28/01/2026
Genitourinary Tuberculosis — A Urologist’s Perspective
Genitourinary tuberculosis (GUTB) remains a diagnostic and therapeutic challenge because of its indolent onset, protean manifestations, and frequent delay between pulmonary exposure and urologic disease. This concise, clinically focused review synthesizes pathophysiology, diagnostic strategy, and practical management priorities that a urologist needs to apply at the bedside and in the operating room.
Pathogenesis and Anatomic Patterns Relevant to Urology
Key mechanism — Hematogenous seeding of renal cortex with later rupture into the collecting system produces bacilluria and contiguous spread down the urinary tract. Dormant cortical granulomas may reactivate decades after primary infection.
Anatomic patterns that determine presentation and management
- Renal parenchymal disease — cortical granulomas, papillary necrosis, cavitation, dystrophic calcification (putty kidney). May be unilateral or bilateral; bilateral disease risks renal failure.
- Collecting system disease — infundibular scarring, caliectasis, ureteral strictures (segmental corkscrew or rigid pipestem ureter), hydronephrosis.
- Bladder disease — pancystitis, fibrosis, bladder contraction (thimble bladder), distorted ureteric orifices (golf‑hole ureter).
- Ge***al tract involvement — epididymis, prostate, seminal vesicles, fallopian tubes, endometrium; infertility is a common presenting complaint in women.
Surgical implication — The site and chronicity of fibrosis (intrarenal vs distal ureter vs bladder) dictate reconstructive options and prognosis for renal recovery.
Clinical Presentation and Differential Diagnosis
Typical clinical clues
- Sterile pyuria and acidic urine with repeatedly negative routine bacterial cultures.
- Painless microscopic or gross hematuria in most cases.
- Lower urinary tract symptoms (frequency, urgency, dysuria) once bladder involved.
- Scrotal mass or chronic epididymitis in men; infertility, menstrual irregularities, pelvic pain in women.
- Systemic constitutional symptoms are uncommon.
Important differentials to exclude
- Common infectious causes of epididymitis/urethritis (gonorrhea, chlamydia).
- Urothelial malignancy or renal cell carcinoma when radiology shows mass or calcification.
- Reflux nephropathy and other causes of ureteric strictures.
- Post‑BCG cystitis when history of intravesical therapy exists.
Red flags for urgent urologic action
- Obstructive uropathy with rising creatinine or bilateral hydronephrosis.
- Large tubo‑ovarian abscess or scrotal fistula.
- Nonfunctioning kidney with ongoing infection or suspected malignancy.
Diagnostic Approach: Practical, Stepwise Strategy
1. Clinical suspicion and baseline tests
- History: prior TB, endemic exposure, HIV status, infertility, prior instrumentation.
- Urinalysis: persistent pyuria, hematuria, acidic pH.
- Baseline renal function and electrolytes.
2. Microbiologic confirmation
- Collect 3–6 early‑morning urine specimens for acid‑fast stain, mycobacterial culture, and PCR where available. Culture remains the gold standard; automated liquid culture shortens time to detection.
- Recognize false negatives with prior antibiotics (notably fluoroquinolones) or ongoing anti‑TB therapy.
3. Imaging tailored to the urologist
- Contrast CT urography is preferred for anatomic detail: calyceal deformity, ureteral strictures, bladder capacity, perinephric collections.
- Ultrasound for bedside assessment and follow‑up of hydronephrosis.
- Intravenous urography remains useful where CT is limited; it demonstrates functional drainage and classic calyceal/ureteral changes.
- Nuclear renal scan to quantify split renal function when considering nephrectomy or reconstructive surgery.
4. Tissue diagnosis when needed
- Bladder biopsy, endometrial sampling, epididymal/prostatic biopsy, or renal biopsy if urine studies are negative but suspicion remains high.
- Send specimens for histology, AFB stain, and mycobacterial culture; macerate tissue to improve yield.
5. Adjunct tests
- IGRA or tuberculin skin test support exposure history but do not confirm active disease.
- Screen for HIV and other immunosuppressive conditions.
Management Principles from a Urologic Standpoint
Overarching rule — Medical therapy with standard anti‑tuberculous regimens is the backbone of treatment; urologic interventions are adjunctive and guided by anatomy, function, and complications.
Medical therapy
- Treat according to national/regional TB guidelines for drug‑susceptible or drug‑resistant disease; duration and regimen mirror pulmonary TB recommendations.
- Expect urine sterilization within weeks in drug‑sensitive disease, but continue full course to prevent relapse.
- Counsel patients that fertility is often not restored by medical therapy alone when structural damage exists.
Endourologic and drainage interventions
- Early decompression (ureteral stent or percutaneous nephrostomy) is indicated for obstructive hydronephrosis threatening renal function.
- Rationale: prevents irreversible loss while anti‑TB therapy reduces inflammation.
- Timing: perform promptly when obstruction is significant; stent vs nephrostomy choice depends on anatomy and ability to assess resolution.
- Duration: strictures often stabilize over 6–12 months; use nephrostomy clamping and antegrade nephrostogram to confirm resolution before removal.
Reconstructive surgery
- Defer elective reconstructive procedures until at least 4 weeks of effective anti‑TB therapy, and preferably after disease control.
- Ureteral reconstruction options:
- Ureteroureterostomy for short mid‑ureter strictures.
- Ureteral reimplantation for distal strictures.
- Boari flap, psoas hitch, ileal ureter or substitution for long or complex defects.
- Bladder augmentation or orthotopic neobladder for contracted, low‑capacity bladder; neobladder favored when small bladder and pain are dominant.
- Surgical planning must account for fibrosis, poor tissue planes, and higher risk of anastomotic failure; use well‑vascularized tissue and consider staged approaches.
Nephrectomy
- Indicated for nonfunctioning, chronically infected kidney, extensive destruction, or coexisting renal malignancy.
- Preoperative functional assessment (nuclear scan) and at least 4 weeks of anti‑TB therapy are recommended when feasible.
- Nephrectomy can relieve hypertension and recurrent infection; relapse risk after nephrectomy is low.
Ge***al tract TB
- Male: epididymal or prostatic abscesses may require drainage or excision; infertility due to ductal obstruction often requires assisted reproductive techniques.
- Female: surgical management reserved for large tubo‑ovarian abscesses or severe anatomic distortion; fertility outcomes are guarded despite therapy.
Follow‑up, Relapse Prevention, and Practical Tips
Surveillance
- For patients who retain native kidneys, long‑term surveillance up to 10 years is reasonable: urine mycobacterial culture or PCR every 6–12 months initially, and periodic imaging (ultrasound) to detect recurrence or progressive obstruction.
- Educate patients to report new urinary symptoms promptly.
Predictors of renal recovery
- Favorable: distal ureteral stricture, cortical thickness >5 mm, GFR >15 mL/min.
- Unfavorable: intrarenal strictures, extensive cavitary disease, long‑standing obstruction.
Perioperative considerations
- Coordinate with infectious disease or TB program for drug susceptibility results before major reconstructive surgery.
- Anticipate dense fibrosis and altered anatomy; plan for possible staged reconstruction and use of bowel segments when necessary.
- In HIV‑positive patients, anticipate atypical presentations and higher risk of abscess formation; manage antiretroviral timing in consultation with infectious disease.
Practical pearls
- Always consider GUTB in patients with sterile pyuria, recurrent sterile urinary symptoms, unexplained ureteral strictures, or infertility with tubal disease—especially in endemic areas or with prior TB history.
- Avoid empirical fluoroquinolones when TB is suspected, as they can mask disease and induce resistance.
- Document baseline renal function and split function before any definitive surgery.
- Maintain a multidisciplinary approach: urology, infectious disease, radiology, nephrology, and reproductive specialists as needed.
Conclusion
From a urologist’s viewpoint, genitourinary tuberculosis is a disease where timely recognition, appropriate microbiologic confirmation, and strategic integration of medical therapy with targeted urologic interventions determine outcomes. Early decompression and preservation of renal function, judicious timing of reconstructive surgery after effective anti‑TB therapy, and long‑term surveillance are the pillars of care. When structural damage is advanced, realistic counseling about renal recovery and fertility is essential, and reconstructive choices should be individualized to anatomy, function, and patient goals.
Dr Bivek Kumar - Urologist
SPARSH Hospital, Bangalore
Puspa Doctors Hub
