Urogenital Tuberculosis – Causes, Symptoms and Treatment

What is Urogenital Tuberculosis?

Urogenital tuberculosis (UGTB), also referred to as genitourinary tuberculosis (GUTB), is an infectious disease caused by the bacterium Mycobacterium tuberculosis that affects the organs of the urinary and reproductive tracts. It is the most common form of extrapulmonary tuberculosis – meaning tuberculosis occurring outside the lungs – and accounts for up to 30–40% of all extrapulmonary TB cases depending on the region. The disease often progresses slowly and is frequently diagnosed at a late stage.

Causes and Pathogenesis

Urogenital tuberculosis does not typically arise from a direct infection of the urinary tract. Instead, it develops through hematogenous spread, meaning the bacteria travel through the bloodstream from a primary tuberculosis infection, most commonly in the lungs, to the kidneys and other urogenital structures.

• The kidneys are most frequently affected due to their high blood flow.
• From the kidneys, bacteria can spread along the urinary tract to the ureters, bladder, and urethra.
• In men, infection may involve the prostate, epididymis, and testes.
• In women, the fallopian tubes, uterus, and ovaries can be affected.

Symptoms

Urogenital tuberculosis is well known for its non-specific symptoms, which makes diagnosis particularly challenging. Common complaints include:

• Sterile pyuria: white blood cells in the urine without growth of common bacteria in routine cultures
• Hematuria: blood in the urine (visible or microscopic)
• Frequent urination and pain during urination (dysuria)
• Flank pain or dull lower back pain
• In men: painless swelling of the epididymis (epididymitis)
• In women: menstrual irregularities or infertility due to involvement of the fallopian tubes
• General constitutional symptoms such as weight loss, night sweats, and fatigue may also occur

Diagnosis

Diagnosing urogenital tuberculosis is demanding and requires several investigations:

Laboratory Tests

• Urine culture for mycobacteria: First morning urine is cultured on at least three consecutive days. This is the most important diagnostic method.
• PCR (Polymerase Chain Reaction): Rapid detection of mycobacterial DNA in urine
• Urinalysis: Detection of sterile pyuria and hematuria
• Tuberculin skin test (Mantoux) or Interferon-Gamma Release Assay (IGRA)

Imaging

• Renal ultrasound: Detection of structural changes in the kidneys
• CT scan of the abdomen: Detailed visualization of calcifications, cavities, and ureteral changes
• Intravenous pyelography (IVP): Assessment of kidney function and urinary tract anatomy
• Cystoscopy in cases of suspected bladder involvement

Treatment

The treatment of urogenital tuberculosis follows the same fundamental principles as pulmonary tuberculosis and is based on a combination antibiotic therapy.

Standard Therapy

• Intensive phase (2 months): Combination of isoniazid, rifampicin, pyrazinamide, and ethambutol
• Continuation phase (4 months): Isoniazid and rifampicin
• The total duration of therapy is typically 6 months, but may be extended to 9–12 months in complicated cases.

Surgical Treatment

In advanced cases, surgical intervention may be required, for example in:

• Severe kidney destruction (nephrectomy)
• Ureteral strictures treated by balloon dilation or stenting
• Bladder contracture (bladder augmentation surgery)

Prognosis and Prevention

With early diagnosis and consistent antibiotic therapy, the prognosis for urogenital tuberculosis is favorable. However, if left untreated, the disease can lead to irreversible organ damage, chronic kidney failure, or infertility. The most effective prevention lies in controlling primary pulmonary tuberculosis, along with BCG vaccination (Bacillus Calmette-Guerin) in high-risk populations.

References

1. World Health Organization (WHO): Global Tuberculosis Report 2023. Geneva: WHO Press, 2023.
2. Figueiredo AA, Lucon AM: Urogenital tuberculosis: update and review of 8961 cases from the world literature. Rev Urol. 2008;10(3):207-217. PubMed PMID: 19145262.
3. European Association of Urology (EAU): Guidelines on Urological Infections. EAU Guidelines, Edn. presented at the EAU Annual Congress 2023.