From Nature Reviews Urology

Etiology and Management of Genitourinary

Tuberculosis CME
Aula Abbara, MBBS, BSc, MRCP(UK); Robert N. Davidson, MD, FRCP, DTM&H

Faculty and Disclosures

CME Released: 12/09/2011; Valid for credit through 12/09/2012

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1. Abstract and Introduction

2. Epidemiology
3. Pathophysiology
4. Diagnosis
5. Sites of Genitourinary Tuberculosis
6. Management of GUTB
7. Conclusions
8. Key Points

References

Abstract and Introduction

Abstract

Genitourinary tuberculosis (GUTB) is the second most common form of extrapulmonary

tuberculosis, with more than 90% of cases occurring in developing countries. Postmortem
studiesfrom before anti-TB therapy was availablehave provided insight into the prevalence
and natural history of the disease. In GUTB, the kidneys are the most common sites of infection
and are infected through hematogenous spread of the bacilli, which then spread through the renal
and genital tract. Diagnosis of TB is often delayed owing to the nonspecific nature of its
presentation; therefore, a high degree of suspicion should be exercised and a systematic approach
should be taken during investigation. Appropriate culture samples should be obtained to tailor
treatment. Standard treatment should be administered for 6 months; quadruple therapy for 2
months and dual therapy for 4 months. However, additional drugs and prolonged treatment are
required if drug resistance occurs. Although the role of surgery in GUTB has decreased since the
advent of anti-TB therapy, it can still have a role as an adjunct to drug treatment. Today, the
challenges of GUTB and other forms of TB include increasing rates of drug-resistant cases and
co-infection with HIV.

Introduction

Tuberculosis (TB) remains a global health problem, with one-third of the world population
infected and ~9.4 million new cases reported in 2008.[1] Of these, more than 90% of patients
infected were in developing countries, mostly in India (1.6-2.4 million), followed by China (1.0-
1.6 million) and South Africa (0.380.57 million). 75% of the infected individuals are aged 15-54
years and economically productive, 1.4 million (15%) of whom are HIV-positive. 78% of HIV-
positive patients contracting TB are in Africa.[1] TB accounted for 20% of the 1.8 million AIDS-
related deaths in 2009, with most deaths in sub-Saharan Africa.[1] The global prevalence (164 in
100,000 people) and death rate (20 per 100,000 people) of TB have been declining, but the
number of infected individuals is actually increasing.

Multidrug-resistant (MDR) TB is often associated with poorly managed pharmacotherapy,

particularly in middle-income countries. The incidence of MDR TB is increasing and is of global
concern.[1] Genitourinary TB (GUTB) is the second most common form of extrapulmonary TB
(EPTB), after lymph node TB.[2,3] GUTB has the propensity to affect both men and women of
child-bearing age (that is, 20-40 years old), is responsible for extensive morbidity and can render
patients infertile.

The nonspecific presentation of GUTB can result in delayed diagnosis and management of the
disease, which could worsen morbidity. The mainstay of GUTB treatment is antimycobaterial
chemotherapy, and surgical intervention is reserved for patients with complications such as
recurrent infections in a nonfunctioning kidney. In many developing countries, directly observed
therapy has been successfully employed to ensure compliance with treatment and reduce the risk
of drug resistance.[1]

In this Review, we will present the epidemiology and pathophysiology of TB and describe the
currently available diagnostic tests and imaging techniques. We will also elucidate the sites of
GUTB in men and women, and explain the treatment options. Future challenges for the
management of patients with drug-resistant disease and those with HIV co-infections will also be
considered.