EAU guidelines for the management of genitourinary tuberculosis.

The AIDS epidemic caused unexpected worldwide levels of tuberculosis, even in developed countries where the incidence used to be low. Patients with urogenital tuberculosis in developed countries have fewer specific symptoms and lower rates of delayed diagnoses compared with patients from other countries. As a result, the disease tends to be less serious, with more patients presenting without significant lesions of the upper urinary tract on diagnosis. These data point to a correlation of the timing of diagnosis with the severity of urogenital tuberculosis. A systematic search for urogenital tuberculosis, regardless of symptoms, is warranted for early detection.

Urogenital tuberculosis: update and review of 8961 cases from the world literature

Objective: We herein describe the various modes of presentation in genitourinary tuberculosis (GUTB) and a simple diagnostic approach to it. Materials and Methods: We made a literature search through Medline database and various other peer-reviewed online journals to study the various modes of presentation in GUTB. We reviewed over 100 articles published in the last 10 years (1998 -- 2007), which were tracked through the key words like GUTB and extrapulmonary tuberculosis. Results: GUTB has varied presentation and the most common way of presentation is in the form of irritative voiding symptoms, which are found in more than 50% of the patients. The usual frequency of organ involvement is: kidney, bladder, fallopian tube, and scrotum. The usual tests used to diagnose GUTB are the demonstration of mycobacterium in urine or body fluid and radiographic examination. Intravenous urography (IVU) has been considered to be one of the most useful tests for the anatomical as well as the functional details of kidneys and ureters. In cases of renal failure, MRI can be used. Newer examinations such as radiometric liquid culture systems (i.e., BACTEC® , Becton Dickinson,USA) and polymerase chain reaction (PCR) give rapid results and are highly sensitive in the identification of mycobacterium. Conclusion: GUTB can involve any part of the genitourinary system and presentation may vary from vague urinary symptoms to chronic kidney disease. Newer tests like radiometric liquid culture systems and polymerase chain reaction give rapid results and carry high diagnostic value.

Clinical presentation and diagnostic approach in cases of genitourinary tuberculosis

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. Urogenital tuberculosis can be easily overlooked owing to non-specific symptoms, varying manifestations and a lack of awareness of the disease. In this Review, Muneer and colleagues provide a comprehensive overview of the epidemiology, pathogenesis, clinical features, diagnosis and management of this disease.

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Urogenital tuberculosis - epidemiology, pathogenesis and clinical features.

Background: Tuberculous epididymitis is one of the causes of chronic epididymal lesions. It is difficult to diagnose in the absence of renal involvement. Aim : To profile isolated tuberculous epididymitis and to assess our approach in the evaluation of this group of patients. Setting and Design : Retrospective study done at Christian Medical College, Vellore, South India. Methods and Materials : Between 1992 and 2002, 156 fine needle aspiration cytology specimens and 108 epididymal biopsies were carried out in 187 men for evaluation of chronic epididymal nodules. Isolated epididymal tuberculosis was defined as tuberculous infection affecting the epididymis without evidence of renal involvement as documented by the absence of acid fast bacilli in the urine sample and on imaging. The age, laterality, mode of presentation and method of histological diagnosis were studied with the objective of profiling isolated tuberculous epididymitis. Results : Fifty-four of the 187 men (median age 32 years; interquartile range: 21-37 years) had tuberculous epididymitis. Fourteen were excluded from the analysis (10 had associated urinary tract tuberculosis and 4 were lost to follow-up). None of the 40 men with isolated tuberculous epididymitis had urinary symptoms. Bilateral involvement was seen in five (12.5%) cases. The salient presenting features included painful swelling (16 subjects, 40%), scrotal sinus (4, 20%) and acute epididymitis (2, 10%). Past history or concomitant presence of tuberculosis was noted in three subjects each. Anti TB treatment resulted in a complete response in 10 and partial response in 18. Five subjects underwent epididymectomy. Tuberculous epididymitis was found incidentally in 5 (10%) cases on high orchiectomy specimen done for suspected testicular tumour. Conclusions : Tuberculous epididymitis can be the sole presentation of genitourinary tuberculosis.

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Isolated tuberculous epididymitis: a review of forty cases.

Genitourinary tuberculosis in pediatric surgical practice

Exteriorization of the distal esophagus in the abdomen in esophageal atresia.

An isolated bowel segment (IBS) was created in 10 rats by a two staged procedure: (1) Co-optation of the omentum to the submucosa of the bowel segment and (2) division of the mesentery of this segment 6 weeks later. Fluorescein angiography was done in 5 rats and showed that the IBS was sustained by collateral from the omentum. Histological evaluation in 5 other rats showed no adverse changes in the wall or mucous of the IBS. Stomal stenosis has been shown to be of potential advantage for the use of IBS in bowel elongation procedures.

A Chattopadhyay

Papers

Genitourinary tuberculosis in pediatric surgical practice

Exteriorization of the distal esophagus in the abdomen in esophageal atresia.

Creation of an isolated bowel segment by omento - enteropexy evaluation by fluorescein angiography and histopathology.