Genito urinary tuberculosis

genitourinary tb - contains radiological findings of genitourinary tuberculosis including ivp,, hsg, usg and ct findings in kidney, ureter, urinary bladder, uterus and prostate

1. GENITO – URINARY TUBERCULOSIS DR. ANNIE AGARWAL 23/02/2013

2. young to middle-aged adults. M/F ratio= 5:3 Uncommon in children Approximately 20-30% of extra-pulmonary infection Increase in incidence with HIV epidemic and multi drug resistant strains Important to diagnose as non specific clinical presentation and progression to renal failure if undiagnosed and untreated. INTRODUCTION

3. The kidneys are the most common site of GUTB Causative organism : Mycobacterium Tuberculosis. history of previous clinical TB (25%) with a lag time of 2- 20 years

4. SPREAD Hematogenous spread - from the kidneys, the bacilli can spread to the renal tract, prostate and epididymis . Lymphatic spread Observed in two settings : commonly , as a late manifestation of earlier clinical or subclinical pulmonary infection rarely , as part of the multiorgan infection ( miliary tuberculosis) Rarely primary one— BCG Tt for Ca bladder Transplant recipient

5. CLINICAL FEATURES gross / microscopic hematuria sterile pyuria Mild proteinuria urinary frequency, dysuria , ‘intractable’ UTI frequency , urgency, dysuria with involvement of bladder back, flank, or abdominal pain. : => extensive renal disease Constitutional symptoms such as fever, weight loss, fatigue, and anorexia are less common haemospermia ‘acute epididymo-orchitis ’ Hydrocele,discharging scrotal/ perineal sinuses Infertility,spontaneous abortion,ectopic pregnancy. Menstrual irregularities

6. Three other major complications of renal tuberculosis: hypertension (RAS axis mediated) super-infection (12 to 50%) nephrolithiasis (7 to 18%) OTHER COMPLICATIONS: Perinephric inflammation Abscess formation :including psoas abscess Fistulae Sinus tract into adjacent tissues or viscera.

7. PATHOGENESIS

8. Progressive involvement of renal parenchyma coalescence of granulomas leading to unifocal or multifocal mass lesions Seen in advanced renal tuberculosis Increase renal length Increase thickness of renal substance Displacement of collecting system. Parenchymal surface scarring over retracted papillae or pelvis and dilated/ deformed calyces. Associated calcification or calculi Impaired excretion of contrast Erosion of pyramid Cortical / papillary necrosis Caliectasis Cavity Deformed calyx Caseo – cavernous type: enlarged sac filled with caseous material, +/- calcification Calcified shrunken non functioning of kidney Autonephrectomy : end stage d/s Focal or diffuse involvement - fibrosis.

9. Following the drainage of a cavity into the collecting system, there is spread of infection to other parts of the urinary tract. Stimulation of scirrhous reaction causes stenosis and obstruction of parts of the collecting system.

10. Common sites of stricture: neck of a calyx – hydrocalyx , regional hydrocalycosis pelvi – ureteric junction – generalised dilatation of pelvicalyceal system. lower end of the ureter .

11. I maging High dose IVU – traditional gold standard CT – new standard Pyelography (ante/retrograde) – limited use Plain radiographs – important CXR,spine X- Ray,X -Ray KUB US – limited value Nuclear Perfusion Scan – function MRI – little application

12. Plain radiograph of abdomen Renal Size: Small, enlarged or normal Presence of scarring or focal bulge Calcification Calcification of ureter or urinary bladder : rare Evidence of Skeletal Involvement : in hip, sacroiliac joint, spine, paraspinal abscess calcification of lymph nodes, adrenal gland – 10%

13. Calcification : attempt to heal and limit the pathological processes – 50% - types Dense punctate calcification representing healed tuberculoma . Amorphous granular associated with granulomatous masses- autonephrectomy

14. Chest x ray Abnormal in 50 % Active pulmonary tuberculosis – 5- 10% Sequelae of old tuberculosis of past infection.

15. Intravenous urography >70% cases- single kidney involved IVP (abnormal in 85- 90 %) though normal in initial stages. Diagnosis can be made with certainity on urography only if lesion is ulcerated into calyx. Miliary tubercles – involve both the kidneys. globally poor renal function IVU- assess the extent and severity of involvement To monitor response to treatment To look for complications

16. Imaging findings : Parenchymal scars & Irregularity of the papillary tips - “ moth-eaten” calices Small cavities in the papillae communicate with the collecting system fibrotic reaction develops, stenosis and strictures of the caliceal infundibula - Infundibular strictures can lead to localized caliectasis or phantom calyx. Scarring of renal  pelvis (Kerr kink )

17. Moth eaten appearance Normal calices Earliest abnormality – an indistinct feathery outline Irregularity of surface of one or more papillae or calyces with normal renal size and contour . Fuzzy & irregular calices due to papillary necrosis.

18. IVP of 32-year-old woman. A , left renal parenchymal mass (arrows) and left hydroureter due to left distal ureteral stricture (arrowheads). B , magnification of left kidney shows irregular caliceal contour as moth-eaten appearance (arrows) of upper calix and multiple cavities (arrowheads) of lower pole.

19. Golf ball on a tee On IVP : Collecting system shows contrast material in a large papillary cavity, the “golf ball” (∗). Blunted calyx, the “tee,” is adjacent (arrow).

20. Infundibular stenosis causing phantom calyx Phantom calix Infundibular stenosis

21. Phantom calyces Decreased nephrographic opacity and nonfilling of the collecting system elements at the lower pole of left kidney – phantom calyces (ghost : exist, but not visualised , the same are visualized on RGP). Ghost - like RGP

22. Hiked up pelvis => pulled up Cephalic retraction of the inferior medial margin of the renal pelvis at the ureteropelvic junction (UPJ)

23. Cortical scarring with dilatation & distortion of adjoining calyces coupled with strictures of the pelvicaliceal system. Cause luminal narrowing either directly or by causing kinking of the renal pelvis at the UPJ . Kerr kink

24. If the ulcer or stricture extends to the renal pelvis or the pelvic ureteral junction, urine outflow obstruction may occur. IVUmay show delayed function, clubbed calyces, or absence of function. Some show Hydronephrosis - irregular margins and filling defects owing to caseous debris. If tuberculous infection extends directly to the rest of the kidney, the entire kidney becomes a bag of caseous necrotic pus. The kidney enlarges initially but subsequently may return to normal or become atrophic. infection may extend into peri - / pararenal space + psoas

25. Some nonspecifically blunt calices in addition to a track leading to a cavity (arrow).

26. ( A) ‘Cut-off’ upper pole infundibulum . No filling of calices in upper pole. Irregular cavitation in remainder of the kidney . (B) Pathological specimen showing a fibrotic stricture of the upper infundibulum (black arrow) and a caseous pyonephrosis occupying the upper pole. Cavitation elsewhere.  

27. Autonephrectomy . Diffuse, uniform, extensive parenchymal calcifications forming a cast of the kidney with autonephrectomy . End stage of GuTB . Putty kidney

28. Genitourinary tract tuberculosis. Lobar calcification in a large destroyed right kidney in a patient with renal tuberculosis. Note the involvement of the right ureter .

29. URETER Almost always secondry to renal tuberculosis – 50% cases. Spread of infection by bacilluria . ureteral involvement is usually unilateral, bilateral changes are asymmetric when they occur. The most common site of involvement is the lower third of the ureter . Renal damage secondry to ureteral strictures may be more severe than the effect of original parenchymal involvement. Dilatation and stenting of the ureter may restore ureteral patency and salvage a kidney.

30. dilatation resulting from atony and prolonged bacilluria PIPE STEM URETER irregular segments of ureter due to mucosal ulcerations necrosis of ureteral musculature is accompanied by fibrosis - stricture formation- 50%. severe thickening of the wall produces a rigid shortened ureter with narrow lumen beaded or corkscrew appearance . Terminal segment of the ureter

31. Ulcerations causing mucosal irregularity of ureter . Saw tooth appearance

32. Fusion of multiple strictures may create a long, irregular narrowing. Several nonconfluent strictures can produce a “beaded” or “corkscrew” ureter Beaded / Corkscrew ureter Mucosal thickening of ureter

33. Rigid ureter : irregular and lacks normal peristaltic movement, fibrotic strictures noted. Note the distortion, amputation and irregularity of the upper pole calices. Pipe stem ureter Old pipe stem

34. Urinary bladder Inv. in later course of d/s in 1/3 rd cases

35. Back-pressure atrophy The essential features are uniform atrophy of the papillae and uniform loss of renal substance.    1.    Obstructive nephropathy. The appearances vary depending on the completeness, rate of onset, site, duration, and nature of the obstruction. The calices may be grossly dilated or there may be only minimal blunting of the fornices . Rarely the calices may appear normal [38] . The kidney can be large, normal in size, or small. There may be a reasonable amount ofrenal substance but the parenchyma can be reduced to thin septa.    2.    Severe vesicoureteric reflux (generalized reflux nephropathy). This can produce back-pressure changes indistinguishable both radiologically [39] and pathologically [40] from those resulting from obstruction.

36. Genitourinary tract tuberculosis. Intravenous urography series in a man with renal tuberculosis shows marked irregularity of the bladder lumen due to mucosal edema and ulceration

37. Diminutive and irregular urinary bladder – simulating a thimble. Thimble bladder

38. IVP film-The lower end of the right ureter demonstrates an irregular caliber with an irregular stricture at the right vesico-ureteric junction. Note the asymmetric contraction of the urinary bladder, with marked irregularity due to edema and ulceration.

39. Diffuse reflux nephropathy with multiple blunted calices . Left kidney normal in size . Shrunken right kidney.

40. Urethral tuberculosis Male urethra – uncommon, occurs secondry to renal infection. The periurethral glands of Littre may become distended with bacteria and leukocytes and may lead to abscess formation . Associated with prostatic abscess or fistula formation. Result in non specific stricture in bulbo -membranous urethra .

41. Retrograde pyelography Indicated in patients with non functioning kidney to demonstrate ureteric obstruction and cavitation in kidney.

42. Retrograde ureteropyelography showed an atrophic right kidney with diffuse caliceal dilatation, papillary necrosis, and infundibular narrowing.

43. mucosal irregularities and erosions of the ureter .

44. ultrasonography Role of sonography : Guidance for interventional procedures of percutaneouys nephrostomy (PCN) Antegrade dilatation of ureteral stricture Drainage of perinephric abscess. Not a primary modality used for diagnosis: Unable to show early calyceal changes. No information about status of renal function.

45. Kidney Focal lesion of varying echogenecity . Early stages – papillary lesions as areas of hypoechogenicity or hypoechoic foci with echogenic walls or echogenic non shadowing lesions. Sloughed calyx – echogenic flap separated from normal calyceal wall. Large liquefying conglomerate cavities or dilated calyces formed as a result of infundibular stricture appear as hypoechoic nodules or masses. PCS- hydronephrosis or calyectasis . The communicating tract from a cavity appears as a sonolucent track entering the dilated calyx . Heterogenous echotexture of the parenchyma or normal appearing parenchyma may be seen in diffuse involvement. May demonstrate hydronephrosis , parenchymal calcification and perinephric abscess.

46. Usg classification TYPE I : Nephrectasia TYPE II: hydrops type TYPE III: empyema type TYPE IV: inflammatory and atrophy type TYPE V : calcification type TYPE VI: mixed type

47. Sonogram of left kidney shows 1.5-cm hypoechoic nodule ( arrowhead ) in cortex USG Early findings may be missed

48. IVP: cobra head sign, the lucent halo is however thick, irregular and less well defined. Pseudoureterocele Rao A, Yvette K, Chacko N. Tuberculosis of urinary bladder presenting as pseudoureterocele . Indian J Med Sci 2005;59:272-3

49. Usg is poor in assessing ureter but shows back pressure changes and adjacent retroperitoneal disease. UB- focal irregular thickening with reduced capacity. Deformed shape and focal abnormalities better appreciated following distension.

50. Computed tomography Indicated only in patients with strong clinical suspicion but normal IVU and USG. Uses :MDCT: Renal and extra renal spread of disease. Length of ureteric stricture Adjoining retroperitoneal disease Associated spinal or solid organ involvement. excretory urography is sensitive in the detection of early urothelial mucosal changes

51. kidney Spectrum: Multiple small poorly enhancing nodules, uneven caliectasis and calcification. Isolated cortical involvement by focal lesions is well demonstrated. A cavity is well demonstrated with pooling of contrast in delayed images. Better visualisation of retroperitoneal structure Functional status of kidney Detailed information on presence and pattern of calcification In poorly functioning kidneys – nephrogram effect is much better seen on CT. CT may show a variety of abnormalities, many of which are nonspecific. Obstruction of a single major calyx or of a group of minor calyces often occurs because of scarring. The obstructed calyces are dilated and show no excretion of contrast medium, and thinning of the overlying renal parenchyma occurs

52. CT scan in advanced renal tuberculosis. Unenhanced scans show bilateral renal calcification. Note (A) dilated calices in the left mid-kidney (arrowed) and (B) mixed-attenuation left lower pole mass containing calcification.

53. CT identifying   renal calcifications , Coalesced cortical granulomas containing either caseous or calcified material Calices that are dilated and filled with fluid have an attenuation between 0 and 10 HU; debris and caseation , between 10 and 30 HU; putty-like calcification, between 50 and 120 HU; and calculi , greater than 120 HU. Cortical thinning is a common CT finding and may be either focal or global. Parenchymal scarring is readily apparent at CT. Fibrotic strictures of the infundibula ,  renal  pelvis, and ureters may be seen at contrast-enhanced CT and are highly suggestive of  tuberculosis .

54. Ureter : thickening of ureteral wall or pelvis with periureteric inflammation Bladder Tuberculosis thickened bladder wall (= muscle hypertrophy + inflammatory tuberculomas ) filling defects (due to multiple granulomas ) bladder wall ulcerations shrunken bladder - scarred bladder with diminished capacity - thimble bladder. bladder wall calcifications (rare)

55. CT urogram shows severe nonuniform caliectasis and multifocal strictures ( arrowheads ) involving renal pelvis and ureter .. Calcification ( arrow ) is noted in left distal ureter .

56. A, Contrast-enhanced CT scan obtained at level of right renal hilum shows wedge-shaped hypoperfused areas ( arrowheads ). B, CT scan - hypoperfused areas ( arrowheads ) and focal caliectasis ( arrows)

57.   (a)  Contrast-enhanced excretory-phase CT scan shows dilated calices and narrowing of the infundibula (arrowheads). 

58. 53-year-old man with tuberculosis involving collecting system. Contrast-enhanced CT scan of left kidney shows uneven caliectasis caused by varying degrees of stricture at various sites.

59. ( a)  Contrast-enhanced nephrographic -phase CT scan shows dilated calices and thinning of the  renal  cortex (arrow).  (b)  Magnified view from a contrast-enhanced nephrographic -phase CT scan obtained caudad to  a  shows mural enhancement and thickening of the proximal ureter (arrow).

60. Renal Tuberculosis. Coronal reformatted non-enhanced CT scan of the abdomen and pelvis demonstrates a small, left kidney containing globular calcifications (white circle) pathognomonic for renal tuberculosis.

61. CT scan shows dense calcification replacing right kidney, so-called “putty kidney .” in NCCT The left kidney shows large, dense, oval calcifications. Low-density areas in the right kidney probably represent foci of caseous necrosis.

62. MRI MR urography : evaluate poorly or non functioning kidney specially obstructive form for demonstration of ureteric involvement. MR – renal parenchymal changes and details of PCS Used for evaluation of ureteral peristalsis.

63. Genital tuberculosis

64. Male Genital Tuberculosis seeding from infected urine or via the bloodstream. The most common manifestation is tuberculous prostatitis , less common is epididymo-orchitis calcifications in 10% (diabetes more common cause) Tuberculous epididymitis ascending / descending route of infection Tuberculous orchitis direct extension from epididymal infection, rarely from hematogenous spread

65. Prostatic involvement : Plain radiographs-dense calcification within the prostatic bed Cavities / abscesses--discharge into the surrounding tissues  sinuses or fistulae to the perineum or rectum ‘ watering-can perineum.’ Cystourethrography - early cases - filling of the prostatic ducts without evidence of cavitation , Advanced cases the ducts may be greatly dilated. Varying degrees of destruction of prostatic parenchyma with sloughing may produce irregular cavities. Tuberculous prostatitis / prostatic abscess: caseation , cavitation and fibrosis. hypoechoic irregular area in peripheral zone hypoattenuating prostatic lesion hypointense diffuse radiating streaky areas on T2WI (watermelon sign) peripheral enhancement Occasionally fistulous formation

66. Prostatic tuberculosis. Contrast-enhanced CT scan shows a well-defined hypoattenuating lesion within the prostate gland (arrowhead). Scrotal tuberculosis. US image of a testis shows a nonspecific focal area of hypoechogenicity , which proved to represent caseous necrosis secondary to tuberculosis.

67. Prostatic abscess, T2-weighted MRI shows a peripheral enhancing cystic mass with radiating, streaky areas of low signal intensity. Watermelon skin

68. Female genital tract - TB Hematogenous spread. Associated wet or dry peritonitis strongly associated with infertility in women, rates of successful pregnancy remain low even after treatment. Salpingitis (94%): mostly bilateral Tuboovarian abscess: extension into extraperitoneal compartment

69. HSG - GTB obstruction and multiple constrictions of the fallopian tubes. Rigid pipe-stem tubes A clubbed ampula with retort-shaped hydrosalpingx Vascular or lymphatic intravasation of contrast Small shrunken uterine cavity with filling defects with adhesions Long and dilated cervical canal & dye in cervical crypts Bilateral cornual block Punctate opacification of crypts and diverticulae in lumen of tubes

70. Findings in female genital tract Tubal involvement -bilateral but asymmetrical. HSG- flask-shaped dilatation of the fallopian tubes due to obstruction at the fimbria/ the obstruction is at the uterine end of the tube-the tubes are not depicted. sacculation with infiltration of contrast material resembling salpingitis isthmica nodosa. A characteristic HSG feature- irregular contrast distribution occurs resembling a cotton-wool plug. Focal irregularity and areas of calcification may occur within the lumen of the fallopian tubes. In end-stage disease, the tubes become rigid, lack peristalsis, and resemble pipelike conduits. Within the endometrial cavity, tuberculous endometritis- adhesions, which very thin to very thick synechiae. In end-stage disease, the uterine cavity may be obliterated completely. Within the pelvis calcified lymph nodes and ovaries may be observed.

71. HSG may demonstrate a flask-shaped dilatation of the fallopian tubes due to obstruction at the fimbria . Flask shaped fallopian tubes..

72. Focal irregularity and areas of calcification occur within the lumen of the fallopian tubes. Cotton wool plug appearance..

73. Hydrosalphinx

74. Bilateral T.O.masses even after ATT

75. Caseous ulceration of the mucosa of the fallopian tube produces an irregular contour of the lumen of the tubes. Diverticular cavities may surround the ampulla and give a “tuft” like appearance . Thick arrow – hydrosalphinx . Tufted appearance..

76. Scarring fallopian tubes. Irregular and rigid . Filling defect in uterine cavity – adhesion. Pipe stem appearance

77. Multiple constrictions along the course of fallopian tube on HSG due to fibrotic strictures. Beaded appearance..

78. Beaded appearance more on left side

79. Left tube appears as if tubectomy done also described as look of sperm head

80. Both tubes eroded looking. Inner lining of uterine cavity moth-eaten appearance

81. Scarring results in a “T” shaped uterine cavity with intravasation of contrast. T-shaped uterine cavity

82. Appearance similar to Bilateral tubal ligation. Elongation and dilatation of cervical canal

83. Lymph node calcification

84. Bilateral cornual block & intravastion of dye in vessels & lymphatics.

85. Intravasation of dye into myometriums and lymphatics and left terminal hydrosalpingx