy for 4 months. His urinary frequency improved markedly after one month, and his bladder capacity was 420 ml after 4 months of treatment. After 2 and half year follow-up he remains well without any signs of relapse. To our knowledge, this is only the ninth case of teenage onset of urinary tract TB in Japan since 1995. As specified in Clause 22 of the Enforcement Regulations of the Tuberculosis Control Law, chemotherapy and surgical treatment of TB, the mainstays of treatment, should be administered in accordance with the 'Standards for the Treatment of Tuberculosis', issued by the Japanese Minister of Health and revised in 2004. The level of recognition of the 'Standards for the Treatment of Tuberculosis' is low, however. Although the incidence of TB of the urinary tract has dropped dramatically, as urologists we must be aware that treatment of this condition must be given in accordance with the Standards.

[The physicians' awareness of urogenital system tuberculosis]

The chair of public health of the Omsk State medical academy conjointly with the municipal TB dispensary No 4 carried out the medical social study of the urogenital system tuberculosis since no profound and research of this problem was organized on the territory of Omsk oblast. The article presents the fragment of the data related to the survey of he physicians of medical institutions form city of Omsk and the Omsk oblast about the effectiveness of the medical social care to the patients suffering from the urogenital system tuberculosis.

Role of imaging in predicting salvageability of kidneys in urinary tract tuberculosis

OBJECTIVE

To study the role of imaging in predicting salvageability of kidneys and the role of early nephrectomy in urinary tract tuberculosis (TB).

METHODS

This was a retrospective study of 103 cases managed between 1990 to 1998. Intravenous urograms (IVUs) were reviewed and based on the IVU findings. Patients were stratified into three groups. Treatment consisted of immediate surgery, defined as nephrectomy within six weeks of starting anti-TB treatment (ATT) and delayed as nephrectomy done after completion of ATT. Chi square test was applied to find the significance of early nephrectomy. Logistic regression analysis model was used to identify factors predicting salvageabilty of the nephron mass.

RESULTS

Of the 103 cases, 23 had early nephrectomy and all of them achieved cure and had good renal function at follow up. Of the 76 who received only ATT, 43 were cured and the remaining 33 deteriorated symptomatically with high serum creatinine and decreasing GFR. Of the 33 who deteriorated, radiological and biochemical deterioration was seen in 24, two developed flank sinus and one developed multi drug resistant TB. On sub-grouping of the patients based on IVU, it was found that those with major renal lesion alone (group A) or with bladder involvement (group C) required either early or delayed nephrectomy and those who had minor lesion (group B) or bladder involvement with or without minor lesion (group C) did well on ATT alone. Logistic regression model showed cavitory lesions, GFR < 20ml/min/m2 and gross hydronephrosis as statistically significant unfavourable factors and ureteric stricture as a favourable factor.

CONCLUSION

In the era of modem ATT, nephrectomy is still an essential procedure. We recommend early nephrectomy for patients with major renal lesion with or without bladder involvement, gross hydronephrosis and for those who have GFR of < 20 ml/min/m2. Lower ureteric strictures and renal units with GFR of > 20 ml/min/m2 are favourable factors and salvage procedures are successful in these cases. It is likely that nephrectomy removes a large focus of disease and possibly dormant bacteria. With continuance of ATT, this further helps in improved patient outcome.

Tubercular ureteric strictures

OBJECTIVE

To review the presentation of tubercular ureteric strictures and assesses the role of balloon dilatation and open surgical repair in their management.

METHODS

This was a retrospective review of tubercular ureteric strictures managed between January 1993 and December 2002. The records were analyzed to assess clinical presentation and compare the results of balloon dilatation with open surgical repair. Success was defined as adequate drainage on imaging, no worsening of renal function, no recurrence of symptoms and no requirement of intervention on further follow up. The long term success rates were compared using the t-test for proportion.

RESULTS

Of 73 strictures, 88% had lower urinary tract symptoms. Genital abnormalities suggestive of tuberculosis was observed in 40% male patients. Urine examination yielded aseptic pyuria in 85%, positive AFB smears in 36% and positive AFB cultures in 32%. A small capacity bladder and non-functioning renal units were the only consistent findings on intravenous urogram. Nephrectomy was performed in 37% cases due to non salvageable kidneys at presentation. The success rate of stenting fell from 93% on immediate follow up to 59% on a follow-up of 12 months. At 90% success rates on a follow-up of 7 months open surgical repair was superior (p 0.03). Long term success following balloon dilatation in renal units with good function was 78% compared to 25% for poorly functioning units. (p= 0.01)

CONCLUSION

Open surgical repair is superior to balloon dilatation in the management of tubercular ureteric strictures. Renal function may predict the success of balloon dilatation.

[Urogenital tuberculosis: problems of present-day diagnosis and treatment]

The analysis of 4904 cases with tuberculosis admitted to the urological department of Moscow tuberculosis hospital N 7 in 1996-2002 showed increased incidence of new-onset and recurrent urogenital tuberculosis--the share has risen from 2.1 to 7.8%. Of 267 new cases, 49.4% had severe destructive forms. The disease manifested with chronic cystitis in 35 (13.11%), subacute orchoepidydimitis in 35 (13.11%), anatomofunctional alterations of the kidneys (hydronephrotic transformation, non-functioning kidney, ureteritis, etc.) in 76 (28.46%) patients. Bacterial discharge occurred in 52% of new cases. The diagnosis was based on clinical and x-ray data in 48%. Isolated genital tuberculosis, isolated nephrotuberculosis and their combination were revealed in 14.23, 59.57 and 26.2% patients, respectively. Among the patients with advanced destructive forms 75% got disabled completely. This fact indicates the importance of early diagnosis and adequate etiotropic therapy. Active urogenital tuberculosis was treated surgically in 51% patients, most of the operations were made for marked destructive processes in the kidneys. The organ-removing operations were conducted in 73% of them. Preoperative tuberculostatic therapy reduced frequency of postoperative complications. In early diagnosis, the organ was saved in operations in 9.38%. It is recommended to refer patients to the phthisiourologist to be examined for urogenital tuberculosis if they have long-standing urogenital infection, destructive lesions of the upper urinary tracts, calculous prostatitis.

[New approaches to formation of registration group of individuals followed up by antituberculosis institutions in Uzbekistan]

The paper presents the results of a three-year (2000-2002) follow-up of the movement of dispensary contingents registered in tuberculosis facilities in order to develop new dispensary groups. The dispensary groups of patients with active forms of tuberculosis have been ascertained to accumulate a great number of patients with its inactive forms due to the untimely of their transfer to the inactive groups in terms of effective treatment and the clinical forms of tuberculosis. New dispensary grouping will more definitely regulate the transfer of patients from active to inactive groups and strike from the list of dispensary patients. The proposed new grouping excludes registration Groups 0, II, and VII. If required, the persons struck from Groups III and VB and those followed up as Groups 0 and VII patients will be transferred to adult and pediatric polyclinics and followed up in recurrent tuberculosis risk groups.

Genitourinary tuberculosis: a review of 174 cases

In 174 cases of genitourinary tuberculosis diagnosed and treated in our clinic we evaluated, retrospectively, age and sex distributions, symptoms, physical and laboratory findings, primary focus, surgical and medical treatments. Flank pain and non-specific urinary complaints, e.g. dysuria, were the major symptoms. Although some authors prefer short-term medical therapy for the treatment of genitourinary tuberculosis, the relapse rate in our series after 12 months of therapy was 19% and we therefore suggest that therapy should be continued for at least 12 months. The poor nutritional status and social conditions characteristic of subjects from our region may, however, have influenced this high relapse rate.

[Complex tubercular ureteral stenoses (report of 2 cases treated with permanent double-J catheter]

Two patients presenting complex tuberculous ureteral strictures on an only existing kidney were treated with definitive double J stent changed every 6 months. This treatment modality was well tolerated. On the basis of two cases and literature review, different therapeutic measures are discussed.

[Low-energy laser therapy in combined treatment of of patients with urinary tuberculosis]

62 patients received polychemotherapy for tuberculosis of the kidney (control group) and 88 patients with the same diagnosis received the same polychemotherapy plus local laser therapy (study group). Efficiency of the treatment in the control group was 40.4 +/- 6.3%, in the study group--76.5 +/- 4.7%. Thus, the effect in the group with laser radiation was by 36.1% higher than in the controls. Indices of urinalysis, bacterial discharge and intoxication to the end of the hospital stay differed significantly (p < 0.05).

[Urogenital tuberculosis. Experience in 10 years]

OBJECTIVE

To review the clinical, imaging and therapeutic aspects of urogenital tuberculosis.

MATERIAL AND METHODS

From April 1989 to April 1999, 57 patients with urogenital tuberculosis were reviewed in our department. This series consisted of 32 males and 25 females with a mean age of 40 years (range: 18 to 72 years).

RESULTS

The most frequent clinical symptoms were irritative symptoms (47.3%). Fever, anorexia and weight loss were rare (11%). 16% of patients had an isolated genital lesion. 14% presented with renal failure (mean serum creatinine: 18 mg/l). Only 3 cases (5.2%) presented with bacilluria. Urography showed abnormalities in 80% of cases. The most frequent abnormality was a non-functioning silent kidney in 23 cases (40.3%). The positive diagnosis was based on bacteriological (5 cases) and histological data (52 cases). Treatment consisted of antituberculous chemotherapy in all patients, in combination with surgery (75%), and/or endourological procedures (26.3%). Nephrectomy is still indicated for non-functioning tuberculous kidneys in order to prevent the development of hypertension, abscess and fistulas.

CONCLUSION

The diagnosis of urogenital tuberculosis is difficult and often late. A surgical or endourological procedure is often necessary to preserve renal function and to improve quality of life.

Urachal tuberculosis

BACKGROUND

We report on an extremely rare case of urachal tuberculosis that was confirmed using a polymerase chain reaction test of paraffin-embedded material.

METHODS/RESULTS

A 62-year-old man presented with pollakiuria. With a diagnosis of urachal abscess, the patient underwent en bloc resection of the cystic mass. A bacterial culture test of the content showed no organism. The histopathologic findings suggested urachal tuberculosis. The AMPLICOR polymerase chain reaction test by using paraffin-embedded sections revealed the existence of Mycobacterium tuberculosis in the resected tissue. The only positive finding in systemic screening examinations for tuberculosis was old tuberculosis scars in the upper right lung. It was supposed that hematogeneous spreading from the lung lesion may result in urachal tuberculosis after a long latent period.

CONCLUSIONS

Although urachal tuberculosis is an extremely rare condition, tuberculosis must always be kept in mind when observing any infectious diseases.

[Analysing effectiveness of traditional treatment for urogenital tuberculosis by outpatients follow-up]

The paper presents the social and clinical structure of patients with urogenital tuberculosis through studies of 518 outpatient case histories. It has been ascertained that there is a prevalence of common and complicated forms of nephrotuberculosis, 82.4% of patients undergo surgery. Taking into account the fact that a fifth of patients cannot have long-term inpatient treatment, the incidence of Mycobacteriuria (67.9%), the prevalence of the disease, requiring organ-saving operations, the high degree of patients' disability, methods for intensifying urinary tuberculosis should be developed.

[Genitourinary tuberculosis]

Genitourinary tuberculosis, once the most prevailed disease, has become very rare. Urinary frequency, pain on urination and aseptic pyuria are the key symptoms of urinary tuberculosis. At least three consecutive urine cultures for Mycobacterium tuberculosis are necessary. Renal calcification in KUB film, distortion, obliteration and destruction of single or more calices in excretory urography may lead to proper diagnosis. Induration and swelling of the globus minor of epididymis adhering to the skin or with cutaneous fistula are suggestive of genital tuberculosis. It is of extreme importance to suspect the tuberculosis in such patients especially when the symptoms are not relieved by antibiotic treatment. Current short-term chemotherapy using pyrazinamide, isonizid and rifampicin with a help of surgery is successful in most of the patients with genitourinary tuberculosis.

[Epididymal manifestations of urogenital tuberculosis]

The morbidity of tuberculous epididymitis is due to the risk of male infertility secondary to vasal or epididymal obstruction or testicular necrosis. The aim of this study was to emphasize the epidemiological, clinical and therapeutical aspects of tuberculous epididymitis in adult. About eleven cases of epididymal localisation of urogenital tuberculosis, it appears that the diagnosis of the condition is rather difficult and often necessitate pathological exam of a specimen of epididymectomy. In other aspects, if antituberculous drugs are always effective in initial stages, surgery is usually radical, and rarely conservative. The latter procedures are vasovasostomy or vasoepididymostomy whose results are very hazardous.

[Clinical study on 17 cases of genitourinary tuberculosis]

Between 1987 and 1995, 17 patients with genitourinary tuberculosis were treated at Iwate Prefectural Central Hospital. The incidence of newly diagnosed genitourinary tuberculosis was 17 out of 16,363 outpatients (0.1%) during the 9-year period. Twelve patients had urinary tuberculosis and genital as well as urinary organs were affected in 5. Six (35%) patients presented in their fifties and 5 (29%) each in their forties and sixties. Nine (53%) patients had irritative voiding symptoms as the chief complaint. Only 29% had a known history of extra-genitourinaty tuberculosis. In addition to the standard multidrug chemotherapy, nephrectomy was performed in 5 patients and orchiectomy in 2 with epididymal tuberculosis. The incidence of tuberculosis has recently increased in many parts of our country and more attention should be paid to genitourinary tuberculosis.

[Evaluation of complex therapy efficiency for urogenital tuberculosis]

It is most expedient to develop effective modes of improving the etiotropic therapy of urogenital tuberculosis, by applying the multipronged approach which includes chemoenzyme therapy with native and immobilized terrilytine, enhanced activity of basic tuberculostatic agents through their combination with nonspecific antibiotics and the use of helium-neon laser, and delivery of drugs just to the focus of tuberculous inflammation by endolymphatic injection.

[Urogenital tuberculosis]

Urogenital tuberculosis has unspecific clinical symptomatology. This is often a result of the complications of the disease. Clinical symptoms, X-ray examinations, urinary microscopy, cultures and cytological and histological examinations may reveal the diagnosis. Initial treatment is medical therapy, but surgery will often be a necessary supplement. Follow-up during the treatment period is important to avoid unnecessary complications. With appropriate treatment and follow-up, the prognosis will be good.

[Current problems in the management of urologic tuberculosis in the Armed Forces]

According to author's opinion, urogenital tuberculosis is a grave disease, which often leads to patients' invalidism and lethal outcomes. Latent course, difficulties of diagnosis and the absence of due suspiciousness account for the fact, that 62.5% of cases end with cavernous tuberculosis of kidneys. Based on the analysis of 53 case histories, the main causes of postponed diagnosis of urogenital tuberculosis are discussed, the group of risk for development of this disease is delineated and the recommendations for its prophylaxis in servicemen are substantiated.

Urinary tract tuberculosis: a 10-year experience

Ninety-seven patients with urinary tract tuberculosis were reviewed from January 1983 to December 1993 at our hospital. Aside from two cases of military tuberculosis and three cases with coexisting active pulmonary tuberculosis, most urinary tract infections developed from a previous primary lung infection. Patients usually exhibited local symptoms. Fever, weight loss and anorexia were uncommon. Eighty-nine percent of the patients had abnormal urinalysis (hematuria and/or pyuria). Eight percent of the patients also had genital involvement, whereas 38% of these patients had normal intravenous pyelogram and urinalysis. Pyelograms disclosed abnormalities in 94% of the 97 patients and most revealed late changes, which were correlated with higher incidence of azotemia and anemia noted at diagnosis. Chemotherapy is the mainstay of treatment and at least three antituberculous drugs are required for initial therapy due to high drug resistance rate. Reconstructive surgery is warranted to salvage renal function. Except 6 patients run into maintenance hemodialysis, the renal functions of all patients remained stable during the period of follow-up, either receiving chemotherapy alone or combined surgery. Renal calcification may not represent inactive process, which requires further evaluation.

[Posttuberculous cystalgia]

Follow-up outcomes of urogenital tuberculosis with involvement of the bladder are provided for patients of the Novosibirsk regional and city hospitals. The cure was achieved in 42.1% of patients, posttuberculous cystalgia (PTC) developed in 36.8% microcystitis in 21.1% of cases. Age-related hormonal insufficiency contributes to the onset of PTC. An original technique of laser thermopuncture is detailed.

Genitourinary tuberculosis: the importance of early diagnosis and management. Case presentation

Genitourinary tuberculosis is the second most common form of extrathoracic tuberculosis. The most common signs are persistent sterile pyuria in up to 90% of patients, irritative voiding symptoms and painless hematuria in up to 80% of the patients. In Puerto Rico the incidence of tuberculosis is rising, being 9.2 per 100000 population in 1992. A.I.D.S. has had a steady rise since 1983. With the rise in the incidence of both diseases and with the influx immigrants from countries were tuberculosis is endemic we should expect a rise in the number of cases of genitourinary tuberculosis. Chemotherapy is the mainstay of treatment. Surgery is performed less often. Early recognition and management is important to avoid irreversible damage to the genitourinary tract. The cases of a 43 y/o man and a 30 y/o male with A.I.D.S. are discussed.

[Is urogenital tuberculosis a current disease still?]

In 1991, the epidemiology service of the health department of La Rioja announced that the number of deaths and new cases were higher than the national average (45/100,000 in 1991). Our service detected 16 new cases of urogenital tuberculosis during 1990-1991. The most common clinical symptoms being urgency and frequency. The bacteriological diagnosis using the Lowenstein-Jensen culture medium was positive in 87.50% of the cases. Anomalies were detected in 87.50% of the urographic analyses, the more frequently observed being infundibular involvement. Polychemotherapy consisting of rifampicin, ethambutol and isoniazid was administered for a period of 9 months in all of the cases, which resulted in negative cultures in 100% of the patients. Control evaluation was performed every 3 months, including CBK and serial bacilloscopy, biochemical assays, renal ultrasound, examination of eye grounds (1st trimester), chest X-ray and sputum bacilloscopy. Only endourological methods were utilized, except in one patient with coexisting congenital stricture of the pyeloureteric junction.

Tubercular cavity behind the prostate and bladder: an unusual presentation of genitourinary tuberculosis

Genitourinary tuberculosis, which is still common in developing countries, sometimes has an unusual presentation. We report 2 cases of a tubercular cavity behind the bladder and prostate which initially eluded diagnosis, and discuss pathogenesis and management of this rare entity.

[Tuberculosis of the female urethra: a case report]

A 52-year-old female with the chief complaint of miction pain was referred for the examination of a urethral nodule. Physical inspection revealed the meatus to be reddish and swollen. The painless nodule (1 x 1 x 2 cm) was situated between the urethra and vagina on transvaginal examination. Chest X-ray, drip infusion pyelography (DIP) and urethrocystography (UCG) showed no evidence of tuberculosis. Bladder mucosa was normal on cystoscopy. Mycobacterium tuberculosis was not detected from urine or sputum. The nodule was resected along with a portion of the urethra. Histopathological examination revealed tuberculous granuloma of the urethra.

Urinary tuberculosis: experience of a teaching hospital in Syria

This study was designed to show our experience of urinary tuberculosis in one of the large teaching hospitals in Syria. It was a prospective study involving 48 patients (29 males and 19 females) with confirmed tuberculous lesions in the urinary tract. The study period was between 1982-1987. The presenting symptoms were protean, and there were often delays between onset of symptoms and eventual diagnosis. The highest age incidence was in the second and fourth decades. Beside the suggestive clinical manifestations, final diagnosis was reached by various means. Repeated examinations of EMU smears were positive in about 20% of cases. Urine culture was positive in 33.3%, while varied percentage of cases showed some radiological changes suggestive of tuberculosis. Other investigations included cystoscopy and biopsy of suspected lesions. Treatment was conservative by chemotherapy in 45% of cases, with complete recovery in about 33%, while acceptable results were shown in congruent to 19%, and failure of treatment or recurrence of active disease in 48% of cases. Some forms of surgical intervention were carried out in 55% of patients. Cure was seen in 50% of them, while 25% had acceptable results and failure was shown in the remaining 25%. It is concluded that urinary tuberculosis remains an important infectious disease problem in our country. The high rate of failure of both medical or surgical treatment is mainly due to late diagnosis.