Genitourinary Tuberculosis

What is Genitourinary Tuberculosis?

Tuberculosis (TB), a worldwide leading cause of death from infectious diseases, sometimes affects areas other than the lungs. Between 5 and 45% of TB cases impact other parts of the body, and within these, 30 to 40% cases affect the urogenital tract – the urinary system and genital organs. This form of TB, called genitourinary tuberculosis (GUTB), happens when the bacteria causing TB, known as Mycobacterium tuberculosis (MTB), infect the urinary tract or genital area. This term was first used by a Swiss urologist, Hans Wildbolz, in 1937. After someone has had pulmonary tuberculosis (TB affecting the lungs), 2 to 20% of those people may develop GUTB after a gap of 5 to 40 years.

GUTB can influence different parts of the urinary and genital systems in both men and women. In men, it can affect the urethra, bladder, ureters, kidneys, as well as sexual organs like the scrotum, penis, testes, epididymis, or vas deferens. In women, it can impact the vulva, vagina, cervix, uterus, ovaries or fallopian tubes. Among these, infections in the urinary tract are most common compared to genital infections. A key concern about GUTB is that it’s often diagnosed late, which can lead to complications like urethral or ureteric strictures (narrowing of these tubes), kidney failure, infertility, along with many other issues that need specialized attention.

What Causes Genitourinary Tuberculosis?

Genitourinary tuberculosis (GUTB), a type of tuberculosis affecting the urinary system and genitals, is most often caused by infection with the bacteria known as M. tuberculosis. However, it can also result from other related types of bacteria, including Mycobacterium bovis, Mycobacterium africanum, Mycobacterium pinnipedii, Mycobacterium microti, Mycobacterium caprae, and the TB vaccine bacillus Calmette-Guérin (BCG), although these cases are rare.

Typically, GUTB is caused when the bacteria spread through the bloodstream during the initial infection. The bacteria can then remain inactive in the urinary and genital system, only becoming active and causing disease if the immune system becomes weaker, such as due to illness or medication.

Besides spreading through the bloodstream, GUTB can also infect the body through the lymphatic system, which is a part of the immune system, and through sexual transmission. Factors that can increase the risk of these dormant bacteria becoming active again, causing GUTB, include diabetes, old age, being underweight, having other cancers, taking drugs that suppress the immune system, and suffering from kidney failure. Studies estimate that up to 15% of people infected with these bacteria may experience a reactivation of their infection, leading to GUTB.

Risk Factors and Frequency for Genitourinary Tuberculosis

Genito-urinary Tuberculosis (GUTB) is a condition that can develop alongside pulmonary Tuberculosis (TB). It affects 2 to 20% of people with pulmonary TB. The frequency of GUTB varies depending on the country’s development level.

In developed countries, GUTB occurs in 2 to 10% of TB cases.
In developing countries, GUTB is more common with a frequency of 15 to 20% of TB cases.
More than 90% of all GUTB cases are reported in developing countries.
In Brazil, 9.8% of all TB cases were found to also have GUTB.
A UK study reported that 13.5% of GUTB patients also had TB in their lungs.
In the USA, the rate of TB was 3 cases per 100,000 people in 2013, but similar data about GUTB is unavailable.
A large study in Germany found that out of 5,424 autopsied subjects, 3.1% had evidence of GUTB.

Signs and Symptoms of Genitourinary Tuberculosis

Tuberculosis of the urinary and genital system can present differently from person to person. This can range from not having any symptoms to having signs that depend on the organ affected by the tuberculosis. This condition can be common in people from regions where tuberculosis is prevalent or among those with a history of lung tuberculosis. General symptoms include fever, night sweats, loss of appetite, and weight loss. Tuberculosis might also be the underlying cause of recurrent urinary tract infections that don’t improve with normal antibiotic treatment.

Here are some specific types of urinary and genital tuberculosis:

Renal Tuberculosis: This is the most common form, and symptoms are often general and not specific. Late diagnosis may lead to extensive kidney damage and chronic kidney disease.
Ureteric Tuberculosis: It more commonly affects the lower part of the ureters, followed by the ureteropelvic junction. This form is usually associated with renal tuberculosis. Symptoms might include blood in urine or abdominal pain, and complications can include kidney failure.
Bladder Tuberculosis: Usually occurs due to renal tuberculosis. Symptoms might be similar to a urinary tract infection, but standard antibiotics might not be effective. Late-stage disease can cause kidney failure.
Prostatic Tuberculosis: This form of tuberculosis might be initially silent but can eventually lead to trouble urinating, as well as pelvic pain and sexual dysfunction.
Scrotal Tuberculosis: This can lead to painful or painless swelling in the scrotum and could result in reduced sperm count or absence of sperm.
Penile Tuberculosis: Symptoms might include ulcers or swelling on the penis, as well as urethral pain, discharge, or strictures. It can also cause erectile dysfunction.
TB of the vulva, vagina, or cervix: This can cause pain during intercourse, bleeding after intercourse, pelvic pain, and infertility. Fistulae, an abnormal connection between organs, can also develop.
Uterine Tuberculosis: Symptoms are often vague, but might include irregular menstrual bleeding, painful periods, and vaginal discharge. Some people also report feeling a mass in the abdomen or abdominal pain not related to periods.
Ovarian and Fallopian Tube Tuberculosis: Many people with this form don’t have symptoms. Some people might experience chronic or acute abdominal pain. Many cases are discovered during fertility investigations.

Testing for Genitourinary Tuberculosis

When evaluating a patient for Genitourinary Tuberculosis (GUTB), or TB that affects the urinary system, the process includes a detailed examination, asking about their medical history, and using laboratory tests and imaging (like X-rays and scans). The best way to confirm GUTB involves identifying a kind of bacteria, M.tuberculosis, in a patient’s clinical samples. These samples can come from urine, fluid obtained from a prostate massage, biopsied tissue, pus, or discharge fluid. Several techniques can be used to identify this bacteria:

Smear microscopy: This method involves staining the sample and then examining it under a microscope. The staining techniques used include Ziehl–Neelsen (ZN) or auramine staining, and a more recent technique that uses light-emitting diodes. Smear microscopy can identify the bacteria in about 40% of cases.

The GeneXpert MTB/RIF assay: Recommended by the World Health Organisation (WHO), this test not only rapidly identifies the bacteria but can also detect a certain type of resistance to the drug rifampicin, which is often used to treat TB. Its accuracy ranges from 63% to 91% depending on the type of sample tested.

Mycobacterium culture: This method, which involves growing the bacteria in a lab, is considered the gold standard, or best method, for diagnosing active TB. In suspected GUTB cases, three urine samples taken on consecutive mornings are used for smear microscopy and culture. Nowadays, medical professionals are shifting from traditional to more rapid and automated culture systems to speed up diagnosis. The MGIT liquid culture system is currently viewed as the best test, according to the WHO.

Whole-genome sequencing (WGS) and Next-generation sequencing (NGS): These methods can provide detailed genetic information about the bacteria in a sample. These techniques are significantly faster than growing a culture but currently aren’t widely available due to their higher cost and need for specialised equipment.

Histology: This is the study of bodily tissues under a microscope. Symptoms of TB include inflammation and an excess of acid-fast bacilli (a type of bacteria) in biopsy tissues.

Besides these direct methods, indirect methods can also provide supportive evidence of TB, which include:

Blood tests: These routine tests check overall blood cell count, CRP (a marker of inflammation), and kidney function. If the patient’s CRP is high and their kidneys aren’t working well, it might suggest the presence of GUTB.

Urinary lipoarabinomannan (LAM): LAM, which is part of the cell wall of the Mycobacterium tuberculosis bacteria, might be detected in the urine of those with active TB.

Additionally, doctors can use tools like X-rays, ultrasound scans, Urography (a method of visualising the urinary tract), CT scans, MRI scans, and PET-CT scans to gain more information about a patient’s condition. Other approaches, such as minimally invasive procedures to observe the urinary tract (like cystourethroscopy, ureteroscopy, and hysteroscopy) and hysterosalpingography (an X-ray test to examine a woman’s uterus and fallopian tubes), can also aid doctors in obtaining samples for further confirmatory testing.

Treatment Options for Genitourinary Tuberculosis

Genitourinary tuberculosis (GUTB), an infection of the urinary system and reproductive organs, is typically treated similarly to tuberculosis that affects the lungs. The standard treatment regimen involves a combination of four different medications – rifampicin, isoniazid, pyrazinamide, and ethambutol – taken over a six-month period. For the first two months, all four drugs are used. For the remaining four months, only rifampicin and isoniazid are used.

However, this treatment plan may need to be extended for certain patients. Those living with HIV, experiencing kidney abscesses (pus-filled cavities), or having bone infiltration (spreading of the tuberculosis bacteria into the bones) may require a longer duration of treatment.

Additionally, for patients with multidrug-resistant tuberculosis (MDR-TB) – a type of tuberculosis that doesn’t respond to the standard drugs – further custom treatment plans are required. Medications used for this condition may include fluoroquinolones, bedaquiline, delaminid, aminoglycosides, among others. The treatment duration for MDR-TB can be extensive, potentially needing 18 to 24 months to fully address the infection.

Besides medical treatment, some situations may require surgical interventions. For instance, if GUTB leads to ureteral stricture (narrowing of the tube that carries urine from the kidney to the bladder) and hydronephrosis (swelling of a kidney due to a build-up of urine), procedures like early stenting (insertion of a tube to keep the ureter open) or percutaneous nephrostomy (creating a new route for urine drainage) may be used.

A nephrectomy, or removal of the kidney, might be necessary in severe cases. This could include situations where the kidney is no longer functioning, cases where there is co-existing kidney cancer, or where the tuberculosis infection has extensively spread throughout the entire kidney.

The conditions linked to a urinary tract infection could be various. They might include:

Urinary Tract Infection (UTI)
Urethritis (inflammation of the urethra)
Epididymitis (inflammation of the epididymis, a tube at the back of the testicles)
Prostatitis (swelling and inflammation of the prostate gland)
Cancerous conditions like renal cell carcinoma or testicular tumors
Chronic Pyelonephritis (recurring kidney infection)
Infertility
Urethral stricture (narrowing of the urethra)
Hydrocele (swelling in the scrotum)
Spermatocele (fluid-filled cyst in the testicles)
Bacillus Calmette Guerin (BCG) Cystitis (bladder inflammation due to BCG therapy for bladder cancer).

What to expect with Genitourinary Tuberculosis

The outlook for Genito Urinary Tuberculosis (GUTB) is very good if it’s caught early and the patient follows the prescribed treatment plan closely. Genito Urinary Tuberculosis is a form of Tuberculosis that affects the reproductive and urinary systems in the body. The cure rate with the appropriate anti-tubercular therapy (ATT), which is a type of treatment specifically for tuberculosis, is usually around 90%.

In some cases, about 6.3%, the condition may return after an average of 5.3 years of treatment with appropriate anti-tubercular therapy. However, these relapses are relatively rare.

Possible Complications When Diagnosed with Genitourinary Tuberculosis

Additional infections
Narrowing of body passages
Abnormal connection between organs
High blood pressure due to kidney problems
Long-term kidney failure
Inability to conceive a child
Abscess in the prostate gland
Decreased bladder size
Inflammation of the kidneys due to tuberculosis
TB ulcers in the vagina

Preventing Genitourinary Tuberculosis

The aim with treating Genitourinary tuberculosis (GUTB), a type of tuberculosis that affects the urinary system and genitals, is to find it early and start Anti-Tuberculosis Therapy (ATT). Patients should understand the importance of strictly following the ATT treatment plan and maintaining a balanced diet. If there are concerns about a patient not sticking to their treatment, a healthcare professional may supervise their medication intake, which is known as Directly Observed Therapy (DOT).

Patients need to be made aware of possible side effects of ATT and should come back to the doctor right away if they notice any. It’s also important to know that a person can still spread the infection to others through sexual contact up to 4 weeks after starting ATT.

Frequently asked questions

Genitourinary Tuberculosis (GUTB) is a form of tuberculosis that occurs when the bacteria causing TB infect the urinary tract or genital area. It affects different parts of the urinary and genital systems in both men and women, and can lead to complications if not diagnosed and treated early.

Genitourinary Tuberculosis is reported to be more common in developing countries, with a frequency of 15 to 20% of TB cases.

Signs and symptoms of Genitourinary Tuberculosis can vary depending on the specific organ affected. However, some general signs and symptoms include: - Fever - Night sweats - Loss of appetite - Weight loss Here are the signs and symptoms associated with specific types of Genitourinary Tuberculosis: - Renal Tuberculosis: Often presents with general symptoms and can lead to extensive kidney damage and chronic kidney disease if not diagnosed and treated promptly. - Ureteric Tuberculosis: Commonly affects the lower part of the ureters and ureteropelvic junction. Symptoms may include blood in urine or abdominal pain, and complications can include kidney failure. - Bladder Tuberculosis: Usually occurs due to renal tuberculosis. Symptoms may resemble a urinary tract infection, but standard antibiotics may not be effective. Late-stage disease can cause kidney failure. - Prostatic Tuberculosis: Initially silent, but can eventually lead to trouble urinating, pelvic pain, and sexual dysfunction. - Scrotal Tuberculosis: Can cause painful or painless swelling in the scrotum and may result in reduced sperm count or absence of sperm. - Penile Tuberculosis: Symptoms may include ulcers or swelling on the penis, urethral pain, discharge, or strictures. It can also cause erectile dysfunction. - TB of the vulva, vagina, or cervix: Can cause pain during intercourse, bleeding after intercourse, pelvic pain, and infertility. Fistulae, abnormal connections between organs, can also develop. - Uterine Tuberculosis: Symptoms are often vague but may include irregular menstrual bleeding, painful periods, vaginal discharge, feeling a mass in the abdomen, or abdominal pain not related to periods. - Ovarian and Fallopian Tube Tuberculosis: Many cases are asymptomatic, but some people may experience chronic or acute abdominal pain. This form is often discovered during fertility investigations.

Genitourinary tuberculosis (GUTB) is most often caused by infection with the bacteria known as M. tuberculosis. However, it can also result from other related types of bacteria, including Mycobacterium bovis, Mycobacterium africanum, Mycobacterium pinnipedii, Mycobacterium microti, Mycobacterium caprae, and the TB vaccine bacillus Calmette-Guérin (BCG), although these cases are rare. The bacteria can spread through the bloodstream during the initial infection or through the lymphatic system. GUTB can also be transmitted sexually.

The conditions that a doctor needs to rule out when diagnosing Genitourinary Tuberculosis are: - Urinary Tract Infection (UTI) - Urethritis (inflammation of the urethra) - Epididymitis (inflammation of the epididymis, a tube at the back of the testicles) - Prostatitis (swelling and inflammation of the prostate gland) - Cancerous conditions like renal cell carcinoma or testicular tumors - Chronic Pyelonephritis (recurring kidney infection) - Infertility - Urethral stricture (narrowing of the urethra) - Hydrocele (swelling in the scrotum) - Spermatocele (fluid-filled cyst in the testicles) - Bacillus Calmette Guerin (BCG) Cystitis (bladder inflammation due to BCG therapy for bladder cancer)

The types of tests needed for Genitourinary Tuberculosis (GUTB) include: - Smear microscopy: This involves staining a sample and examining it under a microscope to identify the bacteria. - The GeneXpert MTB/RIF assay: This test rapidly identifies the bacteria and can also detect resistance to the drug rifampicin. - Mycobacterium culture: This method involves growing the bacteria in a lab and is considered the gold standard for diagnosing active TB. - Whole-genome sequencing (WGS) and Next-generation sequencing (NGS): These methods provide detailed genetic information about the bacteria in a sample. - Histology: This involves studying bodily tissues under a microscope to look for signs of TB. - Blood tests: Routine tests that check blood cell count, CRP (a marker of inflammation), and kidney function. - Urinary lipoarabinomannan (LAM): LAM, which is part of the cell wall of the Mycobacterium tuberculosis bacteria, might be detected in the urine of those with active TB. In addition to these direct methods, doctors may also use imaging tests such as X-rays, ultrasound scans, Urography, CT scans, MRI scans, and PET-CT scans to gather more information about the patient's condition. Minimally invasive procedures like cystourethroscopy, ureteroscopy, and hysteroscopy, as well as hysterosalpingography, can also aid in obtaining samples for further testing.

Genitourinary tuberculosis (GUTB) is typically treated similarly to tuberculosis that affects the lungs. The standard treatment regimen involves a combination of four different medications - rifampicin, isoniazid, pyrazinamide, and ethambutol - taken over a six-month period. For the first two months, all four drugs are used. For the remaining four months, only rifampicin and isoniazid are used. However, certain patients may require a longer duration of treatment, such as those living with HIV, experiencing kidney abscesses, or having bone infiltration. In cases of multidrug-resistant tuberculosis (MDR-TB), custom treatment plans are required, which may include different medications and a longer treatment duration of 18 to 24 months. In some situations, surgical interventions like stenting, nephrostomy, or nephrectomy may be necessary.

The prognosis for Genitourinary Tuberculosis (GUTB) is very good if it's caught early and the patient follows the prescribed treatment plan closely. The cure rate with the appropriate anti-tubercular therapy (ATT) is usually around 90%. In some cases, about 6.3%, the condition may return after an average of 5.3 years of treatment, but these relapses are relatively rare.

You should see a urologist or a specialist in infectious diseases for Genitourinary Tuberculosis.

Genitourinary Infectious Disease Tuberculosis Urinary Tract Infection Urogenital Infection