During the study period of 21 years, a total of 120 cases were suspected to have GUTB. However, after applying the diagnostic criteria mentioned above, 38 cases were excluded. Finally a total of 82 patients were included in the analysis.
Clinical characteristics
The majority were males (54.9%, n=45). The median age of the sample was 51 years (range: 26-75). The common presenting symptoms or reasons for referral to the urology unit were haematuria (n=13,15.8%), scrotal mass/sinus (n=12, 14.6%), storage symptoms, urosepsis and dysuria (each 6.1%). The physical examination was unremarkable in the majority except in those with scrotal manifestations (n=12, 14.6%) and one patient had abdominal wall abscess. Three had a nodular prostate gland on digital rectal examination. Past history of TB or contact history of TB was positive in only 2 (2.4%) patients.
Basic investigations
Mantoux was performed in 70 patients and all were either positive (>10mm) (n=62, 88.6%) or equivocal (>5mm) (n=8, 11.4%). Strongly positive Mantoux (>15mm) was seen among 23 (32.9%). Only 18.2% of scrotal TB had strongly positive Mantoux whereas in others, 52.5% were strongly positive (p=0.036). ESR was available in 69 patients and was >30 and >50 in 54 (78.3%) and 33 (47.8%) patients respectively. The mean ESR was significantly lower in those with scrotal TB than others with abdominal manifestations (27 vs. 61, p=0.002).
Only 8 (9.8%) patients had elevated serum creatinine (>1.5mg/dl) at the time of diagnosis. Chest x-ray and x-ray KUB abnormalities were detected in 9 (11%) and 6 (7.3%) respectively.
CT-Urogram
CT-urogram was performed in 72 (87.8%) and abnormalities were detected in 57 (79.2%) patients. Isolated upper tract involvement was seen in 59.8% (n=49) and isolated lower tract abnormalities were detected in 3 (3.7%) patients. Another 3 (3.7%) patients had both upper and lower tract findings. Common findings at presentation were ureteric strictures (n=19 (26.4%), 15 were lower ureteric), non-functioning kidney (n=6, 8.3%), renal inflammation of abscess (n=7, 9.7%), stones or calcifications (n=6, 8.3%), contracted bladder (n=3, 4.2%) and masses (n=4, 5.6%) (Table 1).
Table 1
Summary of CT-urogram findings at the time of diagnosis
CT-Urogram findings
|
Total
|
Male
|
Female
|
N
|
%
|
N
|
%
|
N
|
%
|
Bilateral abnormalities
|
Yes
|
9
|
12.5%
|
7
|
20.0%
|
2
|
5.4%
|
No
|
63
|
87.5%
|
28
|
80.0%
|
35
|
94.6%
|
Both upper and lower tract anomalies
|
Yes
|
3
|
4.2%
|
3
|
8.6%
|
0
|
0.0%
|
No
|
69
|
95.8%
|
32
|
91.4%
|
37
|
100.0%
|
Only lower tract anomalies
|
Yes
|
3
|
4.2%
|
1
|
2.9%
|
2
|
5.4%
|
No
|
69
|
95.8%
|
34
|
97.1%
|
35
|
94.6%
|
Only upper tract anomalies
|
Yes
|
49
|
68.1%
|
21
|
60.0%
|
28
|
75.7%
|
No
|
23
|
31.9%
|
14
|
40.0%
|
9
|
24.3%
|
Ureteric stricture
|
Yes
|
18
|
25.0%
|
7
|
20.0%
|
11
|
29.7%
|
No
|
54
|
75.0%
|
28
|
80.0%
|
26
|
70.3%
|
Renal stones
|
Yes
|
3
|
4.2%
|
2
|
5.7%
|
1
|
2.7%
|
No
|
69
|
95.8%
|
33
|
94.3%
|
36
|
97.3%
|
Renal or ureteric calcification
|
Yes
|
3
|
4.2%
|
2
|
5.7%
|
1
|
2.7%
|
No
|
69
|
95.8%
|
33
|
94.3%
|
36
|
97.3%
|
Small bladder
|
Yes
|
3
|
4.2%
|
3
|
8.6%
|
0
|
0.0%
|
No
|
69
|
95.8%
|
32
|
91.4%
|
37
|
100.0%
|
Renal mass
|
Yes
|
3
|
4.2%
|
1
|
2.9%
|
2
|
5.4%
|
No
|
69
|
95.8%
|
34
|
97.1%
|
35
|
94.6%
|
Bladder mass
|
Yes
|
1
|
1.4%
|
0
|
0.0%
|
1
|
2.7%
|
No
|
71
|
98.6%
|
35
|
100.0%
|
36
|
97.3%
|
Non-functioning kidney
|
Yes
|
6
|
8.3%
|
2
|
5.7%
|
4
|
10.8%
|
No
|
66
|
91.7%
|
33
|
94.3%
|
33
|
89.2%
|
Renal abscess
|
Yes
|
4
|
5.6%
|
2
|
5.7%
|
2
|
5.4%
|
No
|
68
|
94.4%
|
33
|
94.3%
|
35
|
94.6%
|
Peri-renal abscess
|
Yes
|
2
|
2.8%
|
1
|
2.9%
|
1
|
2.7%
|
No
|
70
|
97.2%
|
34
|
97.1%
|
36
|
97.3%
|
Spinal TB
|
Yes
|
2
|
2.8%
|
2
|
5.7%
|
0
|
0.0%
|
No
|
70
|
97.2%
|
33
|
94.3%
|
37
|
100.0%
|
Psoas abscess
|
Yes
|
3
|
4.2%
|
2
|
5.7%
|
1
|
2.7%
|
No
|
69
|
95.8%
|
33
|
94.3%
|
36
|
97.3%
|
Cystoscopy
Cystoscopy was performed only in those with lower urinary tract symptoms, haematuria, dysuria and in those with unclear diagnoses. Out of 42 patients who underwent a cystoscopy, 31 (73.8%) had abnormal cystoscopic characteristics that were further investigated by a bladder biopsy. Common predominant abnormality was inflamed bladder epithelium which was seen among 30 (71.4%) patients. Other anomalies included bladder or vesicoureteric mass (n=2), contracted bladder (n=2) and golf hole ureteric orifice (n=1). The histopathology was suggestive of TB in 25/31 patients (80.6%). All positive bladder biopsies had severely inflamed bladder epithelium.
Diagnosis
Microbiological diagnosis was achieved in only 42 (51.2%), whereas the rest were diagnosed histologically which included cystoscopy and bladder biopsy, percutaneous biopsy, open surgical biopsy or assessment of resected specimen. Only 6 patients had caseation in histology. Commonest organs involved were kidney (64.6%, n=53), ureters (51.2%, n=42), bladder (43.9%, n=36) and testis/epididymis (14.6%, n=12). Three patients with nodular prostate underwent trans-rectal ultrasound guided biopsy and only 1 patient had prostate TB. There were none with urethral TB.
Pulmonary and other extra-pulmonary manifestations
Four patients had concurrent pulmonary TB and other organ systems included psoas abscess (n=3), spine (n=2), anterior abdominal wall (n=1) and colon (n=1).
Treatment and follow up
All were treated primarily with anti-TB drugs however, 50 (61%) had indications for some form of intervention. Median duration of follow-up was 24 months (range: 6- 96). The preferred initial treatment was 2-month phase including four drugs, followed by a 4-months of maintenance with isoniazid and rifampicin. The majority of interventions were reconstruction surgeries (n=20, 24.4%) followed by excision surgeries (n=19, 23.2%) and drainage procedures (n=11, 13.4%). A summary of therapeutic interventions and their indications are given in Table 2. High ESR (>50) or positive Mantoux were not predictive of the need for therapeutic interventions (p=0.126 and p=0.744, respectively).
Table 2
Summary of therapeutic interventions and their indications
Type of intervention
|
N
|
Indications
|
Reconstructive Surgery (n=20, 24.4%)
|
Ureteric reimplantation
|
14
|
Lower ureteric strictures (n=14)
|
Boari flap reconstruction
|
2
|
Lower and mid ureteric stricture (n=1)
Lower ureteric stricture (n=1)
|
Uretero-ureterostomy
|
1
|
Upper ureteric stricture (n=1)
|
Resection of colovesical fistula tract and repair
|
1
|
Colovesical fistula (n=1)
|
Patient refused ureteric reimplantation
|
2
|
Lower ureteric stricture (n=2)
|
Excision Surgery (n=19, 23.2%)
|
Nephrectomy
|
5
|
Non-functioning kidney (n=5)
|
Excision of epididymal mass
|
4
|
Epididymal mass (n=4)
|
Epididymectomy
|
4
|
Epididymal mass (n=4)
|
Orchidectomy
|
4
|
Large testicular/ epididymal mass (n=4)
|
Nephroureterectomy
|
2
|
Non-functioning kidney with a ureteric mass (n=1)
Extensive nephroureteric calcification (n=1)
|
Drainage procedures (n=11, 13.4%)
|
JJ stenting (via cystoscopy)
|
8
|
Lower ureteric stricture (n=3)
Mild ureteric stenosis (n=2)
Lower ureteric stricture with ureteritis cystica (n=1)
Psoas abscess with hydronephrosis and hydroureter (n=1)
Pyonephrosis (n=1)
|
Percutaneous nephrostomy
|
1
|
Pyonephrosis (n=1)
|
Guided aspiration
|
1
|
Renal abscess (n=1)
|
Open drainage (twice)
|
1
|
Psoas, peri-renal and anterior abdominal wall abscesses (n=1)
|
Drug toxicity
Seven patients (5 females and 2 males) developed significant drug toxicities. Six patients developed hepatitis with increased liver enzymes. All of them had discontinuation of isoniazid and rifampicin. Four patients had improvement of liver enzymes (ALT less than 50 U/litre in 2-3 weeks) after discontinuation therapy. Isoniazid and rifampicin were restarted and increased to full dose gradually without subsequent complications. In one patient, streptomycin, moxifloxacin and ethambutol was given during first three weeks (after stopping isoniazid and rifampicin) due to evidence of severe disease with a strongly positive Mantoux. One patient died of progressive liver derangement and liver failure in three weeks.
One patient developed extensive skin rash and itching and had low blood pressure without any evidence of hepatotoxicity. The patient was admitted and successfully treated with prednisolone and chlorpheniramine. Desensitization was performed successfully with gradual increment of drugs after two weeks under prednisolone cover.
Renal impairment
Eight patients had serum creatinine more than 1.5 mg/dl at the time of diagnosis (median: 2.4 mg/dl; range: 1.6 – 5.83). One patient had serum creatinine of 1.3 mg/dl at diagnosis that rose to 2.13 mg/dl and then came down to 1.7 mg/dl which was stable thereafter. One patient had normal creatinine at diagnosis that gradually rose to 3.2 mg/dl after 4 years. He is currently on an indwelling catheter for thimble bladder syndrome. Of the 8 patients with deranged creatinine at diagnosis, three had progressive deterioration of renal functions and two of them (one had thimble bladder) died of end stage renal disease while having renal replacement therapy in the form of haemodialysis (3 years and 5 years after starting ATT). One underwent a successful kidney transplant. Three and two patients each had “recovery” and “stability” of renal functions respectively.
Thimble bladder syndrome
Five patients (2 males and 3 females) had severe storage symptoms and bladder capacity less than 150 ml. One male patient died of progressive renal impairment and end stage kidney disease while being managed with an indwelling catheter. Another male is currently being followed up while on an indwelling catheter with a serum creatinine of 3.2 mg/dl. Both needed indwelling catheters to manage disabling storage symptoms. The three women were managed without catheters. All refused bladder augmentation because of reluctance to perform clean intermittent catheterisation post-surgery. All were managed with antimuscarinic drugs such as oxybutynin or tolterodine.
Relapses
Two patients with relapsing disease were detected. One patient who was treated for renal TB presented with an epididymal mass and sinus formation after four years of treatment completion. Category two regime was given including streptomycin and the usual ATT.
Another patient who underwent nephrectomy for renal TB presented with severe haematuria, dysuria and frequency, 2 years after treatment completion. Cystoscopy showed severe inflammation of bladder epithelium and the bladder biopsy was positive. The patient was treated with ATT for 9 months. Streptomycin was avoided due to single kidney.