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Genitourinary tuberculosis
Genitourinary tuberculosis arrives by the bloodstream from a pulmonary focus, sometimes years earlier, affects the kidney first and descends to the ureter, bladder and epididymis; the classic clue is "sterile" pyuria with acidic urine and haematuria, and treatment is a 6-month drug regimen with urological management of strictures and damage.
Why it matters in the exam
The exam asks about the common route of infection — haematogenous, from the lung — and about findings pointing to the diagnosis: frequency and urgency, dysuria, pyuria with a negative routine culture, microscopic haematuria and acidic urine. There are often no pulmonary symptoms at diagnosis. On imaging: renal calcification, destroyed calyces, a "putty kidney" and self-destruction of the kidney (autonephrectomy), a ureter with multiple strictures that looks "beaded", and a small contracted bladder (a "thimble bladder"). In the epididymis — a hard painless mass, and a "beaded" vas deferens.
Diagnosis: 3 to 5 early-morning urine samples for staining and culture for tuberculosis, and a molecular test (Xpert MTB/RIF) that also detects rifampicin resistance; biopsy shows granulomas with caseous necrosis. A chest X-ray and an exposure history are part of the evaluation. The iatrogenic form must also be remembered: BCG instilled into the bladder to treat cancer can cause local or disseminated infection.
Drug treatment is as for drug-susceptible pulmonary tuberculosis: 2 months of isoniazid, rifampicin, pyrazinamide and ethambutol, followed by 4 months of isoniazid and rifampicin. A ureteral stricture may actually worsen during healing, so imaging follow-up is done and a stent or nephrostomy placed when needed. Reconstructive surgery (ureteral reimplantation, bladder augmentation) is done after at least 4 to 6 weeks of drug treatment, and nephrectomy suits a non-functioning kidney with pain, infections or hypertension.
Key points
- Spread by blood from a pulmonary focus.
- Sterile pyuria and acidic urine.
- 3 to 5 early-morning urine cultures and Xpert.
- 6-month treatment: 2 months of 4 drugs and 4 months of 2.
- Beaded ureter and thimble bladder.
Summary table
| Organ | Typical finding | Treatment beyond drugs |
|---|---|---|
| Kidney | Calcification, destroyed calyces, putty kidney | Nephrectomy for a non-functioning symptomatic kidney |
| Ureter | Multiple strictures, beaded appearance | Stent or nephrostomy; reimplantation |
| Bladder | Small and contracted (thimble) | Bladder augmentation |
| Epididymis and vas | Hard mass, beaded vas | Sometimes excision |
| Urine | Sterile pyuria, acidic urine, haematuria | 3 to 5 morning cultures and Xpert |
In the full version for subscribers
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Sources
- WHO Consolidated Guidelines on Tuberculosis: Module 4 Treatment, 2022 — Drug-susceptible TB treatment
- EAU Guidelines on Urological Infections, 2025 edition — Genitourinary tuberculosis
- Campbell-Walsh-Wein Urology, 12th edition (2020) — Tuberculosis and Parasitic Infections of the Genitourinary Tract
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.