AJR 2005; 184:143-150
© American Roentgen Ray Society
Genitourinary Tuberculosis: Comprehensive Cross-Sectional Imaging
Yoon Young Jung1,
Jeong Kon Kim1 and
Kyoung-Sik Cho1
1 All authors: Department of Radiology, Asan Medical Center, University of
Ulsan, College of Medicine, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736,
South Korea.
Received February 10, 2004;
accepted after revision June 30, 2004.
Address correspondence to J. K. Kim.
Introduction
The genitourinary tract is the most common site of extrapulmonary
involvement of tuberculosis
[1–3].
Although definitive diagnosis of genitourinary tuberculosis is established by
positive results on urine culture or histologic examination of biopsy or
surgical specimens, diagnosis is often difficult and delayed
[2,
3]. Therefore, radiologic
examination is used widely to determine the presence or absence of disease and
to monitor the therapeutic efficacy in a clinical situation.
Although excretory urography has contributed greatly to the diagnosis of
urinary tuberculosis and many radiologists are familiar with its findings,
cross-sectional imaging including CT, MRI, and sonography are required for
evaluating patients with genitourinary tuberculosis because these techniques
can provide information regarding changes in the renal parenchyma, adjacent
organs, and genital organs that is not available on excretory urography
[3–5].
However, the appearance of genitourinary tuberculosis on these techniques
still is not widely known. This pictorial essay shows and we discuss the
comprehensive cross-sectional imaging features of genitourinary
tuberculosis.
Urinary Tract Involvement
The process of urinary tract tuberculosis can be described according to its
initial hematogenous dissemination, its reactivation, and its destructive
spread [1,
6]. Through hematogenous
dissemination, tuberculous bacilli are trapped in periglomerular capillaries,
leading to numerous small abscesses
[4,
6]. In a host with normal
immunity, those lesions are suppressed and converted to inactive granulomas
[4,
6]. However, when the immunity
of the host is compromised, suppressed tuberculosis lesions are reactivated
and propagate to adjacent papillae, and these papillary lesions then rupture
into the collecting system and spread distally, leading to multifocal active
inflammation followed by fibrosis, scarring, and calcifications
[3].
Renal Parenchyma
Renal parenchymal involvement in tuberculosis usually is associated with
collecting system involvement. Localized tissue edema and vasoconstriction
caused by active inflammation result in focal hypoperfusion as seen on
contrast-enhanced CT or MRI. This finding is similar to that of acute
pyelonephritis caused by other organisms
[1,
7] (Figs.
1A,
1B,
1C, and
1D).
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Fig. 1A. —55-year-old man with urinary tuberculosis involving renal
parenchyma and calices. Contrast-enhanced CT scan obtained at level of right
renal hilum shows wedge-shaped hypoperfused areas (arrowheads).
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Fig. 1B. —55-year-old man with urinary tuberculosis involving renal
parenchyma and calices. CT scan obtained at level 2.5 cm caudad to A
shows hypoperfused areas (arrowheads) and focal caliectasis
(arrows).
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Fig. 1C. —55-year-old man with urinary tuberculosis involving renal
parenchyma and calices. Gadolinium-enhanced T1-weighted images obtained with
fat suppression corresponding to A and B show hypoperfused areas
(arrowheads, D) and focal caliectasis (arrows).
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Fig. 1D. —55-year-old man with urinary tuberculosis involving renal
parenchyma and calices. Gadolinium-enhanced T1-weighted images obtained with
fat suppression corresponding to A and B show hypoperfused areas
(arrowheads, D) and focal caliectasis (arrows).
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In rare cases, urinary tuberculosis manifests only as single or multiple
parenchymal nodules without urinary tract involvement
[4]. Patients with this form,
known as the pseudotumoral type, present with variable-sized well-defined
parenchymal nodules on cross-sectional images
[4,
5] (Figs.
2A and
2B). This type of urinary
tuberculosis may mimic renal neoplasms, thereby leading to unnecessary
surgery.
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Fig. 2B. —48-year-old man with tuberculosis confined to renal cortex.
Contrast-enhanced CT scan shows hypoattenuated nodules in left kidney
(arrowheads). CT scan also shows multiple hypoattenuated nodules in
liver (arrows).
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Calix, Pelvis, and Ureter
The collecting system is the most common site of urinary tuberculosis. In
the early stage of urinary tuberculosis, a few calices are involved and only
papillary necrosis or calyceal deformity is depicted on imaging studies
[1,
3,
8]. Fibrosis occurring after
healing of acute inflammation results in multifocal strictures
[2,
3].
The most characteristic cross-sectional imaging finding of urinary
tuberculosis is uneven caliectasis similar to the findings on excretory
urography [4,
5,
8]
(Fig. 3). Uneven caliectasis is
caused by the varying degree of fibrosis and obstruction at various sites
[1]. Cross-sectional images can
show severe caliectasis that is not shown on excretory urography because of
its poor opacification [4].
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Fig. 3. —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.
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When the renal pelvis and ureter are involved by tuberculosis,
hydronephrosis becomes severe
[2,
4]. The involved segments show
wall thickening and enhancement on CT and MRI (Figs.
4A,
4B, and
4C). In patients with healed
or chronic tuberculosis, calcifications may be noted
[1,
3,
4,
8] (Figs.
4A,
4B, and
4C). In long-standing
tuberculosis, as the atrophy of the renal parenchyma and hydronephrosis
progress, the kidney loses its morphology and appears as multiple thin-walled
cysts or as a multiloculated cyst
[4]
(Fig. 5). The last product of
inadequately treated tuberculosis is dystrophic calcifications involving both
entire kidneys, known as "putty kidney"
[4]
(Fig. 6).
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Fig. 4A. —39-year-old woman with tuberculosis involving entire segment
of left urinary tract. CT urogram using curved multiplanar reformation shows
severe nonuniform caliectasis and multifocal strictures (arrowheads)
involving renal pelvis and ureter. Calcification (arrow) is noted in
left distal ureter.
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Fig. 5. —45-year-old man with long-standing tuberculosis.
Contrast-enhanced CT scan of right kidney shows severe hydronephrosis. Right
kidney looks like multiple thin-walled cysts or a multiloculated cyst.
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Bladder and Urethra
Almost all cases of bladder involvement by tuberculosis result from the
downward spread of disease along the urinary tract. The involved bladder
becomes distorted; ragged; and, finally, shrunken
[1,
3,
4,
8]. CT or MRI shows wall
thickening and shrinkage [4,
8]
(Fig. 7). Advanced bladder
involvement also may be complicated by vesicoureteral reflux due to fibrosis
at the ureteral orifice
[4].
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Fig. 7. —65-year-old man with tuberculosis involving urinary bladder.
Contrast-enhanced CT scan shows focal wall thickening and enhancement
(arrowheads) in anterior bladder wall, suggesting active
inflammation.
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Genital Organ Involvement
The incidence of genital organ involvement by tuberculosis in males has
been reported as 30–90% in various studies
[4]. The route of disease
spread includes hematogenous seeding, lymphatic spread, and direct extension
from the lower urinary tract
[4].
The epididymis is one of the most common sites of genital tuberculosis in
males. Tuberculous epididymitis usually starts at the tail of the epididymis
and can propagate to the entire duct
[4]. Sonographic features of
tuberculous epididymitis include swelling and heterogeneous echotexture of the
involved segment [4,
8] (Figs.
8A,
8B,
8C,
8D,
8E,
8F,
8G,
8H, and
8I). MRI findings of
tuberculous epididymitis have been reported as enlargement of the epididymis
with relatively low signal intensity on T2-weighted images, thereby indicating
chronic inflammation or fibrosis
[4] (Figs.
8A,
8B,
8C,
8D,
8E,
8F,
8G,
8H, and
8I). The seminal vesicles and
the vas deferens also can be involved by tuberculosis, and cross-sectional
images show wall thickening, contraction, or intraluminal or wall
calcifications [4,
6]
(Fig. 9).
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Fig. 8A. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. Gray-scale sonogram shows swelling and heterogeneous
hypoechogenicity of left epididymal tail (arrowheads).
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Fig. 8D. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Fig. 8E. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Fig. 8F. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Fig. 8G. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Fig. 8H. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Fig. 8I. —57-year-old man with tuberculosis involving left epididymis
and spermatic cord. –I, T1-weighted (D and E), T2-weighted
(F and G), and gadolinium-enhanced T1-weighted (H and
I) MR images of left spermatic cord and epididymis show that left
spermatic cord (arrows, D, F, and H) and
epididymis (arrowheads, E, G, and I) are
swollen. Note internal low signal intensity on T2-weighted images and
enhancement of gadolinium-enhanced T1-weighted images. Low signal intensity on
T2-weighted images means chronic inflammation or fibrosis.
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Tuberculosis can involve the prostate as a form of prostatitis or abscess
[2]. On sonography, tuberculous
prostatitis reveals hypoechogenicity and increased vascularity, similar to
that of prostate cancer [1]
(Figs. 10A and
10B). In patients with
prostatic abscess, T2-weighted MRI shows a peripheral enhancing cystic mass
with radiating, streaky areas of low signal intensity, so-called
"watermelon skin"
[1] (Figs.
11A,
11B,
11C, and
11D). In patients with
long-standing prostatic tuberculosis, diffuse dystrophic calcifications can be
observed.
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Fig. 11A. —40-year-old man with tuberculous prostatitis causing abscess,
which was drained and treated with antituberculous medication. Gray-scale
sonogram shows low-echoic mass replacing prostate (arrows). Posterior
enhancement of mass suggests that this lesion is cyst.
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Fig. 11B. —40-year-old man with tuberculous prostatitis causing abscess,
which was drained and treated with antituberculous medication. T1-weighted MR
image shows swelling of prostate and internal low signal intensity
(asterisk).
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Fig. 11C. —40-year-old man with tuberculous prostatitis causing abscess,
which was drained and treated with antituberculous medication. T2-weighted MR
image shows low signal intensity (arrowheads) surrounding high signal
intensity (asterisk).
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Fig. 11D. —40-year-old man with tuberculous prostatitis causing abscess,
which was drained and treated with antituberculous medication. On
gadolinium-enhanced T1-weighted image, area of low signal intensity on
T2-weighted image shows enhancement (arrowheads), implying a wall of
abscess.
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Most women with genital tuberculosis present with infertility because the
fallopian tubes are affected in 94% of these patients
[1]. Tuberculous salpingitis
usually affects the bilateral fallopian tubes and reveals multifocal
strictures and calcifications
[1]. A tuboovarian abscess that
extends through the peritoneum into the extraperitoneal compartment also can
suggest tuberculosis [1].
Endometrial involvement is seen in 50% of the patients with tubal tuberculosis
[4]. Tuberculosis endometritis
may mimic severe uterine adhesions
[8].
Adrenal Gland Involvement
The adrenal gland is not a rare site for tuberculous involvement. Adrenal
tuberculosis is the most common cause of adrenal insufficiency (Addison's
disease) [8]. Adrenal
tuberculosis manifests as unilateral or bilateral adrenal enlargement, central
necrosis, and calcifications
[1]
(Fig. 12). When the disease is
treated adequately, adrenal atrophy with calcification may be seen
[1,
8]. The radiologic differential
diagnosis includes metastases, lymphoma, primary neoplasm, and hemorrhage.
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Introduction
Urinary Tract Involvement
