International Uroloyy and Nephrology 24 (5), pp. 471--480 (1992)
Urinary Tuberculosis" Experience of a Teaching Hospital in Syria M. Z. SHAMMAA, S. HADIDY, R. AL-ASFARI, M. N. SIRAGEL-DIN Departments of Urology and Clinical Pathology, Aleppo University Hospital, Aleppo, Syria (Accepted January 10, 1992) This study was designed to show our experience of urinary tuberculosis in one of the large teaching hospitals in Syria. It was a prospective study involving 48 patients (29 males and 19 females) with confirmed tuberculous lesions in the urinary tract. The study period was between 1982-1987. The presenting symptoms were protean, and there were often delays between onset of symptoms and eventual diagnosis. The highest age incidence was in the second and fourth decades. Beside the suggestive clinical manifestations, final diagnosis was reached by various means. Repeated examinations of EMU smears were positive in about 2 0 ~ of cases. Urine culture was positive in 33.3~, while varied percentage of cases showed some radiologieal changes suggestive of tuberculosis. Other investigations included cystoscopy and biopsy of suspected lesions. Treatment was conservative by chemotherapy in 45~ of cases, with complete xecovery in about 33~, while acceptable results were shown in ~_19~, and failure of treatment or recurrence of active disease in 48~ of cases. Some forms of surgical intervention were carried out in 55~ of patients. Cute was seen in 50~ of them, while 25~ had acceptable results and failure was shown in the remaining 25~. It is concluded that urinary tuberculosis remains an important infectious disease problem in our country. The high rate of failure of both medical or surgical treatment is mainly due to late diagnosis.
Introduction I n the w o r l d at large a b o u t 10 million persons each y e a r still continue to develop tuberculosis, a n d at least three million die f r o m this disease [1 ]. I n rich countries, tuberculosis has ceased to represent a p u b l i c health p r o b l e m in c o n t r a s t to the situation in d e v e l o p i n g countries [2]. It was suggested t h a t the m a g n i t u d e o f the tuberculosis p r o b l e m c a n be m e a s u r e d t h r o u g h tuberculosis prevalence surveys [3]. H o w e v e r , i m p l e m e n t a t i o n o f such surveys is rarely a d o p t e d in developing countries because o f the relatively high cost a n d the necessity for skilled, enthusiastic a n d d e v o t e d m a n p o w e r . The m a g n i t u d e o f the p r o b l e m is d e m o n s t r a t e d by the occasional i n d i v i d u a l reports, like this one. M a n y w o r k e r s in rich countries, like the U n i t e d States a n d E n g l a n d , have i n d i c a t e d a fall in incidence o f p u l m o n a r y tuberculosis which has n o t been reflected in e x t r a p u l m o n a r y lesions, especially u r o g e n i t a l tuberculosis [4-7]. I n a preVSP, Utrecht Akad~miai Kiad6, Budapest
472
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vious work we tried to show the seriousness of the problem of extrapulmonary tuberculosis in our area by presenting our experience with 50 cases of tuberculous meningitis in children [8, 9]. In this study, we aim to demonstrate our experience with 48 cases of confirmed urinary tuberculosis. We wish to emphasize, especially to general practitioners, that if looked for, many cases of urogenital tuberculosis could be discovered. It is not, as sometimes quoted, "a once in a lifetime diagnosis" [10]. Patients and methods
Aleppo University Hospital is a 600-bed state-supported teaching hospital that serves as the main teaching facility for Aleppo Medical School. Most patients are accepted from outpatient clinics and they come from Aleppo city and the Northern provinces of Syria, a population of about 2 million. The study period started in July 1982 and ended in July 1987. Patients considered to have urinary tuberculosis and fulfilling all or most of the following criteria were included in this study: (1) Clinical manifestations compatible with tuberculous infection and identification of M. tuberculosis by direct smear or culture of urine; (2) imaging procedures suggestive of urinary tuberculosis; (3)biopsy or surgical specimen revealing histological changes compatible with TB; (4) clinical and radiological data compatible with urinary tuberculosis and showing response to antituberculous treatment. Full clinical history and complete examination were carried out in each patient. The following investigations were done in all or most of our cases: 1. microscopical examination and culture of 3 samples of EMU; 2. plain X-ray of the chest and abdomen; 3. i.v. pyelography for all patients and other imaging procedures for selected cases; 4. cystoscopy and biopsy of suspected lesions (25 cases); 5. full haematology profile on Technicon haemalog 8; 6. biochemical profile on Technicon SMA 12/60, including kidney and liver functions. Treatment
Chemotherapy - All patients received isoniazid (5 mg/kg/day) plus rifampicin (10 mg/kg/day) for a period of 9 months. - In the first 3 months of the course, streptomycin i.m. (1 g/day) was given or ethambutol (15 mg/kg/day), according to the tolerance of the patient. - Three patients with advanced condition and poor clinical state had only isoniazid and ethambutol for 2 years. International Urology and Nephrology 24, 1992
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Therapy was handled to the patients free of charge, on a weekly basis from outpatient clinics. This was a means of checking the taking of therapy and for follow-up.
Suryery Surgical intervention included unilateral nephrectomy, partial nephrectomy, augmentation cystoplasty, ureteral dilatation, and ileal reconstruction of the ureter. Throughout the duration of treatment, patients were examined and investigated at least once during the first month and every three months thereafter. Care was given to any changes in liver or kidney functions. Patients were advised to report to hospital on noticing symptoms like nausea, vomiting, jaundice or marked asthenia. Results
Epidemiology and clinicalfeatures During the study period, 48 patients were diagnosed as having urinary tuberculosis (29 males and 19 females, with a ratio of 1.52 : 1). The age distribution is shown in Table 1. The presenting symptoms in descending order of frequency were dysuria and frequency of urination, colics and vague pain in the renal angles, haematuria, malaise, fever, fatigue and weight loss, as summarized in Table 2. Persistence of complaints before diagnosis varied from a few months to a few years. Delay in diagnosis to more than one year was seen in about half of the patients (Table 3). Table 1 Age distribution Age group (years)
Number of patients
Per cent
70
1 8 14 13 6 3 2 1
2 16.6 29.1 27.1 13.5 6.3 4.1 2.0
Total
48
100
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Table 2 Main presenting symptoms Symptoms
Number
Per cent
37 37
77.0 77.0
23 15 15 12 10 3 2
47.9 31.2 31.2 25.0 20.8 6.2 4.1
Frequency Dysuria Renal colic and vague lower back pain Frank haematuria Fever Anorexia and loss of weight Night sweating Mass in loin Oliguria Table 3
Persistence of complaints before establishing the diagnosis Persistence 2
months months years years Total
Number of patients
Per cent
3 21 11 13
6.2 43.7 22.9 27.0
48
Investigations
The investigations were protean and are summarized in Table 4. Although only about 33 % of patients had positive cultures of M. tuberculosis and 21% positive smears from the three E M U samples, yet diagnosis was established by one or the other criteria. Plain X-rays of the abdomen showed few changes in one third of the cases, mainly calcification in the renal area or along the course of the ureters. On the other hand, i.v. urography showed many features like nonfunctioning kidney (50%), distortion and atypical calyces in one or more poles (30 %), hydronephrosis (25 %), stenosis of ureter (33 %), while normal appearance was seen in 12.5 ~ of cases. The bladder showed various alterations like defects on one side of the wall (37.5~), thick and irregular outlines (18.7~) and contracted bladder (10.4 ~). Cystoscopy was done for 27 patients; only three of them showed no apparent pathological changes. Patchy cystitis was seen in 11 patients (40.7 ~), small capacity in 7 (25.9 ~), tubercles and granulation tissue in 9 (33.3 ~). International Urology and Nephrology 24, 1992
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Biopsy was done for 25 patients during cystoscopy. The histological changes were compatible with the diagnosis of tuberculosis in 15 cases. Cystoscopy a n d biopsy were repeated in patients with negative results a n d five of t h e m were positive in the second setting. D a t a of associated extraurinary tuberculosis in the studied group are s h o w n in Table 5. Table 4 Procedures adopted in establishing the diagnosis Positive findings Number done n u m b e r per cent type
Investigation
3 EMU (direct smear)
48
10
20.8
Culture of urine
48
16
33.3
Plain X-ray of chest
48
8
16.6
Plain X-ray of abdomen bilateral renal calcification unilateral renal calcification calcification along the ureter
48
14
29.2
Intravenous pyelogram no abnormality detected no secretion of dye in one kidney various findings suggestive of T.B.
48
Cystoscopy normal bladder patchy cystitis small capacity tubercles and granulation tissue ulceration
27
Biopsy during cystoscopy positive in 1st biopsy positive in 2nd biopsy
25
1 10 3 42
87.5 6 24 18
24
88.0 3 11 7 9 6
20
80.0 15 5
Table 5 Extraurinary foci of tuberculosis Site
Pulmonary tuberculosis Female genital system Male genital system Skeletal Cold abscess 2
Number of patients
8 3 3 1 1
Per cent
16.6 6.2 6.6 2.0 2.0
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Treatment
Treatment was either conservative by the usual chemotherapeutic regime (45 %), or by some sort o f surgical intervention (55 %). Indications for conservative treatment were early tuberculous lesions, bilateral foci, or late stage of chronic renal failure. In 26 patients (54.2 %), drug therapy was combined with some sort of surgical treatment as shown in Table 6. Indications for nephrectomy were non-functioning kidney, advanced destructive lesion, or failure of conservative treatment. Complications following surgical treatment are summarized in Table 7. Lastly, the overall outcome of treatment after a mean period o f about three years' follow-up is summarized in Table 8. These results indicate failure of both therapeutic and surgical treatments in one third o f patients. This high percentage is probably due to the late diagnosis of the disease. Table 6 Type of surgical intervention Type o f surgery
Number
Nephrectomy Partial nephrectomy Ureteral dilatation Ileal reconstruction of ureter Augmentation cystoplasty Fistulectomy
19 1 1 1 4 2
Per cent
73.0 3.8 3.8 3.8 15.3 7.6
Table 7 Surgical complications Type o f complication
Massive bleeding Wound infection Failure to remove kidney, taking biopsy only Injury of pleura Injury of suprarenal Injury of inferior vena cava Injury of duodenum Fistula Immediate postoperative death
International Uroloyy and Nephroloyy 24, 1992
Number
Per cent
3 3
11.5 11.5
3 3 1 1 1 2 1
11.5 11.5 3.8 3.8 3.8 7.6 3.8
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Table 8 Results of treatment Result
Recovery (complete disappearance of signs and symptoms) Partial amelioration of signs and symptoms Failure of treatment or recurrence of manifestations Total
Chemotherapy (con= servative)
Surgery combined with drug therapy
8
13
4
7
10
6
22
26
Discussion The diagnosis of urinary tuberculosis could be more difficult to establish than pulmonary tuberculosis because of the nonspecific manifestations of the disease and the lack o f simple screening tests such as chest radiograph [7]. A more important factor in missing the diagnosis of urinary tuberculosis is that many general practitioners think of the condition as a rarity and forget to put it in the differential diagnosis of conditions such as sterile pyuria, recurrent urinary infection of unknown origin, haematuria of undetermined origin, and people who are known to have contacts with tuberculous patients [10]. This prospective study was planned to demonstrate our experience in the diagnosis and treatment of urinary tuberculosis. Males predominated over females in a ratio of 1.5 : 1 and the majority of patients were 20-40 years of age. This agrees with many other studies [11-13]. This means that the disease attacks the young, more active and productive strata of the community. However, few reports indicate a change in age incidence towards older age groups [14]. The presenting symptoms o f frequency, dysuria, renal colic, lower back pain, and haematuria, separately or in combination, occurred in different proportions from 20-56 % of the time [15, 16]. The absence of urinary manifestations in a fair number of cases, and the low percentage of patients with the general symptoms of tuberculosis such as anorexia, weight loss, night sweating etc., are probably the main causes of delay in the diagnosis o f urinary tuberculosis in this series as well as in others [7, 17]. This delay is sometimes justified due to absence o f specific and general manifestations and the lack of experienced persons and diagnostic tools to isolate, identify and culture the bacilli. However, in a fair number of cases the delay in diagnosis could be avoided by awareness of the presence of tuberculosis in suspected cases and by training technicians in developing countries about the methods of identification and culturing of bacilli [17]. The late diagnosis in this series, and in the third world in general, is reflected on the outcome of treatment. 2*
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In this study, urine examination and cultures were positive in only 33 ~ of cases. Few other studies, even in developed countries, have shown that a significant proportion of urine screenings and cultures are negative in such patients. However, this proportion is definitely higher in developing countries. This is mainly due to lack of experienced technicians and absence of reference laboratories. The second tool of investigation in this study were the different imaging procedures. It was not only important in suggesting the diagnosis, but also in delineating the extent and nature of the lesions and lastly in assessing the progress and repair process. In this study, about 8 8 ~ of i.v. pyelograms showed some radiological changes in one or both kidneys, ureters or urinary bladder. In a similar study done on 52 patients, Roylance and his associates [ 18] demonstrated that the renal abnormalities were found in almost all patients (98 ~), while abnormalities in ureters and bladder were found in 43 ~ and 33 ~ of cases, respectively. Calcifications in the renal area were found by Roylance et al. in 31 ~ of patients [18], similar to what we have found in our patients. Calcification along the course of the ureter was seen in three of our cases, a finding claimed to be rare and late in urinary tuberculosis [19]. Another important finding in our series was the large number (50 ~ ) that showed no secretion of the dye in one kidney. The cause of this may be explained by the late presentation of the patients. Cystoscopy and biopsy of suspected lesions were done in about half of the patients. This procedure was very helpful because in 20 out of 25 cases the histological changes were compatible with tuberculosis. Gow [23], in a review on genito-urinary tuberculosis, mentioned that bladder biopsy should only be carried out when there are tubercles or an ulcer distant from the normal ureteric orifice. Cystoscopy also helps in detecting patchy cystitis, ulceration, granulation tissue, tubercles - features suggestive of tuberculosis. Concerning treatment, very few reports have been published from developing countries. Our experience may therefore represent the state of affairs in the management of urinary tuberculosis in those areas. The following review is a summary of the most important points that could be deduced from our study. (a) Chemotherapy should be free of charge, as is the case in Syria. (b) Each hospital should adopt some way to make sure that the patients do take the drugs. This may be the most difficult part of treatment in developing countries [23]. (c) We think that the 9-month course with the previously mentioned drugs is effective in most cases. It is also more comfortable to both the patient and the hospital. (d) The bacteriological investigations, especially cultures and sensitivity testing, are insufficient in Syria and probably completely lacking in many of the developing countries. This situation should be corrected. Chemotherapeutic treatment of urinary tuberculosis is most encouraging if the disease is diagnosed early. Unfortunately, there remains a disturbingly high incidence presenting with advanced renal destruction, obstruction, strictures and contraction of the bladder, that necessitate different surgical interventions [12, 21]. In this study more than half of the patients were operated upon. The operations included 19 nephrectornies and only 7 reconstructive operations. The picture International Urology and Nephrolooy 24, 1992
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is different in developed countries where an increasing rate of reconstructive surgical procedures has been accompanied by a corresponding decline in the number of nephrectomies [21]. Conservative surgery is expensive, but its excellent long-term results [12, 21, 22] have justified the efforts and costs, and more of such operations are done in Syria. Conclusions
The following conclusions could be deduced from our experience in Syria, and may reflect at the same time the picture of urinary tuberculosis in other developing countries: 1. Urinary tuberculosis is not uncommon, but unfortunately many cases are not diagnosed. 2. When diagnosis is made, it is usually too late, and unjustified in a fair number of cases. 3. The delay in diagnosis is reflected in the high percentage of treatment failures. 4. Bacteriological investigations and sensitivity testing for TB bacilli should be given more attention in developing countries. References 1. Styblo, K., Rouillon, A. : Estimated global incidence of smear-positive tuberculosis" Unreliability of officially reported figures on tuberculosis. Bull. International Union Against Tuberculosis, 56, 118 (1981). 2. Waaler, H. T. : Tuberculosis in the world: V. Tuberculosis and socio-economic development. Bull. International Union Against Tuberculosis, 57, 202 (1982). 3. Shimao, T. : Tuberculosis in the world: III. Tuberculosis prevalence surveys. Bull. International Union Against Tuberculosis, 57, 126 (1982). 4. Bruce, L. G. : The incidence of genito-urinary tuberculosis in the western region of Scotland. Br. J. Urol., 42, 637 (1970). 5. Farer, L. S., Lowell, A. M., Meador, M. P.: Extrapulmonary tuberculosis in the United States. Am. J. EpidemioL, 109, 205 (1979). 6. Centers for disease control: Tuberculosis in the United States, 1980 (HHS publication No. CDC-83-83322). US Department of Health & Human Services, Atlanta 1983. 7. Weir, M. R., Thornton, G. F. : Extrapulmonary tuberculosis: Experience of a community hospital and review of the literature. Am. J. Med., 79, 467 (1985). 8. Hadidy, S., Aktaa, A., Matar, A., Zakeria, A. : Tuberculous meningitis in Northern parts of Syria : Epidemiology. Garyounis Med. J., 8, 29 (1985). 9. Hadidy, S., Aktaa, A., Matar, A., Zakeria, A. : Tuberculous meningitis in Northern parts of Syria: II. Results of investigations and treatment. Garyounis Med. J., 8, 35 (1985). 10. Jafri, M. A. : Once in a life-time; urinary tuberculosis. Postgrad. Doctor (Middle East), 7, 198 (1984). 11. Venugopa, A.: Tuberculosis of genito-urinary tract. In: K. N. Rao (ed.): Textbook of Tuberculosis. Vikas Publishing House PVT Ltd., India 1981, pp. 434-454. 12. O'Flynn, D. : Surgical treatment of genito-urinary tuberculosis. Br. J. Urol., 42, 667 (1970). 13. Gow, J. G. : Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease. Br. J. Urol., 42, 647 (1970). International Urology and Nephrology 24, 1992
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14. Borthwick, W. M. : Present position of urinary tuberculosis. Br. J. UroL, 42, 642 (1970). 15. Christensen, W. I. : Genito-urinary tuberculosis: Review of 102 cases. Medicine (Baltimore), 53, 377 (1974). 16. Simon, H. B., Weinstein, A. J., Pasternak, M. S. : Genito-urinary tuberculosis. Clinical features in a general hospital population. Am. J. Med., 63, 410 (1977). 17. Page, M. I., Lunn, J. S. : Experience with tuberculosis in a public teaching hospital. Am. J. Med., 77, 667 (1984). 18. Roylance, J., Penry, B., Davies, R., Roberts, M. : Radiology in the management of urinary tract tuberculosis. Br. J. UroL, 42, 679 (1970). 19. Friedenberg, R. M., Ney, C., Stechenfeld, R. A.: Roentgenographic manifestation of tuberculosis of ureter. J. UroL, 99, 25 (1968). 20. Fox, W. : The current state of short course chemotherapy. Tubercle, 60, 177 (1979). 21. Kerr, W. K., Gale, G. L., Peterson, K. S. S.: Reconstructive surgery for genito-urinary tuberculosis. J. UroL, 101, 254 (1969). 22. Kerr, W. K., Gale, G. L., Struthers, N. W. : Prognosis in reconstructive surgery for urinary tuberculosis. Br. J. UroL, 42, 672 (1970). 23. Gow, J. G.: Genito-urinary tuberculosis. Postgrad. Doctor (Middle East), 8, 37 (1985).
International Urology and Nephrology 24, 1992
Urinary Tuberculosis" Experience of a Teaching Hospital in Syria M. Z. SHAMMAA, S. HADIDY, R. AL-ASFARI, M. N. SIRAGEL-DIN Departments of Urology and Clinical Pathology, Aleppo University Hospital, Aleppo, Syria (Accepted January 10, 1992) This study was designed to show our experience of urinary tuberculosis in one of the large teaching hospitals in Syria. It was a prospective study involving 48 patients (29 males and 19 females) with confirmed tuberculous lesions in the urinary tract. The study period was between 1982-1987. The presenting symptoms were protean, and there were often delays between onset of symptoms and eventual diagnosis. The highest age incidence was in the second and fourth decades. Beside the suggestive clinical manifestations, final diagnosis was reached by various means. Repeated examinations of EMU smears were positive in about 2 0 ~ of cases. Urine culture was positive in 33.3~, while varied percentage of cases showed some radiologieal changes suggestive of tuberculosis. Other investigations included cystoscopy and biopsy of suspected lesions. Treatment was conservative by chemotherapy in 45~ of cases, with complete xecovery in about 33~, while acceptable results were shown in ~_19~, and failure of treatment or recurrence of active disease in 48~ of cases. Some forms of surgical intervention were carried out in 55~ of patients. Cute was seen in 50~ of them, while 25~ had acceptable results and failure was shown in the remaining 25~. It is concluded that urinary tuberculosis remains an important infectious disease problem in our country. The high rate of failure of both medical or surgical treatment is mainly due to late diagnosis.
Introduction I n the w o r l d at large a b o u t 10 million persons each y e a r still continue to develop tuberculosis, a n d at least three million die f r o m this disease [1 ]. I n rich countries, tuberculosis has ceased to represent a p u b l i c health p r o b l e m in c o n t r a s t to the situation in d e v e l o p i n g countries [2]. It was suggested t h a t the m a g n i t u d e o f the tuberculosis p r o b l e m c a n be m e a s u r e d t h r o u g h tuberculosis prevalence surveys [3]. H o w e v e r , i m p l e m e n t a t i o n o f such surveys is rarely a d o p t e d in developing countries because o f the relatively high cost a n d the necessity for skilled, enthusiastic a n d d e v o t e d m a n p o w e r . The m a g n i t u d e o f the p r o b l e m is d e m o n s t r a t e d by the occasional i n d i v i d u a l reports, like this one. M a n y w o r k e r s in rich countries, like the U n i t e d States a n d E n g l a n d , have i n d i c a t e d a fall in incidence o f p u l m o n a r y tuberculosis which has n o t been reflected in e x t r a p u l m o n a r y lesions, especially u r o g e n i t a l tuberculosis [4-7]. I n a preVSP, Utrecht Akad~miai Kiad6, Budapest
472
S h a m m a a et al. : Urinary tuberculosis
vious work we tried to show the seriousness of the problem of extrapulmonary tuberculosis in our area by presenting our experience with 50 cases of tuberculous meningitis in children [8, 9]. In this study, we aim to demonstrate our experience with 48 cases of confirmed urinary tuberculosis. We wish to emphasize, especially to general practitioners, that if looked for, many cases of urogenital tuberculosis could be discovered. It is not, as sometimes quoted, "a once in a lifetime diagnosis" [10]. Patients and methods
Aleppo University Hospital is a 600-bed state-supported teaching hospital that serves as the main teaching facility for Aleppo Medical School. Most patients are accepted from outpatient clinics and they come from Aleppo city and the Northern provinces of Syria, a population of about 2 million. The study period started in July 1982 and ended in July 1987. Patients considered to have urinary tuberculosis and fulfilling all or most of the following criteria were included in this study: (1) Clinical manifestations compatible with tuberculous infection and identification of M. tuberculosis by direct smear or culture of urine; (2) imaging procedures suggestive of urinary tuberculosis; (3)biopsy or surgical specimen revealing histological changes compatible with TB; (4) clinical and radiological data compatible with urinary tuberculosis and showing response to antituberculous treatment. Full clinical history and complete examination were carried out in each patient. The following investigations were done in all or most of our cases: 1. microscopical examination and culture of 3 samples of EMU; 2. plain X-ray of the chest and abdomen; 3. i.v. pyelography for all patients and other imaging procedures for selected cases; 4. cystoscopy and biopsy of suspected lesions (25 cases); 5. full haematology profile on Technicon haemalog 8; 6. biochemical profile on Technicon SMA 12/60, including kidney and liver functions. Treatment
Chemotherapy - All patients received isoniazid (5 mg/kg/day) plus rifampicin (10 mg/kg/day) for a period of 9 months. - In the first 3 months of the course, streptomycin i.m. (1 g/day) was given or ethambutol (15 mg/kg/day), according to the tolerance of the patient. - Three patients with advanced condition and poor clinical state had only isoniazid and ethambutol for 2 years. International Urology and Nephrology 24, 1992
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Therapy was handled to the patients free of charge, on a weekly basis from outpatient clinics. This was a means of checking the taking of therapy and for follow-up.
Suryery Surgical intervention included unilateral nephrectomy, partial nephrectomy, augmentation cystoplasty, ureteral dilatation, and ileal reconstruction of the ureter. Throughout the duration of treatment, patients were examined and investigated at least once during the first month and every three months thereafter. Care was given to any changes in liver or kidney functions. Patients were advised to report to hospital on noticing symptoms like nausea, vomiting, jaundice or marked asthenia. Results
Epidemiology and clinicalfeatures During the study period, 48 patients were diagnosed as having urinary tuberculosis (29 males and 19 females, with a ratio of 1.52 : 1). The age distribution is shown in Table 1. The presenting symptoms in descending order of frequency were dysuria and frequency of urination, colics and vague pain in the renal angles, haematuria, malaise, fever, fatigue and weight loss, as summarized in Table 2. Persistence of complaints before diagnosis varied from a few months to a few years. Delay in diagnosis to more than one year was seen in about half of the patients (Table 3). Table 1 Age distribution Age group (years)
Number of patients
Per cent
70
1 8 14 13 6 3 2 1
2 16.6 29.1 27.1 13.5 6.3 4.1 2.0
Total
48
100
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Table 2 Main presenting symptoms Symptoms
Number
Per cent
37 37
77.0 77.0
23 15 15 12 10 3 2
47.9 31.2 31.2 25.0 20.8 6.2 4.1
Frequency Dysuria Renal colic and vague lower back pain Frank haematuria Fever Anorexia and loss of weight Night sweating Mass in loin Oliguria Table 3
Persistence of complaints before establishing the diagnosis Persistence 2
months months years years Total
Number of patients
Per cent
3 21 11 13
6.2 43.7 22.9 27.0
48
Investigations
The investigations were protean and are summarized in Table 4. Although only about 33 % of patients had positive cultures of M. tuberculosis and 21% positive smears from the three E M U samples, yet diagnosis was established by one or the other criteria. Plain X-rays of the abdomen showed few changes in one third of the cases, mainly calcification in the renal area or along the course of the ureters. On the other hand, i.v. urography showed many features like nonfunctioning kidney (50%), distortion and atypical calyces in one or more poles (30 %), hydronephrosis (25 %), stenosis of ureter (33 %), while normal appearance was seen in 12.5 ~ of cases. The bladder showed various alterations like defects on one side of the wall (37.5~), thick and irregular outlines (18.7~) and contracted bladder (10.4 ~). Cystoscopy was done for 27 patients; only three of them showed no apparent pathological changes. Patchy cystitis was seen in 11 patients (40.7 ~), small capacity in 7 (25.9 ~), tubercles and granulation tissue in 9 (33.3 ~). International Urology and Nephrology 24, 1992
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Biopsy was done for 25 patients during cystoscopy. The histological changes were compatible with the diagnosis of tuberculosis in 15 cases. Cystoscopy a n d biopsy were repeated in patients with negative results a n d five of t h e m were positive in the second setting. D a t a of associated extraurinary tuberculosis in the studied group are s h o w n in Table 5. Table 4 Procedures adopted in establishing the diagnosis Positive findings Number done n u m b e r per cent type
Investigation
3 EMU (direct smear)
48
10
20.8
Culture of urine
48
16
33.3
Plain X-ray of chest
48
8
16.6
Plain X-ray of abdomen bilateral renal calcification unilateral renal calcification calcification along the ureter
48
14
29.2
Intravenous pyelogram no abnormality detected no secretion of dye in one kidney various findings suggestive of T.B.
48
Cystoscopy normal bladder patchy cystitis small capacity tubercles and granulation tissue ulceration
27
Biopsy during cystoscopy positive in 1st biopsy positive in 2nd biopsy
25
1 10 3 42
87.5 6 24 18
24
88.0 3 11 7 9 6
20
80.0 15 5
Table 5 Extraurinary foci of tuberculosis Site
Pulmonary tuberculosis Female genital system Male genital system Skeletal Cold abscess 2
Number of patients
8 3 3 1 1
Per cent
16.6 6.2 6.6 2.0 2.0
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Treatment
Treatment was either conservative by the usual chemotherapeutic regime (45 %), or by some sort o f surgical intervention (55 %). Indications for conservative treatment were early tuberculous lesions, bilateral foci, or late stage of chronic renal failure. In 26 patients (54.2 %), drug therapy was combined with some sort of surgical treatment as shown in Table 6. Indications for nephrectomy were non-functioning kidney, advanced destructive lesion, or failure of conservative treatment. Complications following surgical treatment are summarized in Table 7. Lastly, the overall outcome of treatment after a mean period o f about three years' follow-up is summarized in Table 8. These results indicate failure of both therapeutic and surgical treatments in one third o f patients. This high percentage is probably due to the late diagnosis of the disease. Table 6 Type of surgical intervention Type o f surgery
Number
Nephrectomy Partial nephrectomy Ureteral dilatation Ileal reconstruction of ureter Augmentation cystoplasty Fistulectomy
19 1 1 1 4 2
Per cent
73.0 3.8 3.8 3.8 15.3 7.6
Table 7 Surgical complications Type o f complication
Massive bleeding Wound infection Failure to remove kidney, taking biopsy only Injury of pleura Injury of suprarenal Injury of inferior vena cava Injury of duodenum Fistula Immediate postoperative death
International Uroloyy and Nephroloyy 24, 1992
Number
Per cent
3 3
11.5 11.5
3 3 1 1 1 2 1
11.5 11.5 3.8 3.8 3.8 7.6 3.8
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S h a m m a a et aL : Urinary tuberculosis
Table 8 Results of treatment Result
Recovery (complete disappearance of signs and symptoms) Partial amelioration of signs and symptoms Failure of treatment or recurrence of manifestations Total
Chemotherapy (con= servative)
Surgery combined with drug therapy
8
13
4
7
10
6
22
26
Discussion The diagnosis of urinary tuberculosis could be more difficult to establish than pulmonary tuberculosis because of the nonspecific manifestations of the disease and the lack o f simple screening tests such as chest radiograph [7]. A more important factor in missing the diagnosis of urinary tuberculosis is that many general practitioners think of the condition as a rarity and forget to put it in the differential diagnosis of conditions such as sterile pyuria, recurrent urinary infection of unknown origin, haematuria of undetermined origin, and people who are known to have contacts with tuberculous patients [10]. This prospective study was planned to demonstrate our experience in the diagnosis and treatment of urinary tuberculosis. Males predominated over females in a ratio of 1.5 : 1 and the majority of patients were 20-40 years of age. This agrees with many other studies [11-13]. This means that the disease attacks the young, more active and productive strata of the community. However, few reports indicate a change in age incidence towards older age groups [14]. The presenting symptoms o f frequency, dysuria, renal colic, lower back pain, and haematuria, separately or in combination, occurred in different proportions from 20-56 % of the time [15, 16]. The absence of urinary manifestations in a fair number of cases, and the low percentage of patients with the general symptoms of tuberculosis such as anorexia, weight loss, night sweating etc., are probably the main causes of delay in the diagnosis o f urinary tuberculosis in this series as well as in others [7, 17]. This delay is sometimes justified due to absence o f specific and general manifestations and the lack of experienced persons and diagnostic tools to isolate, identify and culture the bacilli. However, in a fair number of cases the delay in diagnosis could be avoided by awareness of the presence of tuberculosis in suspected cases and by training technicians in developing countries about the methods of identification and culturing of bacilli [17]. The late diagnosis in this series, and in the third world in general, is reflected on the outcome of treatment. 2*
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S h a m m a a et aL : Urinary tuberculosis
In this study, urine examination and cultures were positive in only 33 ~ of cases. Few other studies, even in developed countries, have shown that a significant proportion of urine screenings and cultures are negative in such patients. However, this proportion is definitely higher in developing countries. This is mainly due to lack of experienced technicians and absence of reference laboratories. The second tool of investigation in this study were the different imaging procedures. It was not only important in suggesting the diagnosis, but also in delineating the extent and nature of the lesions and lastly in assessing the progress and repair process. In this study, about 8 8 ~ of i.v. pyelograms showed some radiological changes in one or both kidneys, ureters or urinary bladder. In a similar study done on 52 patients, Roylance and his associates [ 18] demonstrated that the renal abnormalities were found in almost all patients (98 ~), while abnormalities in ureters and bladder were found in 43 ~ and 33 ~ of cases, respectively. Calcifications in the renal area were found by Roylance et al. in 31 ~ of patients [18], similar to what we have found in our patients. Calcification along the course of the ureter was seen in three of our cases, a finding claimed to be rare and late in urinary tuberculosis [19]. Another important finding in our series was the large number (50 ~ ) that showed no secretion of the dye in one kidney. The cause of this may be explained by the late presentation of the patients. Cystoscopy and biopsy of suspected lesions were done in about half of the patients. This procedure was very helpful because in 20 out of 25 cases the histological changes were compatible with tuberculosis. Gow [23], in a review on genito-urinary tuberculosis, mentioned that bladder biopsy should only be carried out when there are tubercles or an ulcer distant from the normal ureteric orifice. Cystoscopy also helps in detecting patchy cystitis, ulceration, granulation tissue, tubercles - features suggestive of tuberculosis. Concerning treatment, very few reports have been published from developing countries. Our experience may therefore represent the state of affairs in the management of urinary tuberculosis in those areas. The following review is a summary of the most important points that could be deduced from our study. (a) Chemotherapy should be free of charge, as is the case in Syria. (b) Each hospital should adopt some way to make sure that the patients do take the drugs. This may be the most difficult part of treatment in developing countries [23]. (c) We think that the 9-month course with the previously mentioned drugs is effective in most cases. It is also more comfortable to both the patient and the hospital. (d) The bacteriological investigations, especially cultures and sensitivity testing, are insufficient in Syria and probably completely lacking in many of the developing countries. This situation should be corrected. Chemotherapeutic treatment of urinary tuberculosis is most encouraging if the disease is diagnosed early. Unfortunately, there remains a disturbingly high incidence presenting with advanced renal destruction, obstruction, strictures and contraction of the bladder, that necessitate different surgical interventions [12, 21]. In this study more than half of the patients were operated upon. The operations included 19 nephrectornies and only 7 reconstructive operations. The picture International Urology and Nephrolooy 24, 1992
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is different in developed countries where an increasing rate of reconstructive surgical procedures has been accompanied by a corresponding decline in the number of nephrectomies [21]. Conservative surgery is expensive, but its excellent long-term results [12, 21, 22] have justified the efforts and costs, and more of such operations are done in Syria. Conclusions
The following conclusions could be deduced from our experience in Syria, and may reflect at the same time the picture of urinary tuberculosis in other developing countries: 1. Urinary tuberculosis is not uncommon, but unfortunately many cases are not diagnosed. 2. When diagnosis is made, it is usually too late, and unjustified in a fair number of cases. 3. The delay in diagnosis is reflected in the high percentage of treatment failures. 4. Bacteriological investigations and sensitivity testing for TB bacilli should be given more attention in developing countries. References 1. Styblo, K., Rouillon, A. : Estimated global incidence of smear-positive tuberculosis" Unreliability of officially reported figures on tuberculosis. Bull. International Union Against Tuberculosis, 56, 118 (1981). 2. Waaler, H. T. : Tuberculosis in the world: V. Tuberculosis and socio-economic development. Bull. International Union Against Tuberculosis, 57, 202 (1982). 3. Shimao, T. : Tuberculosis in the world: III. Tuberculosis prevalence surveys. Bull. International Union Against Tuberculosis, 57, 126 (1982). 4. Bruce, L. G. : The incidence of genito-urinary tuberculosis in the western region of Scotland. Br. J. Urol., 42, 637 (1970). 5. Farer, L. S., Lowell, A. M., Meador, M. P.: Extrapulmonary tuberculosis in the United States. Am. J. EpidemioL, 109, 205 (1979). 6. Centers for disease control: Tuberculosis in the United States, 1980 (HHS publication No. CDC-83-83322). US Department of Health & Human Services, Atlanta 1983. 7. Weir, M. R., Thornton, G. F. : Extrapulmonary tuberculosis: Experience of a community hospital and review of the literature. Am. J. Med., 79, 467 (1985). 8. Hadidy, S., Aktaa, A., Matar, A., Zakeria, A. : Tuberculous meningitis in Northern parts of Syria : Epidemiology. Garyounis Med. J., 8, 29 (1985). 9. Hadidy, S., Aktaa, A., Matar, A., Zakeria, A. : Tuberculous meningitis in Northern parts of Syria: II. Results of investigations and treatment. Garyounis Med. J., 8, 35 (1985). 10. Jafri, M. A. : Once in a life-time; urinary tuberculosis. Postgrad. Doctor (Middle East), 7, 198 (1984). 11. Venugopa, A.: Tuberculosis of genito-urinary tract. In: K. N. Rao (ed.): Textbook of Tuberculosis. Vikas Publishing House PVT Ltd., India 1981, pp. 434-454. 12. O'Flynn, D. : Surgical treatment of genito-urinary tuberculosis. Br. J. Urol., 42, 667 (1970). 13. Gow, J. G. : Results of treatment in a large series of cases of genito-urinary tuberculosis and the changing pattern of the disease. Br. J. Urol., 42, 647 (1970). International Urology and Nephrology 24, 1992
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14. Borthwick, W. M. : Present position of urinary tuberculosis. Br. J. UroL, 42, 642 (1970). 15. Christensen, W. I. : Genito-urinary tuberculosis: Review of 102 cases. Medicine (Baltimore), 53, 377 (1974). 16. Simon, H. B., Weinstein, A. J., Pasternak, M. S. : Genito-urinary tuberculosis. Clinical features in a general hospital population. Am. J. Med., 63, 410 (1977). 17. Page, M. I., Lunn, J. S. : Experience with tuberculosis in a public teaching hospital. Am. J. Med., 77, 667 (1984). 18. Roylance, J., Penry, B., Davies, R., Roberts, M. : Radiology in the management of urinary tract tuberculosis. Br. J. UroL, 42, 679 (1970). 19. Friedenberg, R. M., Ney, C., Stechenfeld, R. A.: Roentgenographic manifestation of tuberculosis of ureter. J. UroL, 99, 25 (1968). 20. Fox, W. : The current state of short course chemotherapy. Tubercle, 60, 177 (1979). 21. Kerr, W. K., Gale, G. L., Peterson, K. S. S.: Reconstructive surgery for genito-urinary tuberculosis. J. UroL, 101, 254 (1969). 22. Kerr, W. K., Gale, G. L., Struthers, N. W. : Prognosis in reconstructive surgery for urinary tuberculosis. Br. J. UroL, 42, 672 (1970). 23. Gow, J. G.: Genito-urinary tuberculosis. Postgrad. Doctor (Middle East), 8, 37 (1985).
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