Urinary Tuberculosis

Introduction

I am Dr. Bhi VI from Guam of India.
I'm going to talk on ultrasound of urinary tuberculosis.

Pathology of Urinary Tuberculosis

The pathology of tuberculosis happens in two phases.
One is during the initial seeding, which happens during primary tuberculosis infection,
and then next it happens as reactivation.

Initial Seeding

The initial seeding, it is in the kidney, it is bilateral
and occurs as numerous small granuloma in the renal cortex.
These granulomas either spontaneously
or on treatment totally resolved.

Reactivation Phase

In the reactivation phase
whenever the immunity of the patient goes down.
There is reactivation of the granulomas in the kidney.
And now the primary site is medulla.
And we developers microscopic granulomas.
These granulomas coalesce
to form a large macroscopic granuloma,
which can be seen on imaging,
and which proceeds onto necrosis forming a focal papillary cavity,
which can erode into the colleagues with spread of infection
to the renal pelvis, ureter, and bladder.

The characteristic feature of reactivation is destruction
and healing, destruction in the form of granuloma,
coalescent granuloma cavitation rupture into the collecting
system and healing happens by fibrosis,
granuloma formation, and calcification.

Ultrasound Features in the Kidney

This is a schematic diagram of
the microscopic granulomas coalescing to form larger
microscopic granuloma, which
when we do ultrasound using the conventional
convex probe, which may not be seen as seen here,
we see a coronal scan of the kidney.
The paren camera looks unremarkable,
whereas there is mild dilatation of the collecting system.
And when you use a high frequency linear transfuser,
the resolution improves
and you see the parenchyma of the kidney,
and you see two coalescent granulomas in the middle of the kidney.

The then in the coalescent granuloma
necrosis happens in the center and forms a cavity.
That cavity erodes into the cex
and the infection spreads to the urothelium.
So this is a coalescent gran necrosis happens in the center.
The necrosis forms a cavity in the granuloma.
And if the cavity, papillary cavity is close
to a cic, that causes fuzziness of the cly on the IVP.
So this is a papillary cavity, very close to the cly.
And because of the proximity, it erodes into the cly
with the escape
of the infection from the gran into the collecting system.
And this communication between the CX
and the granuloma varies in size.
And when it, when there is hydro
nephrosis, it is much bigger.
And here we see two kidneys, one
with a papillary cavity communicating with the cice.
Another kidney, there are large cavities,
parenchymal cavities,
and two of them are communicating
with the hydro nephrotic cx.
Because of the hydro nephrosis,
the communication looks very big.

Spread to Pelvicalyceal System

Then the infection spreads to the pelvic cell system
with the occurrence of granulomas in the urothelium.
With the convex conventional convex probe,
you see the urothelial thickening.
And with the high frequency probe, that is much better.
You see the renal pelvis and the cx,
and you see the urothelial thickening of the renal pelvis.
And the same thing we can see in the upper ureter,
the urothelial thickening of the upper ureter.
And in the case of mid
and lower ureter, the,
there are three different appearances.
One may be the urothelial thickening causes narrowing
of the ureter with proximal dilatation,
or there may be uniform thickening,
urothelial thickening assembling a lead pipe.
Or it may be the granula granuloma may be intermittent with
the lumen of the ureter in between appearing like a beaded ureter,
which is also described in the IVP coming
to the lower retary.
We see classically the urothelial thickening
of the lower retary extending up to the
uterosacral junction.
And at this stage because of the involvement of the UU uterosacral junction,
patient becomes symptomatic
and he develops dysurea the same urothelial thickening.

Bladder Involvement

And the spread of infection to the urinary bladder is seen
as focal urothelial thickening anywhere along the urinary bladder here,
another case sewing urothelial thickening marker in the
dome of the urinary bladder.
And another patient showing marked urothelial thickening
involving most of the urinary bladder.
So at this stage, because of the involvement of the bladder,
patient is symptomatic
and the HEB can have dysphoria frequency of metrition
and hematuria.
So urothelial thickening and the
because of the infection of the urothelium, occurrence
of granulomas, there is spasm of the
detrusor muscle of the urinary bladder, which causes
the contraction of the urinary bladder,
which is still reversible with the treatment.
So with this contraction of the urinary bladder,
patients will have extreme frequency of nutrition.

Abscess Formation

Now, the spread of infection, instead
of going eroding into the caly, it can spread outside
with occurrence of an ABSs renal abs
and rupturing into the perinephric space
and producing a perinephric abscess.
So this is a coronal scan
of a kidney showing the renal abscess
and a perinephric abscess.
This app, this mimics like any other non-specific renal perinephric abs,
but only the symptoms will be different.

Healing Features

Then the next characteristic feature
of reactivation tuberculosis in the kidney is healing
and the healing can be due in the form
of fibrosis, granuloma formation and calcification.

Fibrosis and Calyceal Ectasia

So fibrosis of a minor infant develop
of a minor caly results in dilatation, minor ectasis,
which is cut off from the rest of the collecting system,
which an ultrasound is seen as a small cystic area
in the, or in the region of the cex.
So that is minor ectasis.
In the minor caic cases, when the cale is cut off,
there may be accumulation of milk of calcium, which is seen
as a echogenic fluid, fluid level.
And when you shift the patient the fluid,
fluid level will shift indicating
that it is milk of calcium.
And the fibrosis can involve the infantum
of a major cex resulting in major ectasis.
So, which an ultrasound will this is a coronal scan,
you see the kidney, and there is dilatation of the upper major caly,
which an IVP will be cut off.
So we'll be seeing only the lower caly.
So this is major ectasis.
And major caic cases can involve one major caic
or multiple major caic like this.
And it may be associated with cavitated granulomas and urothelial thickening.
The major caic cases can be asymmetric as seen here.
The middle lower lysis are dilated here.
The upper and lower lysis are dilated,
and you see the middle lysis still looks normal.
So asymmetric ectasis is very characteristic
of tuberculosis.
All the caly can be symmetric as seen here.
All the lysis are symmetrically dilated, both in coronal
and axial scan.
Due to this is due to the pelvic strictures stricture
of the renal pelvis with the dilatation
of all the lysis.
The s stricture can involve,
the fibrosis can involve the few pelvic re junction
resulting in a PUJ stricture, resulting in hydronephrosis,
dilatation of the lysis and pelvis.
And as an evidence of tuberculosis,
you'll see the urothelial thickening
and the cavity cating granuloma in the upper pole,

Other Appearances

or another appearance of urinary tuberculosis is tuberculous spy nephrosis,
where you see hydronephrosis with fluid,
fluid level indicating debris inside the collecting system.
And you also see some cavities indicating
that it is tuberculosis.

The fibrosis of the ureter results in reary stricture
with the narrowing of the segment of ureter
with proximal dilatation and hydronephrosis.

Now fibrosis can be complex and
because of multiple granulomas in the one pole
of the kidney, they undergo healing with atrophy
of the parenchyma, fibrosis of the cais,
resulting in finally a polar atrophy.
So when there is polar atrophy, there is a peculiar kink
of the renal pelvis, which is seen that is the evolving atrophy of the pole.
So this is the initial granulomas
and ectasis which undergoes fibrosis
and results in atrophy of the entire upper pole, which
the lower part of the kidney is maintained.
And there is a peculiar kink of the renal pelvis
because of fibrosis of the pole of the kidney.
And fibrosis
of the lower ureter on the ureterovesical junction
results in pulling up of the ureter, the which is seen
as a patless reary phi
and the cystoscopy, it is described as a golf hole,
ure uric phi.
Because of this fibrosis
and pulling up of the ureter, the ure oris becomes patalis resulting in sico uric reflex,
which is seen here by color doppler.
You see that the flow is towards the transfuser, indicating
that the flow is from the bladder into the ureter.
That is tro cycle retic reflex.

Calcification

The healing of fibrosis
and calcification can happen together,
and the multiple specs of calcification joined together
to form an amorphous calcification with overlying scar.
So here you see a granuloma,
which on high frequent she shows a granuloma
with multiple specs of calcification.
Another two granulomas with specs of calcification,
these calcifications with which increase
and coalesce and form a large amorphous calcification
with atrophy of the overlaying parenchyma, which is
very characteristic late sign of tuberculosis, a CCL of tuberculosis.

The he, the calcification can also happen
in the collecting system.
This is a high frequency scan shows hid necrosis,
the urothelial thickening
and tiny calcifications in the urothelium,
or the calcification may be more extensive involving
one large cic
and rarely can involve the entire collecting system
of the kidney, which makes the kidney non-functioning.
And it is called the tuberculous art neph.
These are two cases sewing the calcification
of the anterior hydro nephrotic sac
calcification involving the ureter.
You see a tiny pick of calcification in the urothelium
of the ureter and coming to the healing of bladder tuberculosis.

Bladder Contraction

The fibrosis results in
contraction of the urinary bladder.
It is called marked contraction is called the thi bladder
because it's markedly contracted.
And at this stage it is irreversible.
And because of the severe contraction
of the urinary bladder, patients will have very severe frequency of nutrition almost,
they may have
to fast once in a few minutes.

Confirmation and Diagnosis

So these are the ultrasound features of tuberculosis
and how to confirm that it is tuberculosis.
It can be done by urine smear for the mycobacterium tuberculosis
and culture of the urine
for mycobacterium tuberculosis, which is proof
of tuberculosis, urinary tuberculosis,
or it can be a cystoscopic biopsy of the bladder urothelium looking for the typical omas,
but sometimes it may not be that easy.

Case Example

This is an example of a 29-year-old man who presented
with bilateral flank pain, intermittent hematuria, dysuria
and frequency lasting for one year
with the recurrent attacks of fever, with chills.
And ultrasound shows the convex,
the coronal scan of the kidney showing mild hydro nephrosis.
And there is urothelial thickening, there is
retic reflex,
and in the kidney you see granuloma cavitating
granulomas in the parenchyma
and took IVP was done to confirm,
which showed poor functioning of the kidney,
left kidney, with smudging of the contrast due
to cavities and the dilated lysis.
So IVP was not useful,
and urine came as negative for tuberculosis.
So then u ureteroscopy was done to confirm,
the ureteroscope showed a golf full ureter.
And the upper ureter, there was a stricture
with marked mucosal thickening.
You see the polypoid, mucosal thickening
and a catheter was put proximal to the stricture,
and pus was aspirated.
And RGP showed multiple cavities
and hydro nephrosis
and this pus when sent for culture, proved
that it is tuberculosis became positive for tuberculosis.
So sometimes the proof proving confirmation
of tuberculosis may be little long drawn.

Differential Diagnosis

Now, differential diagnosis are the conditions are papillary, necrosis, biogenic infection and malignancy.
All these conditions can mimic the appearances described earlier in tuberculosis.
But what is the hallmark of diagnosis of tuberculosis?
It is involvement of multiple sites of the urinary tract
and different stages of the disease like granuloma,
fibrosis, cavitation, calcification in the same patient.
This is the hallmark of diagnosis.
And next one is the appropriate clinical setting.

So here you see a patient the high frequency scan shows cavitating granuloma in the parenchyma hid neros,
urothelial thickening calcification,
and multiple be appearance of the ureter
and urothelial thickening of the urinary bladder.
So multiple sites of involvement
and multiple stages hid neros due
to stricture calcification.
So multiple stages of disease seen in the same patient is a very characteristic of tuberculosis.
And next is the appropriate clinical setting.

So patients are not referred as
to rule out urinary tuberculosis
because the symptoms are not very classical.
But what is important the symptoms are when the this is involves the upper tract patients are asymptomatic,
but the disease involves the lower tract starting from
the tro cycle junction bladder,
then patients become symptomatic.
And the symptoms are dysurea frequency
of UR and hematuria.
These are the major symptoms.
And what is important is the chronicity of the symptoms.
So the patients will be symptomatic for months together.
So that is typical of tuberculosis.

So some of the features described may not be seen on CT scan
and the parenchymal lesions
and features proximal to obstruction are not seen on IVP
because of poor function in impaired.
When there is impaired renal function in the patient both CT scan and IVP are not useful
because the contrast is not going to be secreted
and maybe contraindicated.
So as a result ultrasound is the best modality
to diagnose urinary tuberculosis.

Tuberculosis of the Male Genital Tract

Now, coming to the tuberculosis of the male genital tract,
they spread this by hematogenous root,
and the primary site of involvement is the epidem.
The other regions by direct congu infection from the epidem happens now, tubercle
of the prostate, the ation of choice is the
transrectal ultrasound,
and many patients the ation fails
to reveal any lesion in the prostate.
There may be focal areas
of decreased echogenicity they're seen here,
or there may be dystrophic calcifications as CLA or rarely.
You may see a an abscess in the prostate as seen here,
which may extend outside the prostate also.
So this mimics like any other nonspecific abscess
of the prostate, or there may be fistula tract
to the perineum orano urethral fistula due
to prosthetic tuberculosis as seen here.
This is a retal scan showing the prostate,
and there is some gas in the urethra.
So on a longitudinal scan,
you see gas bubbles in the urethra.
And on withdrawing the probe, you'll see the extension
of the gas through gas outline tract extending from the prosthetic erytra
to the a**l canal.
So that is evidence of urethral fistula.
Uh, due patient had other features
of tuberculosis in the urinary tract,
and he became positive on urine examination
for tuberculosis.

Now, CA of tubercle of the prostate,
it results in it can result in infertility due
to obstruction to the ejaculatory ducts,
which are seen on scrotal scan
as dilated tubules in the EPIs are ectasia
of the ready testis.
And the seminal vesicles are dilated
and the EPIs may be having multiple cyst.
So these are the features of obstruction
to e********d ducts as a result of fibrosis due to healing
of tuberculosis coming to scrotal tuberculosis,

Scrotal Tuberculosis

the patients present with pain
and swelling of the scrotum, and it is insidious in onset
and chronic in duration.
Tuber close of the emis, there are various features.
One is a diffusely enlarged heterogeneously
hypoechoic epidermis.
So this is an example of uniformly enlarged heterogeneous appearance of epi deems with the cop areas.
And when you do color doppler, there is peripheral flow increased flow in the epidermis,
or it can be an nodular enlargement of focal area of the epidem.
Or there may be a heterogeneous focal enlargement
of the epidem with necrotic area with hyperemia around
on color doppler,
or it may be diffusely enlarged uniformly enlarged epidem.
So these are the appearance of the EPIs in tuberculosis,
or you may get an abscess in the commonly in the tail of the EPIs.
And this abscess can extend into the scrotal wall
as a scrotal wall abscess, which can rupture
outside to the exterior.
And with the emptying of the puss,
it can result in a chronic sinus.
So this ultrasound of the scrotum showing the sinus tract extending from the skin
to the tail of epidermis.
So these are the features of epidermal tuberculosis coming
to tuberculous archis,

uh,
the testis may be enlarged with multiple small hypo coic nodules,
and there may be blurred separation of the testis
and epidem, and there may be changes coexisting
granuloma in the masses in the test.
Epidem also, or there may be diffuse enlargement
of the testis with which is echo power
tub plus of the seminal vesicles and vaa differe.
One form is a small solid seminal vesicle
like this with or without calcifications.
Here there are calcifications in the in the vast deference,
we can see a focal mass in the vast deference
or the vast deference may be calcified when there is sql
of tuberculosis, rarely there may be an abscess in the seminal vesicle which can extend
outside the seminal vesicle.
So this turned by a transtectal biopsy
was proved to be tuberculosis.

Differential Diagnosis of Male Genital Tuberculosis

Now, differential diagnosis of male genital tuberculosis is chronicity
and the presence of a sinus tract is very much suggestive
of tuberculosis.
And the appearance may be nonspecific
and if there is lack of response
to non-specific antimicrobial agents to think
of tuberculosis and look for evidence
of tuberculosis in the rest of the genital urinary system
are two year biopsy to confirm that it is tuberculosis.

Tuberculosis of the Female Genital Tract

Now we come to the last portion, tuberculosis
of the female genital tract.
There again, the spread is hematogenous,
and here the primary site
of involvement is the fallopian tube with other parts infected by direct.

Now, tuberculosis of the female genital tract because it is intraperitoneal, we have two forms.
One is the wet form and the dry form.
In the wet form we have got ascites,
which is usually septated with the particles in the echo in the ascitic fluid.
And you may see thickened fallopian tubes floating in
the ascitic fluid.
So this is the weight form.
And in the dry form we may see tick called fallopian tube in two cases,
and then on colored operate may show hyperemia,
or it can be seen as a tubo, variant abscess
or hydro seing as seen here.
And that is a hydro
or rarely is a tub.
Ovarian abs. Now tubercle
of the female genital tract when it's healing
by fibrosis result may result in tubal block,
which can result in infertility.
So this can be investigated by Len Infusion sonography.
Here you see this fluid filled fallopian tube.
And there is, this is by color doppler and cyst.
You see normal spill extensive color due to normal spill.
Here, there is no spill because of the tubal block.
So that is the tubal block due to healing
of tuberculosis of the Philippian tube in the middle.

Tuberculosis is rare
and very difficult to diagnose.
We don't have specific features on ultrasound,
but on saline infusion sonohysterography,
we may see irregular contour of the endometrium
as a sign of tuberculosis.
Or you may see a polyp and
or you may see a sin one are many cy
and the entire cavity may be scarred like asherman's syndrome,
RMA, see fine endometrial calcifications, SSEA
of endometrial tuberculosis.

Conclusion

Thank you very much for your patient listening.
Thank you.