Male genital tuberculosis --Hard to diagnose but prevalence is not that uncommon

 

What we need to know about male genital Kochs ?? . Tuberculosis (Tb) still remains a global health problem. With nearly one third of the world’s population infected, it is responsible for maximum number of deaths in adults resulting from a single infectious cause .Of its world health burden, more than 90% of the infected individuals belong to the developing countries where the incidence ranges from 192 to 232 per 100,000 population with 19 to 30 deaths per 100,000 population per year, This re-emergence has been attributed to the AIDS pandemic, emergence of multi drug resistant bacilli (MDR) and immigration

What we need to be aware of MDR Kochs?

MDR Tb is often the result of poor compliance to pharmacotherapy and with its increasing incidence, is another cause for concern. Extra-pulmonary Tb (EPTB), which accounts for about 10% of the overall Tb burden, most commonly affects the lymph nodes, urogenital organs, pleura and the skeletal system .Thus, although the global prevalence and death rate of Tb is declining, the number of individuals infected is actually increasing .

 

Can GUTB cause renal failure or ureteric obstructive uropathy ?? GUTB, which accounts for 20–40% of EPTB cases, is the second most common site in developing and third most common site in developed nations .Despite the fact that involvement of genitourinary organs is almost always secondary to Tb elsewhere in the body and is rarely contagious, GUTB can result in a significant morbidity and even mortality due to renal failure. Isolated involvement of genital organs is reported in about 5–30% of the cases of GUTB, with higher rates in epidemic situations..

 

 Take home message :--GUTB is classified as a severe form of EPTB with a high bacillary load .Because of its non-specific symptoms, it is recommended that the diagnosis of GUTB should always be considered in a patient presenting with long standing vague urinary symptoms with no obvious cause It is estimated that upto 20% of the patients with clinical pulmonary Tb have genitourinary organ involvement; 2–10% in developed countries and 15–20% in developing countries .Evidence of previous or active pulmonary involvement can be found in 56–87% of the patients with GUTB Genitourinary organs are commonly involved together rather than in isolation and it is the duration of disease prior to diagnosis that dictates the number of organs involved. Involvement of urinary organs is commoner and in 53% of the cases of renal Tb, an associated genital lesion can be identified . Similarly, 49–88% cases of genital Tb have an associated lesion in the urinary tract .Isolated involvement of genital organs is rare, 5–30% of all the cases, and it depends on the burden of Tb in the community, ethnic status and thoroughness of evaluation for Tb at other sites .Also, there is some evidence that genital involvement from Tb might be commoner in India as compared to other countries ,Because of all these factors and its asymptomatic nature, the true incidence of genital Tb is largely unknown.

Q.1: Where is the site of Infection of MGTB(Male genital TB) ?? The most common genital sites of tuberculous infection are the epididymis and prostate; the testicle is infected in a lower proportion of cases. The usual modes of genital involvement include descending infection from the kidneys, intracanalicular or direct extension from neighboring foci in the genital tract, and hematogenous seeding. Urogenital TB (UGTB) is the second most common form of extrapulmonary TB (EPTB) in countries with severe epidemic situation and the third most common form in regions with low incidence of TB. Male genital TB (MGTB) seems to be a rare disease. Nevertheless, 77% of men who died from TB of all localizations had prostate TB that had mostly been overlooked during their life time. The epididymis or the prostate can be involved by haematogenous spread, with the rest of the genital organs being involved by canalicular, urinary or contiguous spread Besides significant morbidity, involvement of reproductive organs can result in infertility, which can even be the presenting complaint

 

 

Q. 2: How male genital organs are affected?? Mode of transmission from Lugs to epididymis??  Ans:=Aerosolized Mycobacterium tuberculosis bacilli infect and invade the pulmonary alveoli and cause primary pulmonary tuberculosis. This subclinical pulmonary infection leads to bacillemia and haematogenous implantation of the Tb bacilli in the kidneys, epididymis and the prostate amongst various other organs of the body. Initially, the implantation occurs in the more vascular parts such as cortex of the kidneys and globus minor of the epididymis, and is bilateral. With the development of immunity, these lesions cicatrize in about 6 months or so, and a latent phase then ensues. Amongst the genitourinary organs, renal involvement is the commonest, in about 80%, and the epididymis are the most commonly affected genital organs in about 22–55% of patients . Genital Tb can result from primary reactivation of the latent bacilli either in the epididymis or the prostate or by secondary spread from the already infected genitourinary organs via the urinary system, by canalicular spread both antegrade and retrograde or by lymphatic spread which probably plays a minor role .The epididymis are more frequently involved hematogenously but retrograde canalicular spread from infected prostate and urinary system has also been described. The disease usually starts in the globus minor, which is commonest site for haematogenous spread as well as the first site in retrograde canalicular spread, and then spreads to the other parts. Because of blood testes barrier, testes can only be involved by direct extension from the epididymis and isolated testicular involvement with normal epididymis should raise concerns for a malignant testicular lesion. In tubercular prostatitis, the lateral and peripheral lobes are frequently involved with mucosal or submucosal lesion being seen only in advanced cases, suggesting haematogenous spread as the primary mechanism of involvement rather than direct extension from the urinary tract .Seminal vesicles are involved by the canalicular route and this involvement is seldom isolated. Despite its constant exposure to infected urine, urethral Tb is rare and is never isolated. Sexual transmission is thought to be possible as viable bacilli have been demonstrated in semen of the patients with pulmonary as well as prostatic Tb and such transmission was confirmed by molecular typing which showed identical organisms isolated from penile ulcer and endometrial biopsy of a couple . The normal mucosa is highly resistant to Tb bacilli, thus it has been postulated that the mucosal abrasions caused by vigorous sexual activity permits their inoculation .Besides these, reinoculation of the male partner through his own infected ejaculate and secondary involvement via urethra may also lead to the development of penile lesions in a patient of genital Tb

 

 

It is asymtomatic almost always !!   Ans:  Local symptoms are usually insidious and progressive. Systemic manifestations such as fever, chills, and sweats are infrequently present in isolated genital tuberculosis.

Q.3: What is the D/D ??  Tuberculous genital infection can be confused with other bacterial (including nontuberculous mycobacterial) infections, fungal disease, tumors, and cysts as well as with a number of less common illnesses. Although some diagnostic and therapeutic indications for surgical excision still exist, the preferred approach to treatment is primarily multiple-drug antituberculosis chemotherapy.