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Genitourinary Tuberculosis: Comprehensive Cross-Sectional Imaging

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

Top Introduction Urinary Tract Involvement Genital Organ Involvement Adrenal Gland Involvement References

 
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

Top Introduction Urinary Tract Involvement Genital Organ Involvement Adrenal Gland Involvement References

 
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).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (158K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   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).

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.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —48-year-old man with tuberculosis confined to renal cortex. Sonogram of left kidney shows 1.5-cm hypoechoic nodule (arrowhead) in cortex.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   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).

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].

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   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.

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).

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —39-year-old woman with tuberculosis involving entire segment of left urinary tract. Contrast-enhanced CT scan shows wall thickening and enhancement of left ureter (arrowhead).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C. —39-year-old woman with tuberculosis involving entire segment of left urinary tract. Sonogram shows severe nonuniform caliectasis (arrows).

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6. —50-year-old woman with putty kidney. CT scan shows dense calcification replacing right kidney, so-called "putty kidney."

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].

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   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.

Genital Organ Involvement

Top Introduction Urinary Tract Involvement Genital Organ Involvement Adrenal Gland Involvement References

 
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).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (118K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B. —57-year-old man with tuberculosis involving left epididymis and spermatic cord. Power Doppler sonogram shows increased vascularity in swollen epididymis.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C. —57-year-old man with tuberculosis involving left epididymis and spermatic cord. Gray-scale sonogram shows swelling and hypoechogenicity of left spermatic cord (arrowheads).

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (98K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9. —46-year-old man with tuberculosis involving seminal vesicle and vas deferens. Gray-scale sonogram shows dilatation and wall thickening of seminal vesicle (arrowheads).

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.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A. —57-year-old man with tuberculous prostatitis. Gray-scale sonogram shows hypoechoic nodule (arrows) in peripheral zone.

View larger version (91K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B. —57-year-old man with tuberculous prostatitis. Color Doppler sonogram shows hypervascularity in same nodule (arrows) as that shown in A.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   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.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   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).

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   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.

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

Top Introduction Urinary Tract Involvement Genital Organ Involvement Adrenal Gland Involvement References

 
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.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12. —45-year-old woman with adrenal tuberculosis. Contrast-enhanced CT scan shows swollen left adrenal gland (arrow). Calcifications (arrowheads) are noted in both adrenal glands.

References

Top Introduction Urinary Tract Involvement Genital Organ Involvement Adrenal Gland Involvement References

 

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2. Wang LJ, Wong YC, Chen CJ, Lim KE. CT features of genitourinary tuberculosis. J Comput Assist Tomogr1997; 21:254 -258[Medline]
3. Gibson MS, Puckett ML, Shelly ME. Renal tuberculosis. RadioGraphics2004; 24:251 -256[Free Full Text]
4. Kim SH. Genitourinary tuberculosis. In: Pollack HM, Dyer R, McClennan BL, eds. Clinical urography, 2nd ed. Philadelphia, PA: Saunders, 2000:1193 -1228
5. Wang LJ, Wu CF, Wong YC, Chuang CK, Chu SH, Chen CJ. Imaging findings of urinary tuberculosis on excretory urography and computerized tomography. J Urol2003; 169:524 -528[Medline]
6. Birnbaum BA, Friedman JP, Lubat E, Megibow AJ, Bosniak MA. Extrarenal genitourinary tuberculosis: CT appearance of calcified pipe-stem ureter and seminal vesicle abscess. J Comput Assist Tomogr 1990;14:653 -655[Medline]
7. Das KM, Indudhara R, Vaidyanathan S. Sonographic features of genitourinary tuberculosis. AJR1992; 158:327 -329[Free Full Text]
8. Harisinghani MG, McLoud TC, Shepard JA, Ko JP, Shroff MM, Mueller PR. Tuberculosis from head to toe. RadioGraphics2000; 20:449 -470[Abstract/Free Full Text]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jung, Y. Y. Articles by Cho, K.-S. Search for Related Content PubMed PubMed Citation Articles by Jung, Y. Y. Articles by Cho, K.-S. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?