Urinary Tuberculosis - HD

Ultrasound of Urinary Tuberculosis

Hi, I am Dr. Bhi wi from Kur of India.

I'm going to talk on ultrasound of urinary tuberculosis.

Pathology of 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.

The initial seeding, it is in the kidney, it is bilateral and occurs as numerous small granulomas in the renal cortex.

These granulomas, either spontaneously or on treatment, totally resolve 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 develop microscopic granulomas.

These granulomas coalesce to form a large macroscopic granuloma, which can be seen on imaging, and which proceeds on to necrosis forming a focal papillary cavity, which can erode into the calyx 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, and rupture into the collecting system and healing happens by fibrosis, granuloma formation, and calcification.

Ultrasound Imaging of Granulomas and Cavities

Now, this is a schematic diagram of the microscopic granulomas coalescing to form a larger microscopic granuloma, which when we do ultrasound using the conventional ConX probe, which may not be seen as seen here, we see a coronal scan of the kidney.

The parenchyma looks unremarkable, whereas there is mild dilatation of the collecting system.

And when you use a high frequency linear transducer, 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 calyx and the infection spreads to the urothelium.

So this is a coalescent granuloma.

Granuloma necrosis happens in the center.

The necrosis forms a cavity in the granuloma, and if the cavity, papillary cavity is close to your calyx, that causes fuzziness of the calyx on the IVP.

So this is a papillary cavity, very close to the calyx.

And because of the proximity, it erodes into the calyx with the escape of the infection from the granuloma into the collecting system.

And this communication between the calyx and the granuloma varies in size.

And when there is hydronephrosis, it is much bigger.

And here we see two kidneys, one with a papillary cavity communicating with the calyx.

Another kidney, there are large cavities, parenchymal cavities, and two of them are communicating with the hydronephrotic calyx.

Because of the hydronephrosis, the communication looks very big.

Spread of Infection to the Urothelium

Then the infection spreads to the pelvicalyceal system with the occurrence of granulomas in the urothelium with the conventional convex probe, you see the urothelial thickening and with a high frequency probe, that is much better.

You see the renal pelvis and the calyx, 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, there are three different appearances.

One, maybe the urothelial thickening causes narrowing of the ureter with proximal dilatation, or there may be uniform thickening, urothelial thickening resembling a lead pipe.

Or it may be the granuloma may be intermittent with the lumen of the ureter seen in between appearing like a beaded ureter, which is also described in the IVP coming to the lower ureter, we see classically the urothelial thickening of the lower ureter extending up to the ureterovesical junction.

And at this stage because of the involvement of the UV junction, patient becomes symptomatic and he develops dysuria.

This same urothelial thickening and the spread of infection to the urinary bladder is seen as focal urothelial thickening anywhere along the urinary bladder here, another case showing urothelial thickening marked 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 he can have dysuria, frequency of micturition and hematuria.

So urothelial thickening and because of the infection of the urothelium, occurrence of granulomas, that is spasm of the detrusor muscle of the urinary bladder, which causes the contraction of the urinary bladder, which is still reversible with treatment.

So with this contraction of the urinary bladder, patients will have extreme frequency of micturition.

Spread Outside the Collecting System

Now, the spread of infection, instead of going eroding into the calyx, it can spread outside with occurrence of an abscess, renal abscess and rupturing into the perinephric space and producing a perinephric abscess.

So this a coronal scan of a kidney showing the renal abscess and the perinephric abscess.

This mimics like any other nonspecific renal perinephric abscess, but only the symptoms will be different 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.

Healing Features in Urinary Tuberculosis

Fibrosis and Calyceal Ectasia

So fibrosis of a minor calyx results in minor calycectasis, which is cut off from the rest of the collecting system, which an ultrasound is seen as a small cystic area in the region of the calyx.

So that is minor calycectasis.

In the minor calycectasis when the calyx 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 infundibulum of a major calyx resulting in major calycectasis.

So which an ultrasound will these is a coronal scan, you see the kidney, and there is dilatation of the upper major calyx, which an IVP will be cut off.

So we'll be seeing only the lower calyx.

So this is major calycectasis.

And major calycectasis can involve one major calyx or multiple major calyces like this.

And it may be associated with cavitated granulomas and urothelial thickening.

The major calycectasis can be asymmetric as seen here.

The middle lower calyces are dilated here.

The upper and lower calyces are dilated, and you see the middle calyx is still looks normal.

So asymmetric ectasis is very characteristic of tuberculosis.

All the ectasis can be symmetric as seen here.

All the calyces are symmetrically dilated, both in coronal and axial scan.

Due to this is due to the pelvicalyceal stricture of the renal pelvis.

With the dilatation of all the calyces, the stricture can involve the fibrosis can involve the pelviureteric junction, resulting in a PUJ stricture, resulting in hydronephrosis, dilatation of the calyces and pelvis.

And as an evidence of tuberculosis, you'll see the urothelial thickening and the cavitating granuloma in the upper pole, or another appearance of urinary tuberculosis is tuberculous pyonephrosis, where you see hydronephrosis with the 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 ureteral stricture with 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 calyx, 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 and the ureterovesical junction results in pulling up of the ureter, which is seen as a patulous ureteric orifice, and then cystoscopy.

It is described as a golf hole ureteric orifice.

Because of this fibrosis and pulling up of the ureter, the ureteric orifice becomes patulous resulting in vesicoureteric reflux, which is seen here by color doppler.

You see that the flow is towards the transducer, indicating that the flow is from the bladder into the ureter.

That is vesicoureteric reflux.

Calcification

The healing of fibrosis and calcification can happen together, and the multiple specks of calcification join together to form an amorphous calcification with overlying scar.

So here you see a granuloma, which on high frequency scan, a granuloma with multiple specks of calcification, another two granulomas with specks of calcification, these calcifications which increase and coalesce and form amorphous calcification with atrophy of the overlying parenchyma, which is very characteristic late sign of tuberculosis, a sign of tuberculosis.

The calcification can also happen in the collecting system.

This is a high frequency scan shows hydronephrosis, the urothelial thickening and tiny calcifications in the urothelium, or the calcification may be more extensive involving one large calyx, and rarely it can involve the entire collecting system of the kidney, which makes the kidney non-functioning.

And it is called the autonephrectomy.

These are two cases showing the calcification of the hydronephrotic sac calcification involving the ureter.

You see a tiny speck of calcification in the urothelium of the ureter and coming to the healing of bladder tuberculosis.

The fibrosis results in contraction of the urinary bladder.

It is called marked contraction is called a thick 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 micturition almost they may have to urinate once in a few minutes.

Confirmation of Urinary Tuberculosis

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 cystoscopic biopsy of the bladder urothelium looking for the typical granuloma, 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, frequency, lasting for one year with the recurrent attacks of fever, with chills.

And ultrasound shows the coronal scan of the kidney showing mild hydronephrosis.

And there is urothelial thickening, there is vesicoureteric reflux, and in the kidney you see granulomas cavitating granulomas in the parenchyma.

And to IVP was done to confirm, which showed poor functioning of the left kidney, with smudging of the contrast due to cavities and the dilated calyces.

So IVP was not useful, and urine came as negative for tuberculosis.

So then ureteroscopy was done to confirm the ureteroscopy showed a golf hole 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 hydronephrosis.

And this pus when sent for culture, proved that it is tuberculosis became positive for tuberculosis.

So sometimes the proof proving confirmation of tuberculosis maybe little long drawn.

Differential Diagnosis

Now, differential diagnosis are the conditions are papillary necrosis, bacterial 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 hydronephrosis, urothelial thickening calcification, and multiple beaded appearance of the ureter and urothelial thickening of the urinary bladder.

So multiple sites of involvement and multiple stages hydronephrosis due to stricture calcification.

So multiple stages of disease seen in the same patient.

This is very characteristic of tuberculosis.

And next is the appropriate clinical setting.

So patients are not referred to rule out urinary tuberculosis because the symptoms are not very classical.

But what is important the symptoms are when the disease involves the upper tract, patients are asymptomatic, but this disease involves the lower tract starting from the ureterovesical junction bladder, then patients become symptomatic.

And the symptoms are dysuria, frequency of micturition 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 route, and the primary site of involvement is the epididymis.

The other regions by direct contiguous infection from the epididymis happens now, tuberculosis of the prostate.

The investigation of choice is the transrectal ultrasound, and many patients the investigation fails to reveal any lesion in the prostate.

There may be focal areas of decreased echogenicity as seen here, or there may be dystrophic calcifications as seen here, or rarely.

You may see a abscess in the prostate as seen here, which may extend outside the prostate also.

So this mimics like any other non-specific abscess of the prostate, or there may be fistula tract to the perineum or a ano urethral fistula due to prostatic tuberculosis as seen here.

This is a transrectal 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 see the extension of the gas through gas outlined tract extending from the prostatic urethra to the anal canal.

So that is evidence of ano urethral fistula.

Patient had other features of tubercle in the urinary tract, and he became positive on urine examination for tuberculosis.

Now, sequelae of tuberculosis 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 epididymis are ectasia of the rete testis.

And the seminal vesicles are dilated and the epididymis may be having multiple cysts.

So these are the features of obstruction to ejaculatory ducts as a result of fibrosis due to healing of tuberculosis coming to scrotal tuberculosis, the patients present with pain and swelling of the scrotum, and it is insidious in onset and chronic in duration.

Epididymis Involvement

Tuberculosis of the epididymis were various features.

One is a diffusely enlarged heterogeneously hypoechoic epididymis.

So this is an example of uniformly enlarged heterogeneous appearance of epididymis with the couple areas.

And when you do color doppler, there is peripheral flow increased flow in the epididymis, or it can be a nodular enlargement of a focal area of the epididymis, or there may be a heterogeneous focal enlargement of the epididymis with necrotic area with hyperemia around on color doppler, or it may be diffusely enlarged uniformly enlarged epididymis.

So these are the appearance of the epididymis in tuberculosis, or you may get an abscess in the commonly in the tail of the epididymis.

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 pus, 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 epididymis.

So these are the features of epididymal tuberculosis.

Testis and Other Structures

Coming to tuberculous orchitis the testis maybe enlarged with multiple small hypoechoic nodules, and there may be blurred separation of the testis and epididymis, and there may be changes coexisting granulomas in the masses in the testis epididymis also, or there may be diffuse enlargement of the testis with which is echopoor, two plus of the seminal vesicles and vas deferens.

One form is a small solid seminal vesicle like this with or without calcifications.

Here there are calcifications in the vas deferens, we can see a focal mass in the vas deferens or the vas deferens may be calcified when there is sequel of tuberculosis, rarely there may be an abscess in the seminal vesicle, which can extend outside the seminal vesicle.

So this turned by a transrectal biopsy was proved to be tuberculosis.

Differential Diagnosis for 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 non-specific 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 genitourinary system, 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 continuity.

Now, tuberculosis of the female genital tract because it is intraperitoneal may 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 echos in the ascitic fluid.

And you may see thickened fallopian tubes floating in the ascitic fluid.

So this is the wet form.

And in the dry form we may see thick walled the fallopian tube in two cases, and then on color doppler it may show hyperemia or it can be seen as a tubo-ovarian abscess, or a hydrosalpinx as seen here.

And that is a hydrosalpinx or rarely as a tubo-ovarian abscess.

Now tuberculosis 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 saline infusion sonography.

Here you see this two 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 tubercle.

So the fallopian tube, endometrial 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 synechiae or many synechiae and the entire cavity may be scarred like Asherman's syndrome, or you may see fine endometrial calcifications sign of endometrial tuberculosis.

Thank you very much for your patient listening.