Suspect that a patient has tuberculosis of his urinary tract, if he has a persistent cystitis, which fails to respond to antibiotics, and has pus cells and red cells in his urine, but no bacteria are cultured from it by routine methods. He is usually a young adult without signs of tuberculosis elsewhere. Urinogenital tuberculosis is common in Asia, but is very uncommon in sub- Saharan Africa. Treatment is usually easy, cheap, and effective[md]if the disease is not too far advanced, and he takes his drugs conscientiously. He may improve dramatically, especially if you treat him early, and even strictures of the ureter have been known to heal. So watch for urogenital tuberculosis, and be prepared to treat him on the suspicion that he might have it. The surgery that he may need if he presents late is beyond you. Unfortunately, his disease starts so insidiously that he may not complain of it until late.
Bacilli reach one of his kidneys (usually only one, but sometimes both) in his blood, after which caseation slowly destroys it. Only when the disease has eroded into its calyces do bacilli spread in his urine down to his ureter and bladder, infect them, and cause frequency and pyuria. Eventually, most of his kidney is destroyed, after which the disease may spread outside it, to form a palpable mass in his loin, perhaps with a discharging sinus.
Tuberculosis inflames the mucosa of the bladder and forms tubercles which may ulcerate, coalesce, and form shallow ulcers, especially round the orifices of the ureters and on the trigone. Ultimately, much of the wall of the bladder is destroyed, so that it ends up scarred, red, and contracted. A ureter which drains a tuberculosis kidney is flooded with bacilli, and becomes thick, fibrosed and strictured, usually in its lower third. Above this, his urinary tract dilates to form a hydro- or pyonephrosis.
He may present with: (1) The symptoms of chronic cystitis[md]frequency and dysuria. This later progresses to the burning nocturia and strangury of a small shrunken bladder, which may become secondarily infected. These symptoms make his bladder appear to be the cause of his disease, rather than his kidney. (2) A painless intermittent microscopic haematuria, or sometimes obvious bleeding (a renal carcinoma usually causes obvious bleeding). (3) A dull discomfort in his loin, which gets steadily worse, especially when tuberculosis is complicated by a pyogenic infection (20% of cases). His kidneys are not enlarged or tender, until late. (4) Malaise and the usual general symptoms of tuberculosis. (5) A painless, non-tender, craggy, and occasionally fluctuant tuberculous mass on one side of his scrotum. Otherwise, any genital tuberculosis he may have usually causes no symptoms.
Fig. 29-9 TUBERCULOSIS OF THE URINARY TRACT. A, tuberculosis of the kidney involving the pelvis and the ureter. B, tuberculous ulcers of the bladder. C, tubercles near the orifice of the ureter. Adapted from a drawing by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).
RENAL TUBERCULOSIS EXAMINATION. Examine the patient's kidneys. Several parts of his urinary tract may be involved at the same time, so also feel his testes, his cords, and his prostate for painless non-tender enlargement. A tuberculous prostate feels irregular and boggy; tuberculous vesicles thick and boggy. A tuberculous epididymis feels thick, woody, and craggy. It may caseate, and form sinuses, or it may involve his testis, and cause a secondary hydrocele. His distal spermatic cord is thick and oedematous.
SPECIAL TESTS. Urine with pus cells and red cells, but no bacteria on standard culture (unless there is secondary infection), is strongly suggestive.
A 24-hour urine, or an early morning urine specimen (after a period of dehydration), may show AAFB in a stained film. Repeat the examination 3 times. This needs little equipment, but it does require considerable skill, and much time. So you will probably have to rely on finding pus cells and red cells only. If possible, culture his urine for AAFB.
If you are in an endemic area and routine examination shows no ova of Schistosoma haematobium, examine the deposit from a specimen passed at midday (the time when most ova are passed) on 3 consecutive days.
He is usually anaemic, and his sedimentation rate is raised.
CYSTOSCOPY (23.3), will confirm the diagnosis, show the degree of involvement of his bladder, and exclude schistosomiasis.
X-RAYS. Look for the outline of an enlarged kidney, calcification, and obliteration of his psoas shadow.
An IVU will only be positive if disease is advanced. Look for ''moth-eaten calyces', and dilatation of his renal pelvis, and ureter. If it is very advanced, his kidney will not be functioning.
DIFFERENTIAL DIAGNOSIS. In endemic areas schistosomiasis haematobium is the main one, and is much the most common cause of pain on micturition with pus cells and red cells in the urine, compared with urinary tuberculosis, which is uncommon or rare.
Suggesting schistosomiasis[md](1) small 3 to 5 mm nodules in his epididymis, nearly always in the tail. (2) Calcification of his bladder wall, as shown by a line in the shape of his bladder, which collapses after micturition. (3) Do a cystoscopy before an IVU, which is much more expensive. (4) The special test above.
TREATMENT [s7]OF RENAL TUBERCULOSIS Treat him as an outpatient, with the standard tuberculosis chemotherapy (29.1). If his renal function is impaired, avoid streptomycin, or ethambutol, or give them intermittently. Rifampicin, INAH, and pyrazinamide are safe. Ask him to return every 2 months for regular assessment, including the examination of his urine, and a further supply of drugs.
If he relapses, and you think that he has not taken his drugs faithfully, consider changing to a regime using second-line drugs.
INDICATIONS FOR SURGERY. Operations for renal tuberculosis are beyond the scope of this manual. Refer him.
If his IVU shows no function, or has a moth-eaten appearance, with flecks of calcium, refer him for nephrectomy. Hypertension is an additional reason. If he is toxic and febrile, suggesting that he has a pyonephrosis, or a perinephric abscess, this is urgent. Otherwise, give him 6 weeks of chemotherapy first, to improve his condition for surgery.
If he has a ureteric stricture, refer him for urological investigation before starting chemotherapy. If you cannot refer him, all you can do is to give him chemotherapy. In endemic areas, schistosomiasis is a commoner cause of a stricture.
If he still has extreme frequency and dysuria, after 3 to 6 months of chemotherapy, suspect that he has a small contracted bladder. Confirm this by cystoscopy and a cystogram. Surgery may be possible.