Genitourinary tuberculosis

The problem of extrapulmonary tuberculosis has always remained in the "secondary roles". Periodically (very rarely) monographs were published devoted to this or that particular issue. However, tuberculosis of the genitourinary system is multifaceted and still relevant, to a large extent due to the complexity of diagnosis, caused primarily by the absence of pathognomonic symptoms.

Tuberculosis is a deadly enemy, and you need to “know it by sight”, be able to recognize this insidious disease well and in time.

Epidemiology

In 1960, WHO experts assumed the complete eradication of tuberculosis in the near future, but already in 1993 they were forced to proclaim the slogan "Tuberculosis is a global danger". At the same time, recognizing tuberculosis as a global problem and citing the horrific facts of morbidity and mortality (every 4 years one person falls ill with tuberculosis and every 10 years - dies from it; among women aged 15 to 44 years, tuberculosis is the cause of death in 9%, while military actions take the lives of women only in 4%, acquired immunodeficiency syndrome - in 3% and cardiovascular diseases - in 3% of cases), WHO considers only pulmonary tuberculosis dangerous, not paying any attention to extrapulmonary localizations. Of course, tuberculosis of the respiratory organs is more manifest and dangerous for the life of the patient himself and the health of others. However, tuberculosis of the genitourinary system, firstly, significantly reduces the patient's quality of life. Secondly, although to a lesser extent, it is contagious. In recent years, polyorgan, generalized tuberculosis has been increasingly diagnosed, which requires a special approach, different from the standard (unified) one.

78% of all tuberculosis patients live in Romania, the Baltic countries, the CIS and Russia.

The sharp decline in the incidence rate was due to the introduction of mandatory vaccination against tuberculosis in children on the 5th-7th day of life, as well as the creation of basic anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide, prothionamide, aminosalicylic acid, ethambutol, streptomycin).

The incidence of tuberculosis of the respiratory organs and extrapulmonary localizations varies significantly.

Urogenital tuberculosis ranks second in the overall incidence rate after respiratory disease and is the most common form of extrapulmonary tuberculosis. Approximately the same ratio is observed in different countries: in the USA in 1999, 1460 people fell ill with tuberculosis, of which 17 (1.2%) were diagnosed with urotuberculosis (Geng E. et al., 2002). In 2006, in Siberia and the Far East, among 34,637 people who fell ill with tuberculosis, isolated urogenital disease was found in 313 (0.9%), although generalized forms were encountered many times more often.

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Symptoms urogenital tuberculosis

Urogenital tuberculosis has no characteristic clinical symptoms. When the parenchyma is affected, patients usually do not complain. Active diagnostics of the disease is necessary: examination of people from risk groups who have tuberculosis of other localizations or who are in contact with patients! Other forms of renal tuberculosis can be asymptomatic, with unclear clinical signs, or violent (regardless of the degree of damage to the urinary tract). Sometimes papillitis of a single calyx with the intensity of pain and dysuria, repeated colic and macrohematuria forces the patient to consult a doctor early, and sometimes bilateral cavernous renal tuberculosis manifests itself only with minor pain, which the patient puts up with for years. In this case, the disease is discovered by chance, during an examination for some other reason.

Both tuberculous papillitis and cavernous nephrotuberculosis are usually characterized by one subjective complaint: moderate constant dull aching pain in the lumbar region. This symptom is noted by up to 70% of patients. Other clinical symptoms (dysuria, renal colic ) are caused by the development of complications. Severe intoxication and fever are characteristic of the acute course of tuberculosis of the genitourinary system (registered with a certain cyclicity).

Diagnosis of cavernous and polycavernous tuberculosis of the kidneys does not present any great difficulties. The doctor's task is to recognize nephrotuberculosis at the stage of parenchymal tuberculosis or papillitis, when the patient can be cured without major residual changes.

Symptoms of urogenital tuberculosis have undergone some changes in recent years. Acute onset of the disease is registered seven times less often, patients report dull constant pain in the lumbar region and the appearance of blood in the urine significantly more often. As before, with urogenital tuberculosis, there may be no subjective symptoms.

Forms

Classification of tuberculosis of the genitourinary system includes the following clinical forms:

• tuberculosis of the renal parenchyma (stage I, non-destructive form);
• tuberculous papillitis (stage II, limited destructive form;
• cavernous nephrotuberculosis (stage III, destructive form);
• polycavernous nephrotuberculosis (stage IV, widespread destructive form).

Complications of tuberculosis of the genitourinary system:

• tuberculosis of the ureter;
• tuberculosis of the bladder;
• tuberculosis of the urethra;
• chronic renal failure;
• lumbar fistula.

Mycobacteriuria always occurs with tuberculosis of the renal parenchyma and is possible with other forms of nephrotuberculosis. When mycobacteria of tuberculosis are isolated, in the diagnosis, in addition to its form, "MBT+" is indicated.

Tuberculosis of the renal parenchyma is a minimal initial non-destructive form of nephrotuberculosis (stage I), in which not only clinical but also anatomical cure is possible. At the same time, the structure of the renal pelvis and calyces is normal on urograms; destruction and retention are absent. In urine tests in children, there may be no pathological changes, although in adults, as a rule, moderate leukocyturia is detected.

Mycobacteriuria is impossible with healthy kidneys - the causative agent of tuberculosis is not filtered through healthy glomeruli, so the detection of Mycobacterium tuberculosis in urine is always considered a sign of the disease. Bacteriological verification of renal parenchyma tuberculosis is mandatory, and one positive urine culture result is sufficient, but at least two facts of detection of Mycobacterium tuberculosis by fluorescent microscopy are necessary. It is impossible to distinguish the sides of the lesion in parenchyma tuberculosis, so this disease is always considered bilateral. Complications develop extremely rarely. The prognosis is favorable.

Tuberculous papillitis (stage II, limited destructive form) can be unilateral and bilateral, single and multiple, complicated, as a rule, by tuberculosis of the genitourinary system. Mycobacteriuria cannot always be recorded. Conservative treatment is recommended; with insufficient etiopathogenetic therapy, ureteral stricture may develop. requiring surgical correction. The prognosis is favorable.

Cavernous nephrotuberculosis can be unilateral or bilateral: a situation is possible when tuberculous papillitis is diagnosed in one kidney, and a cavern in the other. Complications develop in more than half of patients. As a rule, surgical treatment is prescribed for cavernous nephrotuberculosis. Complete cure is impossible, but the use of complex etiopathogenetic treatment methods allows in some cases to transform the renal cavity into a sanitized cyst. The usual outcome is the formation of post-tuberculous pyelonephritis.

Polycavernous tuberculosis of the kidney (stage IV, widespread destructive form) involves the presence of several caverns, which leads to a sharp deterioration in organ function. As an extreme variant of the disease, pyonephrosis with the formation of a fistula is possible. At the same time, self-healing is also possible, the so-called autoamputation of the kidney - imbibition of caverns with calcium salts and complete obliteration of the ureter. Complications almost always develop, the formation of a tuberculous lesion in the contralateral kidney is likely. Cure is achieved, as a rule, by performing an organ-removing operation.

Ureteral tuberculosis usually develops in the lower third (with involvement of the vesicoureteral anastomosis). Multiple ureteral lesions with "rosary" deformation, formation of strictures are possible, which leads to rapid death of the kidney (even with limited nephrotuberculosis).

Tuberculosis of the urinary bladder is one of the most severe complications of nephrotuberculosis, causing the greatest suffering to the patient, sharply reducing his quality of life and poorly responding to treatment. The specific process extends to the lower urinary tract in 10-45.6% of patients with tuberculosis of the genitourinary system, and targeted diagnostic measures, including biopsy of the bladder wall, increase the frequency of detection of complications to 80%.

Forms of tuberculous cystitis:

• tubercular-infiltrative:
• erosive and ulcerative;
• spastic cystitis (false microcystis, but in fact - GMP);
• true shrinkage of the bladder (up to complete obliteration).

The above forms can develop into a more severe one sequentially or bypassing the intermediate stage. If the tubercular-infiltrative and erosive-ulcerative forms can be treated conservatively, then with true wrinkling of the bladder, surgical intervention is performed to create an artificial bladder. Spastic microcystis is a borderline condition, very prone to transformation into true microcystis, which means the patient's disability.

In the initial stage, tuberculosis of the bladder manifests itself with paraspecific changes in the mucous membrane in the area of the mouth of the most affected kidney. In tuberculous cystitis, the capacity of the bladder already at the initial stage of the disease, as a rule, decreases. The cystoscopic picture is characterized by great polymorphism.

There are several possible variants of the development of tuberculosis of the bladder.

• Option A - productive inflammation with a latent clinical picture. In the initial stage, millet-like rashes (tubercles) are visualized on the surface of the mucous membrane. Their localization may vary, but most often the rash is found on the back or side wall opposite the mouth of the most affected kidney. The rash is extremely unstable, so a biopsy of the bladder wall should be performed immediately upon detection. The transition of inflammation to the interstitial layer in the absence of early full-fledged treatment usually ends with wrinkling of the bladder of varying degrees.
• Option B - millet-like rashes are surrounded by a hyperemic zone, ulcerations are possible. If left untreated, pathological foci merge until the mucous membrane is completely damaged.
• Option B - the formation of a solitary ulcer with uneven, undermined edges, surrounded by a hyperemic zone with unclear contours.
• Option D - with exudative inflammation, there is total damage to the mucous membrane of the bladder ("flaming bladder"), characterized by bullous edema, the occurrence of contact hemorrhages and severe hyperemia, which prevents identification of the orifices.

In the initial stage of tuberculous urethritis, the mouths remain normal externally, but the catheter encounters an obstacle when moving forward (usually 2-4 cm). Later, bullous edema of the mouth develops. Its severity can be so great that, if catheterization of the mouth is necessary, transurethral electroresection of the bullae is performed first. When a fibrous process forms, the mouth is deformed, acquires a funnel-shaped form and stops contracting.

The presence of pathological elements on the mucous membrane and (or) dysuria is considered an indication for performing a forceps biopsy of the bladder wall with the capture of the submucous layer. A pathomorphological and bacteriological examination of the biopsy is performed. If total damage to the bladder mucous membrane, severe contact hemorrhages and the location of pathological elements in the immediate vicinity of the ureteral orifice are detected, biopsy is contraindicated.

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Diagnostics urogenital tuberculosis

Diagnosis of genitourinary tuberculosis, like any other disease, begins with examination and questioning of the patient. Since the time of Hippocrates, it has been known that the disease leaves its mark on the patient's appearance. The first glance at it can lead to certain thoughts. Thus, shortening of the limb and a hump can indicate tuberculosis of the bones and joints suffered in childhood, although they can also be a consequence of injury. Rough star-shaped scars on the neck remain only after poorly treated tuberculous lymphadenitis. Along with the classic habitus phtisicus (paleness, emaciated face with a feverish blush and shiny eyes), another variant is also encountered - a young emaciated man, often with multiple tattoos (it is known that tuberculosis is most malignant in prisoners). On the contrary, patients with genitourinary tuberculosis give the impression of being absolutely healthy; Women are usually slightly overnourished, ruddy. Patients often adopt a forced position - they hold their hand on their lower back (an exception is acute tuberculosis of the genitourinary system).

Survey

When collecting anamnesis, special attention should be paid to the patient's contact with people or animals sick with tuberculosis. It is necessary to establish its duration and intensity; to clarify whether the patient himself had tuberculosis. Particularly alarming in relation to specific damage to the genitourinary system is the fact of tuberculosis suffered in childhood and (or) disseminated pulmonary tuberculosis.

Children undergo annual tuberculin diagnostics to detect tuberculosis infection and determine indications for revaccination with the vaccine For the prevention of tuberculosis of the genitourinary system, containing live weakened mycobacteria tuberculosis. For this purpose, 0.1 ml of purified tuberculin containing 2 tuberculin units is injected intradermally (on the forearm). The results are assessed after 24, 48 and 72 hours. A negative result is the absence of any skin reaction; doubtful - the formation of a focus of hyperemia up to 5 mm in diameter; a positive test is the occurrence of hyperemia and a papule with a diameter of 5 to 17 mm, which indicates immunity to tuberculosis. If, after the introduction of purified tuberculin, a papule with a diameter of more than 17 mm (hyperergic reaction) forms on the forearm, or a positive reaction occurs for the first time after a negative one, then the child is considered infected: he is subject to observation in a tuberculosis dispensary.

A hyperergic reaction or a change in the tuberculin test in a small child is evidence of an epidemic problem in the family.

This is why the question of whether there are children with a Mantoux reaction turn or a hyperergic test in the family is considered informationally significant.

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Laboratory diagnostics of tuberculosis of the genitourinary system

Routine laboratory tests are of little use in diagnosing urogenital tuberculosis. In the case of a torpid course of the process, the hemogram indices remain within normal values, and in the case of an active, rapidly progressing process, changes characteristic of any inflammation occur: an increase in ESR, leukocytosis, and a band shift in the leukocyte formula.

Urine analysis for tuberculosis of the genitourinary system may be normal only if the renal parenchyma is affected in children. A relatively specific sign (even in combination with non-specific pyelonephritis) is considered to be an acidic urine reaction (pH = 5.0-5.5). In a number of regions of Russia endemic for urolithiasis, an acidic urine reaction is typical for the population. Nevertheless, this is an important symptom, and laboratories should be required to quantitatively determine the urine reaction.

Almost all patients with destructive forms of nephrotuberculosis have pyuria (leukocyturia), although recently patients with renal tuberculosis characterized by the monosymptom hematuria (with a normal content of leukocytes in the urine sediment) have been increasingly observed. A.L. Shabad (1972) considered erythrocyturia to be one of the leading symptoms of renal tuberculosis and found it in 81% of patients, although some researchers recorded this symptom only in 3-5% of patients with nephrotuberculosis.

Hematuria is a component of the triad of the main urological symptoms and the most manifest and alarming among them. When examining urine according to Nechiporenko, the detection of 2 thousand erythrocytes in 1 ml of urine is considered normal. W. Hassen and MJ Droller (2000) recorded microhematuria in 9-18% of healthy volunteers and came to the conclusion that when examining urine sediment microscopy, the detection of no more than three erythrocytes in the field of view can be considered normal.

H. Sells and R. Cox (2001) observed 146 patients for two years after macrohematuria of unknown etiology. All of them were carefully examined, but neither ultrasound, nor excretory urography, nor cystoscopy revealed any diseases of the genitourinary system causing macrohematuria. 92 patients did not present any further complaints from the genitourinary system, and there were no changes in their urine tests. In one of them, renal pelvis stones were found after 7 months; five patients underwent TUR of the prostate (three - because of its adenoma, and two - because of cancer). Fifteen people died during the observation period, but in none of them the cause of death was urological or oncological disease. Only 33 (22.6%) of 146 patients had repeated episodes of macrohematuria.

H. Sells and R. Soh concluded that causeless macrohematuria is not uncommon in urological practice and requires in-depth examination only when it reoccurs, which happens in 20% of such patients.

According to the literature, nephrotuberculosis is combined with urolithiasis in 4-20% of cases. Often, calcified areas of caseous kidney are mistaken for stones. The passage of stones in the anamnesis, the absence of pyuria, repeated colic, and an increase in the salt content in the urine are more indicative of urolithiasis. However, in any case, an active search for tuberculosis mycobacteria in the urine of such patients should be carried out.

The question of what came first still remains open. On the one hand, urogenital tuberculosis as a disease that heals through scarring and calcification contributes to the disruption of urine passage and calcium metabolism, thus creating favorable conditions for stone formation. On the other hand, urolithiasis, sharply disrupting urodynamics in an infected person, serves as a pathogenetic prerequisite for the development of nephrotuberculosis.

According to some data, the combination of urolithiasis and renal tuberculosis is observed in 4.6% of cases. The main clinical symptom in such patients is pain, which often occurs with combined lesions and is less pronounced with isolated nephrotuberculosis. This symptom in tuberculosis of the genitourinary system and urolithiasis has a common origin: chronic or acute retention of urine above the site of obstruction (stone, stricture, edema). The cause of pain can be determined only after analyzing all the data of the clinical and radiological examination.

It should be noted that the combination of urolithiasis and renal tuberculosis significantly aggravates the course of the disease. Thus, if in patients with isolated nephrotuberculosis chronic renal failure was detected in 15.5% of observations, then the development of urolithiasis led to renal dysfunction in 61.5% of patients. Such patients more often developed drug intolerance, intoxication lasted longer, and the effectiveness of treatment was lower. Among patients with combined diseases, 10.2% developed an early relapse of renal tuberculosis, while in the dispensary contingents the relapse rate of the same localization was only 4.8%.

Thus, differential diagnostics between urolithiasis and nephrotuberculosis is difficult due to the similarity of the main symptoms and requires the physician to be constantly alert for tuberculosis in patients with urolithiasis. Patients with renal tuberculosis in combination with urolithiasis are subject to longer observation in active groups of dispensary registration, as they have a higher risk of exacerbation and relapse of the disease.

Increased protein content in urine is not typical for nephrotuberculosis. As a rule, proteinuria in this disease is false, i.e. caused by concomitant pyuria and hematuria.

Functional tests of the liver and kidneys are characterized by normal values for a long time. Chronic renal failure develops only in every third patient with nephrotuberculosis, in advanced cases or in combination with specific pyelonephritis and (or) urolithiasis.

The main method of diagnosing tuberculosis of the genitourinary system remains bacteriological examination. Urine is examined by sowing on various nutrient media (Anikin, Finn-2, Levenshtein-Jensen, "Novaya"). The same portion of urine is subjected to fluorescent microscopy. Such tactics allow us to establish the time of loss of viability of mycobacteria tuberculosis (when the pathogen is still detected by fluorescent microscopy, but it does not grow on the media).

In nephrotuberculosis, mycobacteriuria is scanty, intermittent and therefore difficult to detect. That is why it is necessary to perform at least 3-5 consecutive bacteriological studies (cultures) of urine. Performing them three times during one day increases the seeding of mycobacterium tuberculosis by 2.4 times.

It is necessary to pay attention to the necessity of sterile urine collection, since contamination of the sample with non-specific microflora can lead to a false-negative result. Previously, it was believed that Mycobacterium tuberculosis does not allow the development of intercurrent microflora in urine, and there was even a symptom of renal tuberculosis - aseptic pyuria, i.e. the presence of pus in the urine in the absence of growth of non-specific microflora. Currently, up to 75% of patients have both specific tuberculosis and non-specific inflammation of the renal pelvis and parenchyma, which also reduces the frequency of identification of Mycobacterium tuberculosis.

In addition, as little time as possible should pass between the collection of urine and its sowing (about 40-60 minutes). Failure to comply with these rules significantly reduces the effectiveness of bacteriological testing.

DNA diagnostics have recently become widespread. In India, for example. 85% of patients with renal tuberculosis are diagnosed based on the detection of Mycobacterium tuberculosis in urine using the PCR method. In Russia, this method has limited application due to its high cost and not always clear correlation with the results of cultures. However, in general, verification of Mycobacterium tuberculosis using DNA diagnostics is very promising, since it can hypothetically significantly reduce the time for recognizing tuberculosis of the genitourinary system, as well as immediately determine the sensitivity of Mycobacterium tuberculosis to the main anti-tuberculosis drugs.

Microscopy of urine sediment stained according to Ziehl-Neelsen has not lost its importance, although the sensitivity of this method is not high.

Biological testing (guinea pigs are infected with pathological material) is not currently used.

Bacteriological examination of urine, prostate secretion, ejaculate taken at the time of exacerbation of the main or any of the concomitant diseases, greatly increases the probability of detecting Mycobacterium tuberculosis. However, in a patient with a chronic disease, who has repeatedly taken many antibiotics (including tetracyclines, aminoglycosides and fluoroquinolones), the growth of Mycobacterium tuberculosis may not be obtained without provocation with tuberculin or laser.

Instrumental diagnostics of tuberculosis of the genitourinary system

In recent years, ultrasound diagnostics has become a common and generally accessible method of examination. The use of modern scanners has led to a sharp increase in the frequency of detection of various diseases, in particular tumors and kidney cysts. Sometimes it is difficult to differentiate a cystic formation and a renal cavity. In this case, a pharmacological test may be useful: intravenous administration of 20 mg of furosemide promotes a reduction or, conversely, an increase in the size of the kidney cyst. The cavern, due to the rigidity of the walls, will not change.

X-ray examination of the genitourinary system is one of the most important methods of diagnosing any urological disease, including tuberculosis of the genitourinary system.

The examination begins with a general radiograph, which allows one to establish the presence or absence of shadows suspicious for a calculus, calcification in the kidney or mesenteric lymph nodes, and to determine further tactics (for example, the need to perform an additional radiograph in a standing position).

To assess the secretory and excretory function of the kidneys, excretory urography is used with intravenous administration of 20-40 ml of RKB (iopromil) and subsequent series of images. In the absence or reduction of secretory function, as well as in case of suspected evacuation disorder, delayed images are taken after 30, 60-90 minutes, and later if indicated.

Urograms can be used to evaluate the structure of the renal pelvis and calyces, detect the presence or absence of their destruction or deformation, and determine the relationship between the shadow on the survey radiograph and the renal pelvis-caliceal system. For example, a shadow that is clearly interpreted on a survey image as a calculus in a prolapsed kidney looks like a calcified mesenteric lymph node on an excretory urogram. In the early stages of nephrotuberculosis, characteristic radiographic signs are absent. The destruction is visualized more clearly, the larger the volume of the lesion.

Modern digital X-ray machines allow post-processing, selection of optimal physical and technical parameters, and cropping. Images are taken not at standard times, but at the moment of best contrasting of the renal pelvis and calyces. The ability to evaluate urodynamics in real time is considered important: only with the help of a digital X-ray machine can urine reflux into the calyx be detected during excretory urography. At the time of the study, it is also necessary to perform several tomographic sections, which levels out increased pneumatization of the intestine and provides additional information on the ratio of the formation in the parenchyma and the renal pelvis and calyces.

CT allows obtaining an image without the summation effect, which significantly improves the quality of the assessment of the kidney structure. With its help, it is possible to visualize a radiolucent calculus, measure the density of the pathological focus and, thus, conduct differential diagnostics between a liquid or soft tissue formation. Tuberculous papillitis in the calcification phase on excretory urograms looks like a compaction of a deformed papilla, while on CT scans it is visualized more clearly.

Retrograde pyelography is recommended in case of unclear contrast of the renal pelvis and calyces on excretory urograms (it can be very informative in case of renal tuberculosis). Thanks to this method of examination, it is possible not only to better visualize the upper urinary tract and formed cavities, but also to detect ureteral obstruction due to a formed (or forming) stricture, which is fundamentally important for determining the tactics of patient management.

Micturition cystography allows determining the capacity of the urinary bladder, the presence of its deformation and vesicoureteral reflux: it is possible that the contrast agent may leak into the prostate caverns, which will additionally confirm the damage to the genitals. Given the high frequency of the combination of renal and prostate tuberculosis, all men with nephrotuberculosis are recommended to undergo urethrography, which clearly shows the prostate caverns.

Radioisotope diagnostics of tuberculosis of the genitourinary system

Radioisotope renography plays a certain role only when repeated during a provocative test (Shapiro-Grund test), in which deterioration of the functional indicators of the kidney indicates an exacerbation of the tuberculosis process caused by the introduction of tuberculin. It is also recommended for determining the residual function of the kidney and treatment tactics.

Ureteropyeloscopy and cystoscopy are indicated for patients with persistent pyuria, hematuria or dysuria. If tuberculous inflammation is limited to kidney damage, without involving the urinary tract, the bladder mucosa may be completely normal. At the initial stage of tuberculous cystitis, the bladder capacity may be sufficient, although, as a rule, its decrease is noted. The cystoscopic picture in tuberculosis of the bladder was described above.

In case of severe inflammation of the bladder mucosa, bullous edema and contact hemorrhages, it may be difficult to perform any diagnostic endovesical procedures (for example, catheterization of the ureteral orifice). In this case, immediately after a survey cystoscopy and detection of the above signs, an aseptic solution should be released through the cystoscope drainage system, 1-2 ml of 0.1% epinephrine solution should be injected into the empty bladder in combination with 5-10 ml of 2% trimecaine (lidocaine) solution. After 2-3 minutes of exposure, the bladder is filled with aseptic solution again. Epinephrine causes vasoconstriction and a decrease in mucosal edema, which significantly facilitates identification and catheterization of the ureteral orifice, and local anesthesia allows a larger amount of solution to be injected and, thus, the bladder walls can be straightened better.

It should be noted that the method described above cannot be used in primary, previously unexamined patients, since premature administration of epinephrine and trimecaine will not allow obtaining true information about the capacity of the bladder and the condition of its mucous membrane.

The presence of pathological elements on the mucous membrane and (or) dysuria is considered an indication for performing a forceps biopsy of the bladder wall with the capture of the submucosal layer. The biopsy is sent for pathomorphological and bacteriological examination (culture). There are observations when the histological conclusion indicated paraspecific inflammation, and culture revealed growth of mycobacterium tuberculosis.

Urethroscopic examination does not provide additional information; there is no known case of urogenital tuberculosis diagnosis using this method. Moreover, there are clinical observations when patients underwent urethroscopic examination with biopsy of the seminal tubercle due to persistent prostatitis and colliculitis, while pathomorphologically signs of chronic inflammation were determined. However, it was later found that these were masks of prostate tuberculosis.

Provocative tests

Since verification of the diagnosis by bacteriological examination is currently possible in less than half of patients, in modern clinical practice, differential diagnostics take into account a set of epidemiological, clinical-anamnestic, laboratory and radiological data in combination with the results of provocative tests. Several methods have been developed that allow for a more rapid and highly accurate diagnosis of genitourinary tuberculosis.

Indications for conducting a provocative test:

• epidemiological history: contact with people and animals sick with tuberculosis, presence of children in the family with a virago or hyperergic reaction to tuberculin tests, previous tuberculosis (especially in childhood or disseminated);
• long-term course of pyelonephritis with clinical signs of cystitis, prone to frequent relapses;
• suspicion of destruction of the calyces according to excretory urography;
• persistence of pyuria (leukocyturia) after a course of treatment with uroantiseptics.

Contraindications to performing a provocative test:

• obvious destruction leading to a decrease or loss of kidney function:
• massive pyuria in the absence of growth of common flora;
• severe intoxication;
• fever;
• severe and moderate condition of the patient, caused by both suspected nephrotuberculosis and intercurrent disease;
• malignant tumor of any localization;
• macrohematuria.

In the diagnosis of tuberculosis of the genitourinary system, two types of provocative tests are used.

Koch's tuberculin test with subcutaneous injection of tuberculin

The number of leukocytes in the urine sediment is determined according to Nechiporenko, a general blood test is performed and thermometry is carried out every 2 hours. Then purified tuberculin is injected subcutaneously into the upper third of the shoulder. Tuberculin is a product of the vital activity of mycobacteria - it provokes the activation of latent tuberculosis inflammation. Some studies recommend injecting tuberculin as close as possible to the suspected focus of tuberculosis inflammation: in case of pulmonary tuberculosis - under the shoulder blade, in case of kidney damage - in the lumbar region, etc. However, studies have confirmed that the specific response does not depend on the site of tuberculin injection, therefore standard subcutaneous injection is usually used.

Initially, the third dilution (1:1000) of the so-called old Koch tuberculin (alt-Koch tuberculin) was used to conduct the subcutaneous tuberculin test. However, due to the insufficiently high purification of tuberculin, general reactions occurred. In addition, the complexity of preparing the solution required special training for nurses and did not exclude an error in dosing. It is currently used purified Linnikova tuberculin, which is released in ampoule form in a solution ready for use. The biological activity of 1 ml of this solution corresponds to 20 tuberculin units.

As a rule, 50 tuberculin units are administered to conduct a provocative tuberculin test. An injection of 20 tuberculin units is possible if there is a history of a pronounced reaction or 100 tuberculin units - if there has been no reaction to standard tuberculin diagnostics in the past. For 48 hours after the introduction of tuberculin, continue thermometry every 2 hours, repeat the general blood test and the Nechiporenko test twice, and also perform a bacteriological examination of urine and ejaculate. When evaluating the tuberculin test, the following indicators are taken into account:

• General reaction: deterioration of health, increase in body temperature, increase in dysuria. Changes in the clinical blood test are considered important: with a positive tuberculin test, leukocytosis increases or occurs. ESR increases, the absolute number of lymphocytes decreases:
• injection reaction: hyperemia and infiltrate may form at the site of tuberculin injection;
• focal reaction: increase or occurrence of leukocyturia, hematuria, mycobacteriuria.

In the presence of focal and at least two other reactions - prick and/or general - tuberculosis can be diagnosed. Bacteriological verification of the diagnosis is possible much later, sometimes only after 3 months. Nevertheless, subcutaneous administration of tuberculin increases the isolation of Mycobacterium tuberculosis in tuberculosis of the genitourinary system by 4-15%.

Laser provocation is contraindicated in differential diagnosis with a tumor process.

Upon admission, after a clinical examination and determination of the indications for a provocative test, the patient undergoes general urine and blood tests, a Nechiporenko test, urine culture for Mycobacterium tuberculosis, and fluorescent microscopy of a urine sediment smear.

Then, transcutaneous local irradiation is performed daily using an infrared laser generating continuous radiation with a wavelength of 1.05 m.

A combination of laser provocation and ex juvantibus therapy is possible. If the patient has non-specific inflammation, laser therapy will achieve such effects as improved urodynamics, improved blood supply to the kidney, increased concentration of medicinal substances in the organ, which will ultimately have a positive effect on the treatment results. If the patient had tuberculosis inflammation, it will be activated against the background of laser therapy and will be recorded by control laboratory tests.

The duration of ex juvantibus therapy of the first type is ten days. If after complex non-specific etiopathogenetic treatment complaints of pain in the kidney area and frequent painful urination cease, urine tests return to normal, then the diagnosis of tuberculosis of the genitourinary system can be rejected. Such a patient is subject to observation by a urologist of the general medical network. If laboratory parameters do not improve completely and complaints persist, continued examination is recommended.

Ex juvantibus therapy of the second type - the appointment of 3-4 anti-tuberculosis drugs of narrow action. Only the following drugs are suitable for ex juvantibus therapy of the second type: isoniazid, pyrazinamide, ethambutol, ethionamide (prothionamide) and aminosalicylic acid.

Algorithm for diagnosing tuberculosis of the urinary system

A general practitioner should suspect tuberculosis of the genitourinary system and conduct the minimum examination recommended in such cases, and establishing a diagnosis is the competence of a phthisiourologist (excluding situations of pathomorphological verification of the diagnosis after a biopsy or surgery, but even in this situation, it is necessary to review the micropreparations by a pathologist of an anti-tuberculosis institution with extensive experience in diagnosing tuberculosis).

So, a patient (or in three cases out of five, a female patient) comes to see a phthisiourologist for a consultation. The patient is usually middle-aged and has a history of long-term pyelonephritis with frequent exacerbations.

The first stage involves a thorough examination, questioning of the patient and analysis of the available medical documentation. There are several possible options for further developments.

[ 10 ], [ 11 ], [ 12 ], [ 13 ]

First option

The patient has "stigmas of tuberculosis" - retracted star-shaped scars on the neck after suffering tuberculous lymphadenitis; there are other indications of the disease in the anamnesis or the fluorogram shows foci of calcification of the lung tissue, etc.; in the tests - pyuria and (or) hematuria; on the urograms - destructive changes. This patient, as a rule, has advanced cavernous tuberculosis of the kidneys, and he should immediately be prescribed complex chemotherapy and pathogenetic treatment, against the background of which a complete clinical, laboratory, bacteriological and radiological examination is carried out in order to determine the extent of the lesion.

[ 14 ], [ 15 ], [ 16 ], [ 17 ]

Second option

The same patient, but according to the urogram data, kidney function is not determined. Etiopathogenetic treatment is prescribed for polycavernous nephrotuberculosis, and radioisotope renography is performed dynamically. If kidney function is not restored after 3-4 weeks, then nephrectomy is performed. If the diagnosis is pathomorphologically verified, treatment is continued; if there are no signs of active tuberculous inflammation, the patient is discharged under the supervision of a urologist at the place of residence.

Third option

The patient received good antibacterial treatment in a medical institution, supplemented by a complex of pathogenetic therapy, but moderate leukocyturia (up to thirty cells in the field of view) remains in the tests. Urograms show timely contrasting of the renal pelvis and calyces, there is a suspicion of destruction; retention is possible. In this case, the patient undergoes a laser test.

If, upon its completion, an increase in leukocyturia and erythrocyturia, a decrease in the absolute number of lymphocytes in the peripheral blood and mycobacteriuria are detected, then tuberculosis of the genitourinary system is diagnosed. The form and degree of damage are established after a detailed X-ray and instrumental examination. If there is no improvement in laboratory test results, then ex juvantibus therapy of the first type is carried out. If significant improvement occurs after ten days, nephrotuberculosis can be rejected; the patient is transferred to the observation of a urologist or therapist at the place of residence. If pathological changes in urine tests persist, the fifth option is followed.

The fourth option

A patient with moderate radiographic changes in the kidneys is found to have pyuria. Inadequate therapy for chronic pyelonephritis was performed in a general medical institution. In this case, ex juvantibus type I therapy is prescribed, supplemented by simultaneous laser provocation.

If there is a pronounced positive clinical and laboratory dynamics, the diagnosis is removed, and the patient is transferred under the supervision of a urologist or therapist at the place of residence.

Option five

If pyuria persists, a subcutaneous tuberculin provocation test is performed. A positive provocation result in combination with clinical and anamnestic data allows diagnosing tuberculosis of the genitourinary system and starting complex treatment: the extent of the lesion will be determined during further X-ray and instrumental examination.

Option six

A negative Koch test result is considered an indication for ex juvantibus therapy of the second type. In this case, two outcomes are possible. Improvement of the patient's condition and sanitation of his urine indicate tuberculosis etiology and serve as the basis for establishing the corresponding diagnosis.

Seventh option

If leukocyturia persists for 2 months after taking anti-tuberculosis drugs, then the patient most likely suffers from non-specific pyelonephritis. Such a patient is subject to close observation by a general medical network urologist with a control examination, including urine cultures for Mycobacterium tuberculosis every 3 months, as well as in case of exacerbation of the main or concomitant diseases.

Thus, differential diagnostics of tuberculosis of the genitourinary system involves four levels:

• laser provocation;
• trial treatment of the first type;
• tuberculin provocation test;
• trial treatment of the second type.

The first level of research requires 10-14 days, the second level requires 2 weeks, the third - 1 week, and the fourth level takes 2 months. In general, it may take about 3 months to establish a diagnosis. Obviously, the diagnosis of urogenital tuberculosis is a labor-intensive and lengthy process that requires careful work with the patient in a specialized institution. At the same time, it is clear that the sooner a phthisiourologist starts working with the patient, the greater the chances of a favorable outcome.

Differential diagnosis

Differential diagnostics of urogenital tuberculosis is extremely difficult, primarily due to the absence of pathognomonic symptoms and characteristic radiographic picture. Modern phthisiourology has everything necessary for complete cure of a patient with urogenital tuberculosis, provided it is detected early. The main problem is not even in differential diagnostics of the disease, but in selection of patients suspected of urotuberculosis, since sometimes there are no prerequisites for this. Urogenital tuberculosis can be asymptomatic, latent, chronic and acute under the guise of any urological disease. Diagnostics is especially difficult when nephrotuberculosis is combined with chronic nonspecific pyelonephritis (probability - 75%), urolithiasis (up to 20% of observations), renal malformations (up to 20% of cases), kidney cancer.

Verification of the diagnosis is carried out using bacteriological, pathomorphological examination and on the basis of clinical, laboratory, radiological and anamnestic data (including provocative tests and test therapy).

[ 18 ], [ 19 ], [ 20 ], [ 21 ]

Treatment urogenital tuberculosis

Obtaining clear positive dynamics of the clinical picture and laboratory parameters indicates a tuberculous etiology of the process and requires changing the treatment regimen to a standard one and carrying out a full range of etiopathogenetic measures.

To clarify the diagnosis, it is permissible to perform an open or puncture biopsy of the kidney, but. according to many authors. The risk of this intervention exceeds the possible benefit. The absence of kidney function, confirmed by excretory urography and radioisotope renography, is considered an indication for nephrectomy.

If tuberculosis is suspected, it is advisable to perform the operation in a phthisiourological hospital, with mandatory prescription of anti-tuberculosis polychemotherapy for 2-3 weeks as preoperative preparation and with continuation of treatment after nephrectomy until the results of the pathomorphological examination are received. If tuberculosis of the genitourinary system is excluded, the patient stops taking the drugs: he is transferred to the observation of the urologist of the polyclinic. If the diagnosis is confirmed, the patient is given anti-tuberculosis treatment in full.