Special cases

Special cases

Genitourinary tuberculosis Genitourinary tuberculosis (GU-TB) caused by Mycobacterium tuberculosis can a ff ect any part of the urinary tract. Renal calci fication and ureteric strictures are typical in the upper urinary tract. In the bladder, initial manifestations include a red, oedematous bladder wall with ulceration and visible tubercles (yellow lesions with a red halo). This typically starts around the ureteric orifices and trigone . As the disease progresses, fibrosis and contraction of the bladder occur (‘thimble bladder’), as well as calcification and fistula formation ( Figure 83.31 Patients may present with fevers, weight loss, night sweats, UTI symptoms or haematuria. Investigation may reveal a ster ile pyuria, and cystoscopy with biopsy will confirm the diagno sis. Three early mor ning urine samples for acid-fast bacilli or polymerase chain reaction of the urine can be used for diag nosis of TB infection. Cross-sectional imaging with a CT uro gram should be performed to evaluate the kidneys and ureter as they are likely to also be a ff ected. Treatment consists of antituberculous therapy with isonia zid, rifampicin, pyrazinamide and ethambutol. Severe bladder disease may r equire surgical treatment following completion of antituberculous therapy . Options include augmentation enterocystoplasty , cystectomy and orthotopic bladder substi tution, or ileal conduit urinary diversion. However, the choice of treatment will depend upon the concomitant upper tract involvement and patient preferences. Schistosomiasis Parasitic infection with the trematode Schistosoma haematobium endemic in Egypt, parts of Africa, Israel, Syria, Saudi Arabia, Iran, Iraq and the shores of China’s great lakes. The parasite penetrates the skin and travels to the liver (as schistosomules), where it matures. Adult trematodes migrate to vesical veins and lay eggs (containing miracidium larvae), which leave the body by penetrating the bladder and entering the urine. The active phase is when eggs are actively being laid, whereas the inactive phase is when the adult has died but there is an ongoing reac - tion to the remaining eggs. At the time of infection, a local inflammatory response leads to irritation of the skin (‘swimmer’s itch’). Acute fever (Katayama fever) may ensue at the onset of egg laying (3 weeks to 4 months after infection) with fever, lymphadenopathy , sple - nomegaly and eosinophilia. When the eggs are deposited in the bladder, the typical bladder symptoms of intermittent painless haematuria and terminal dysuria occur. Chronic infection can lead to a small, contracted, fibrotic bladder similar to that seen with tuberculous cystitis. Patients ar e at increased risk of devel - oping ureteric strictures, urethral strictures and squamous cell carcinoma of the bladder. Investigation with midday (to coincide with the time of maximum egg shedding) urine microscopy may show charac - teristic eg gs with terminal spines ( Figure 83.32 ). Cystoscopy may show characteristic ‘sand y patches’ at the trigone (due to calcified dead ova with degeneration of the overlying urothe - lium), ulcera tion or papillomas. In advanced cases, carcinoma may be present. Bladder or rectal biopsies may identify eggs. - ). - - - - s - -

Figure 83.32 Schistosoma haematobium eggs with terminal spines. (Reproduced with permission from Ray D, Nelson TA, Fu CL et al . Transcriptional pro /f_i ling of the bladder in urogenital schistosomiasis reveals pathways of in /f_l ammatory /f_i brosis and urothelial compromise. PLoS Negl Trop Dis 2012; 6 (11): e1912.)

identified, serology (enzyme-linked immunosorbent assay [ELISA]) has high sensitivity and specificity . A CT urogram should be performed to assess for obstructive uropathy second ary to a scarred, contracted bladder. Treatment is with praziquantel 20 /uni00A0 mg/kg in two divided doses 4–6 hours apart. A small, contracted bladder may require reconstruction with augmentation enterocystoplasty , cystectomy and orthotopic bladder substitution, or ileal con duit urinary diversion. Summary box 83.5 Urinary tract infections /uni25CF /uni25CF

UTIs can be classi /f_i ed as uncomplicated or complicated Patients should undergo evaluation for TB and schistosomiasis if suspected based on the history or presence of persistent sterile pyuria