presentations?: Ans: Clinical presentation
may range from a painless scrotal mass, which is the commonest,
to irritative lower urinary tract symptoms, hematuria, dysuria, hemospermia, infertility, ulcerative penile
lesion to being completely
asymptomatic and incidentally diagnosed on histopathology .
Patients
may have symptoms of associated upper tract disease but constitutional symptoms
per se are less common and may suggest an extra-genital disease . History of prior Tb or contact with a patient
of Tb
Q.2: 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 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. 3: Modes of transmission?? . How male genital
organs are affected?? Ans: The usual
modes of genital involvement include descending infection from the kidneys,
intracanalicular or direct extension from neighboring foci in the genital tract,
and haematogenous shedding :
Q. 3B :-Mode of transmission from Lungs to epididymis-How? 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 A) kidneys and B) 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, A) renal involvement is the commonest, in about 80%, and B)
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 .
B) 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, C) 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.
D) 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 .
E) 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 .
E) Penile infection :-
How ? 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
Q. 4 . What is the
prevalence?? Ans: -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.
Q.5 : Is MGTB is
asymtomatic almost always !! Ans: No
.It is not always asymptomatic though local symptoms are usually insidious and
progressive. As
mentioned earlier the
epididymis are the commonest site of involvement in male genital Tb and is
involved in 48.9% of patients with GUTB, which can be the first or the only
presenting feature .
Although termed
epididymo-orchitis, 45% have involvement of epididymis alone, with testicular
involvement developing later as the disease progresses .Eighty percent of
patients with tubercular epididymo-orchitis present with a scrotal mass, which can
be painful in 40–44% .
Bilateral involvement is seen in 34% cases,
4–50% may present late with an abscess
or a fistula and 5–10% may have an associated hydrocele .
Presentation as rapidly enlarging painful hydrocele
due to isolated involvement of tunica albugniea and vaginalis has also been
described .
Q. 6 What may be clinical Findings in local
examination ??
Ans:-Clinical finding of non tender or
tender nodules with or without induration in the vas and epididymis with or
without involvement of testes is suggestive. Presence of multiple pus
discharging sinuses on posterior surface of scrotum, although rare, is
characteristic. Isolated testicular involvement is rare and should raise the
suspicion of a primary testicular malignancy, as should a lesion which fails to
respond after 3 weeks of antitubercular chemotherapy.
Prostatic involvement most commonly presents
with storage lower urinary tract symptoms, that is urinary frequency, nocturia usually without urgency .There may be
associated dysuria, hematuria or
hemospermia.
Isolated hemospermia is considered benign, but
persistent, frequently recurring or high volume hemospermia may be associated
with genital Tb in 15% of cases .Neglected cases or immunocompromised patients
may present with tubercular
prostatic abscess or discharging perineal sinuses .
Q.7: What informations we can receive from rectal examination
? Ans: Rectal examination may reveal non tender
nodular prostate mimicking malignancy, but soft areas of caseous necrosis may
also be appreciated. Tubercular prostatitis can also be clinically silent and
detected incidentally on histopathologic specimens of transurethral prostatic
resection (TURP) .Direct contiguous involvement or canalicular spread to
seminal vesicles and ejaculatory ducts may cause a progressive decline in
volume of ejaculate with oligo or azoospermia or even aspermia and the
resultant infertility
Q. 7 :Can there be systemic
manifestations such as fever, chills, and sweats? Ans: Usually not. Such
symptoms are infrequently present in
isolated genital tuberculosis.
Q.8 : What is the D/D ?? Ans 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.
Q 9 How to diagnose with almost certainity ??
The gold standard for the diagnosis of
tuberculosis at any site is isolation and culture of Mycobacterium tuberculosis
bacilli and, in the cases of suspected genitourinary Tb, it is commonly looked
for in the urinary samples.
Investigation No. A) :
Haemogram with ESR & Chest X’ray is a must and Investigation No. Raised ESR or a
positive Monteux test are neither diagnostic nor localizing but can be used as
supportive evidence in absence of microbiologic evidence . A provocation test,
although seldom used clinically, has been described to increase the detection
rates especially in obscure or latent forms of Tb .The test is performed by
injecting 20, 50 or 100 units of tuberculin subcutaneously and leucocytosis,
leukocyturia, lymphopenia and increased body temperature after 24 and 48 hrs is
considered as positive. After provocation, a 16% increase in detection of
mycobacterium bacilli by culture or PCR has also been reported .
B) Transrectal sonography may be utilized in
patients suspected to have prostatic and seminal vesicle involvement. However, sometimes,
trans rectal ultrasonography (TRUS) guided biopsy may be specifically performed
to diagnose or monitor efficacy of therapy for tubercular prostatitis.
Tubercular prostatitis presents as multiple
hypoechoic areas in the peripheral zones of prostate with areas of
calcification or abscess formation . In absence of calcification, these lesions
may be indistinguishable from malignancy and magnetic resonance imaging (MRI)
may be of help.
Investigation No .C)
MRI:-The presence of
peripheral enhancement or the watermelon skin sign on MRI suggests Tb
. Investigation No. D) FNAC showed a sensitivity and specificity of 87% and 93%
respectively . The presence of epithelioid cell granuloma with multinucleate
giant cell and caseous necrosis can be considered diagnostic for Tb, but even
on histopathology, a definite evidence can only established by demonstrating
mycobacteria on smear or culture.
Investigation No. E) What to look for in Urine & what are
pitfalls and limitations of urine exam?? Traditionally, presence of ‘sterile pyuria’ on microscopic examination of urine was
considered a classic finding of genitourinary involvement. However, superadded
infection with usual coliform bacilli is present in about 30% of the patients .
. Other findings such as leukocyturia, microscopic (50%) or macroscopic
(10%) hematuria and acidic urine are non specific and may be absent in
20% of cases .
Which other tests to
employ for mycobacterial infections ??
Ans: Classic
laboratory tests, such as sputum smears, bacterial cultures, and
histopathologic examination, still play a central role in the screening,
diagnosis, and monitoring of this disease. For the time being, these remain the
most widely used tests because they offer certain advantages. For example, the
microscopic observation of tissue sections permits the distinction between
granulomatous lesions and other clinically or radiographically similar lesions
including cancers as well as the evaluation of the histologic type and stage of
the tubercle lesions. However, some pathologists have become aware that the
number of bacilli in tissue sections stained with acid-fast staining (acid-fast staining histopathology
[ASH]) frequently seems to be much lower than that expected from the
sputum smear data or the patient's condition. All mycobacteria have a
lipid-rich cell wall that avidly retains carbolfuchsin, rhodamine, or auramine
dye even in the presence of acidic alcohol. Formalin and/or xylene might alter
this property of the bacilli.
Investigation no. 9F; How Fallacies are the report receieved by Staining with
Ziel-Neelsen or auramine stain?
Ans: What is the six
decade long problem with microscopy??? Ans: Microscopic observation of the
smears revealed from semen or urethral discharge exhibit that the sensitivity
of both types of acid-fast stains (Ziehl–Neelsen and rhodamine–auramine
staining) for M. tuberculosis decreased drastically with
formalin treatment or with the combined treatment of formalin and xylene .
In case of sputum , however sporadic shedding
of bacilli in low concentrations explains the poor sensitivity and at least 3
or preferably 5 or even 9 early morning samples should be analyzed . Contamination
with Mycobacterium smegmatis or fragments of sperm can give a false positive
smear result ,
Q. Investigation no. 9G : How helpful is Culture in L-J Media ?? Ans; Culture,
although is gold standard, has a widely variable sensitivity of 10.7 to 80% and
can take about 6 to 8 weeks, but has the advantage of providing antibiotic
sensitivity testing .
Q. . Investigation no. 9 H : How important and specific is Nucleic acid
amplification (NAA ??
Ans: Nucleic acid amplification (NAA) allows for rapid diagnosis with
significantly higher yield even in low bacillary concentrations and can detect
Mycobacterial DNA in 80.9% patients with suspected GUTB .
The sensitivity and specificity of polymerase
chain reaction (PCR) on urinary samples range from 94.3% to 95.6% and 85.7% to
94.3% respectively. The disadvantage of PCR is its inability to differentiate
between active and latent infection and thus the need of therapy in equivocal
cases. PCR may be too
sensitive to distinguish between active and inactive or infectious or non-infectious
states of the lesion
Investigation no. 9.I:-- . How important and specific is GeneXpert ?? The more recent self-contained cassette based analysis (GeneXpert®) avoids contamination
and provide results within 2 hours with the advantage of identification of
rifampicin resistance. But, the detection rates of genital TB on urinary analysis may be lower than that for urinary Tb
as the infected sites may not be in direct contact with urinary system or the
concentration of bacilli may be too low. Thus, it becomes necessary to analyze
for evidence of disease on semen and prostatic secretions also.
Samples –to be collected wherefrom? Is it semen/Urine/ Prostatic
message ?? Ans: For suspected
cases of isolated genital Tb, analysis of expressed prostatic secretions (EPS),
post massage urine and ejaculate for mycobacterium by microscopy, culture and
PCR may be helpful. EPS (expressed prostatic secretions) can be collected using with either the
standard four glass test or the modified 3 glass test that is proposed to have
lesser contamination of urine samples with prostatic secretions .
At least
3 but 5 or more samples should be collected and plated within 40 min of
collection . But the search of Mycobacterium in semen or EPS samples by these
methods is often futile even in diagnosed cases of genital Tb or may be
incidentally positive in clinically asymptomatic men undergoing infertility
analysis .
All other obtainable body fluid specimens from
possible sites of infection, such as pus from epididymal or prostatic abscess
and discharge from penile lesion or perineal or scrotal sinuses, must be
subjected to smear, culture and possibly PCR for detection of bacilli.
Q . Investigation no 9 . J. About a third of patients with tubercular prostatitis
may have raised in serum prostate specific
antigen (PSA)
that resolved in half after anti-tubercular chemotherapy, but persistent rise
was not predictive of relapse .
|
Treatement : Management |
GUTB commonly presents as vague long standing
urinary symptoms with or without a positive urine culture and most of these
patients are treated with broad spectrum antibiotics, mainly due to the lack
of clinical suspicion .It is recommended to consider Tb as a differential in
all the cases of urinary tract infection and quinolones should be excluded
from the first line of therapy .Like for the most forms of Tb,
anti-tubercular chemotherapy has become the first line of management for all
forms of genital Tb . |
An optimal schedule and treatment duration
specific for GUTB remains to be defined, but there is a gradual change from
the longer 18–24 months treatment to a shorter 6 months course, and the
latter has become the current standard of care .Most patients are started
with four drugs in the first two months ‘the intensive phase’ of the regimen
(rifampicin, isoniazid, pyrazinamide and ethambutol) and are then shifted to
two drugs in the ‘continuation phase’ (rifampicin and isoniazid) summarizes
schedules and doses of commonly prescribed medications). Longer duration
therapy (9 to 12 months) may be required in immunocompromised or HIV/AIDS
co-infection |
|
|
Relapse/defaulter |
2 months HRZES, 1 month HRZE |
5 months HRE |
Likelihood of drug resistance of low. Change category
after drug sensitivity results available |
|
Rifampicin or
multidrug resistant Tb |
6–9 months Km, Lvx, Eto, Cs, ZE |
18 months Lvx, Eto, Cs, E |
Start empirically. Perform drug susceptibility for at
least HR. Change once results are available |
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