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  • Review Article
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Urogenital tuberculosis — epidemiology, pathogenesis and clinical features

Nature Reviews Urology volume 16, pages 573–598 (2019)Cite this article

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Abstract

Tuberculosis (TB) is the most common cause of death from infectious disease worldwide. A substantial proportion of patients presenting with extrapulmonary TB have urogenital TB (UG-TB), which can easily be overlooked owing to non-specific symptoms, chronic and cryptic protean clinical manifestations, and lack of clinician awareness of the possibility of TB. Delay in diagnosis results in disease progression, irreversible tissue and organ damage and chronic renal failure. UG-TB can manifest with acute or chronic inflammation of the urinary or genital tract, abdominal pain, abdominal mass, obstructive uropathy, infertility, menstrual irregularities and abnormal renal function tests. Advanced UG-TB can cause renal scarring, distortion of renal calyces and pelvic, ureteric strictures, stenosis, urinary outflow tract obstruction, hydroureter, hydronephrosis, renal failure and reduced bladder capacity. The specific diagnosis of UG-TB is achieved by culturing Mycobacterium tuberculosis from an appropriate clinical sample or by DNA identification. Imaging can aid in localizing site, extent and effect of the disease, obtaining tissue samples for diagnosis, planning medical or surgical management, and monitoring response to treatment. Drug-sensitive TB requires 6–9 months of WHO-recommended standard treatment regimens. Drug-resistant TB requires 12–24 months of therapy with toxic drugs with close monitoring. Surgical intervention as an adjunct to medical drug treatment is required in certain circumstances. Current challenges in UG-TB management include making an early diagnosis, raising clinical awareness, developing rapid and sensitive TB diagnostics tests, and improving treatment outcomes.

Key points

  • Between 15% and 40% of the 10 million new patients diagnosed with tuberculosis (TB) annually present with extrapulmonary TB (EPTB), of which a considerable proportion have urogenital TB (UG-TB). Patients who have had a renal transplant, have HIV infection, receive immunosuppressive therapies, have diabetes, have COPD and those undergoing dialysis often experience reactivation of latent TB infection.

  • UG-TB is often missed clinically or is diagnosed late, owing to the lack of awareness among clinicians, its insidious onset, chronic non-specific symptoms, and cryptic and protean clinical manifestations, resulting in disease progression.

  • Specific diagnosis of TB is made by identification of Mycobacterium tuberculosis (Mtb) in clinical samples, by microscopy and culture, or by identification of Mtb DNA. Imaging can aid in identifying disease sites and obstructive lesions, guiding biopsies and surgical interventions

  • Treatment of drug-sensitive TB requires 6–9 months of the WHO-recommended standard treatment regimen, but longer therapy is needed for severe disease or in patients in whom immunosuppression is an underlying risk factor. Multidrug-resistant TB requires between 12 and 24 months of therapy with toxic drugs and careful monitoring.

  • Surgery is indicated for complications of UG-TB. Nephrectomy is required for severely damaged kidneys, and reconstruction procedures include pyeloureteral anastomosis, ureterocalyceal anastomosis, caliceal reconstruction, uretero-ureteral anastomosis and ureter substitution by ileum.

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Fig. 1: Pathogenesis and natural history of Mycobacterium tuberculosis infection.
Fig. 2: Mycobacterium tuberculosis infection.
Fig. 3: Renal tuberculosis.
Fig. 4: Tuberculosis of the ureters.
Fig. 5: Bladder tuberculosis.
Fig. 6: Prostate tuberculosis.
Fig. 7: Tuberculosis of the testes and seminal vesicles.
Fig. 8: Tuberculosis of the penis.
Fig. 9: Female genital tuberculosis and laparoscopic examination for infertility.

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Acknowledgements

A.Z. receives a UK National Institutes of Health Research (NIHR) senior investigator award. A.Z. acknowledges support from the PANDORA-ID-NET grant from the EDCTP Reg/Grant RIA2016E-1609), CANTAM2, TESA2 and EACCR2 EDCTP Networks of Excellence grants, all funded by the European and Developing Countries Clinical Trials Partnership (EDCTP2) programme, which is supported under Horizon 2020, the European Union’s Framework Programme for Research and Innovation. A.Z. and A.M. acknowledge support from the NIHR Biomedical Research Centre at UCLH. Figures 3a, 3b, 3c, 3d, 3i, 7c, 7d and 7e were kindly provided by Professor Sebastian Lucas, St Thomas’s Hospital, London.

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  1. Department of Urology, and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK

    Asif Muneer

  2. Department of Clinical Microbiology, University College London Hospitals NHS Foundation Trust, London, UK

    Bruce Macrae & Alimuddin Zumla

  3. Department of Urology & Renal transplantation, Sri Ramachandra Medical College & Research Institute, Chennai, Tamil Nadu, India

    Sriram Krishnamoorthy

  4. Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, UK

    Alimuddin Zumla

  5. NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK

    Alimuddin Zumla

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All authors researched data for the article, wrote the manuscript and reviewed and edited the manuscript before submission. B.M., S.K. and A.Z. made substantial contributions to discussions of content.

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A.Z. serves on the WHO and other global tuberculosis (TB) expert advisory groups and committees and is editor of two textbooks on TB, which were used as references. The other authors declare no competing interests.

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We reviewed publications in English on the MEDLINE, EMBASE and GOOGLE SCHOLAR for the period up to 1 September 2018 using the search terms “tuberculosis” or “TB” in combination with the terms “urological”, “genital”, “uro-genital”, “epididymo-orchitis”, “kidney”, or “renal” or “ureter” or “bladder” or “testes” or “urethra” or “penis” or “infertility”; websites of global and national public health agencies such as WHO, US-Centres for Disease Control, UK-Public Health England, European Centre for Disease Prevention and Control (ECDC); The 2018 WHO Global TB Report; specialist textbooks on tuberculosis; clinical guidelines developed by specialist societies; and relevant substantive reviews to inform readers of more references.

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Muneer, A., Macrae, B., Krishnamoorthy, S. et al. Urogenital tuberculosis — epidemiology, pathogenesis and clinical features. Nat Rev Urol 16, 573–598 (2019). https://doi.org/10.1038/s41585-019-0228-9

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