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International Journal of Urology (2014)
Editorial Comment Editorial Comment to Nationwide survey of urogenital tuberculosis in Japan Urogenital tuberculosis (UGT) has two main features: diagnostic challenge and the possibility of complete urogenital tract destruction. The latter is the consequence of the former, when the delay of initiation of pharmacological treatment leads to the infection progression and urogenital destruction.1 UGT diagnostic difficulty is caused by the lack of familiarity with the disease because of its rarity, and the lack of UGTspecific symptoms, making the clinical suspicion more difficult. Even with UGT suspicion, the most used and accessible urinary examinations (Ziehl–Neelsen’s acid-fast staining technique or urine culture in Lowenstein–Jensen medium) have low sensibility.2 Therefore, the article by Nakane et al. is highly relevant to the urological community in Japan and worldwide to highlight that although rare, UGT is alive and must be known and remembered.3 In the present article, 355 UGT cases are described showing the features of the disease with data according to other UGT patients series.4 There is a well-established knowledge of UGT physiopathology and the disease evolution sequence. Initially from a pulmonary lesion, hematogenous dissemination of bacilli and colonization of the kidney or prostate parenchyma occurs. In this phase, in immunocompromised patients, a rare UGT form might appear with kidney or prostate parenchymal abscess and systemic symptoms. However, the great majority of patients have no symptoms in this dissemination phase, and might never develop UGT with cicatrization of these tuberculosis lesions. In patients who develop UGT, a reactivation of the infection after a mean latent period of 22 years (range 1–46 years) occurs in the prostate, epididymides or, most frequently, in just one kidney, sparing the other kidney. This accounts for the greater frequency of unilateral renal tuberculosis. Contiguous involvement of the urinary collecting system leads to bacilluria, and ureter, bladder and genital organ infection. The most suggestive UGT radiological finding is an unilateral non-function kidney with multiple urinary collecting system stenosis. Bladder tuberculosis in advanced cases develops a contracted state with fibrosis and eventually vesicoureteral reflux to the contralateral
© 2014 The Japanese Urological Association
kidney. Therefore, the tuberculosis infection goes down from one kidney to the ureter and bladder, and then goes up to the other kidney through reflux.1,2 This knowledge could facilitate the identification of UGT and increases its clinical suspicion. Our last point is a practical one. We recommend that a systematic search of UGT should be carried out in the following situations: investigation of hematuria; persistent storage symptoms; chronic pelvic pain or bladder pain syndrome; recurrent cystitis in females; epidydimal hardening or scrotal fistula in men on physical examination; persistent sterile pyuria; and a non-functional kidney without obvious cause. This search is more efficient, with higher specificity and sensibility with polymerase chain reaction for Mycobacterium tuberculosis identification in the urine. André Avarese Figueiredo M.D., Ph.D. Surgery Department, Medical School, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil [email protected] DOI: 10.1111/iju.12581
Conflict of interest None declared.
References 1 Figueiredo AA, Lucon AM, Falci Junior R, Srougi M. Bladder augmentation for the treatment of chronic tuberculous cystitis. Clinical and urodynamic evaluation of 25 patients after long term follow-up. Neurourol. Urodyn. 2006; 25: 433–40. 2 Figueiredo AA, Lucon AM. Urogenital tuberculosis: updating and review of 8961 cases from the world Literature. Rev. Urol. 2008; 10: 207–17. 3 Nakane K, Yasuda M, Deguchi T et al. Nationwide survey of urogenital tuberculosis in Japan. Int. J. Urol. 2014; doi: 10.1111/iju.12549. 4 Figueiredo AA, Lucon AM, Falci Junior R, Srougi M. Epidemiology of urogenital tuberculosis worldwide. Int. J. Urol. 2008; 15: 827–32.
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International Journal of Urology (2014)
Editorial Comment Editorial Comment to Nationwide survey of urogenital tuberculosis in Japan Urogenital tuberculosis (UGT) has two main features: diagnostic challenge and the possibility of complete urogenital tract destruction. The latter is the consequence of the former, when the delay of initiation of pharmacological treatment leads to the infection progression and urogenital destruction.1 UGT diagnostic difficulty is caused by the lack of familiarity with the disease because of its rarity, and the lack of UGTspecific symptoms, making the clinical suspicion more difficult. Even with UGT suspicion, the most used and accessible urinary examinations (Ziehl–Neelsen’s acid-fast staining technique or urine culture in Lowenstein–Jensen medium) have low sensibility.2 Therefore, the article by Nakane et al. is highly relevant to the urological community in Japan and worldwide to highlight that although rare, UGT is alive and must be known and remembered.3 In the present article, 355 UGT cases are described showing the features of the disease with data according to other UGT patients series.4 There is a well-established knowledge of UGT physiopathology and the disease evolution sequence. Initially from a pulmonary lesion, hematogenous dissemination of bacilli and colonization of the kidney or prostate parenchyma occurs. In this phase, in immunocompromised patients, a rare UGT form might appear with kidney or prostate parenchymal abscess and systemic symptoms. However, the great majority of patients have no symptoms in this dissemination phase, and might never develop UGT with cicatrization of these tuberculosis lesions. In patients who develop UGT, a reactivation of the infection after a mean latent period of 22 years (range 1–46 years) occurs in the prostate, epididymides or, most frequently, in just one kidney, sparing the other kidney. This accounts for the greater frequency of unilateral renal tuberculosis. Contiguous involvement of the urinary collecting system leads to bacilluria, and ureter, bladder and genital organ infection. The most suggestive UGT radiological finding is an unilateral non-function kidney with multiple urinary collecting system stenosis. Bladder tuberculosis in advanced cases develops a contracted state with fibrosis and eventually vesicoureteral reflux to the contralateral
© 2014 The Japanese Urological Association
kidney. Therefore, the tuberculosis infection goes down from one kidney to the ureter and bladder, and then goes up to the other kidney through reflux.1,2 This knowledge could facilitate the identification of UGT and increases its clinical suspicion. Our last point is a practical one. We recommend that a systematic search of UGT should be carried out in the following situations: investigation of hematuria; persistent storage symptoms; chronic pelvic pain or bladder pain syndrome; recurrent cystitis in females; epidydimal hardening or scrotal fistula in men on physical examination; persistent sterile pyuria; and a non-functional kidney without obvious cause. This search is more efficient, with higher specificity and sensibility with polymerase chain reaction for Mycobacterium tuberculosis identification in the urine. André Avarese Figueiredo M.D., Ph.D. Surgery Department, Medical School, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil [email protected] DOI: 10.1111/iju.12581
Conflict of interest None declared.
References 1 Figueiredo AA, Lucon AM, Falci Junior R, Srougi M. Bladder augmentation for the treatment of chronic tuberculous cystitis. Clinical and urodynamic evaluation of 25 patients after long term follow-up. Neurourol. Urodyn. 2006; 25: 433–40. 2 Figueiredo AA, Lucon AM. Urogenital tuberculosis: updating and review of 8961 cases from the world Literature. Rev. Urol. 2008; 10: 207–17. 3 Nakane K, Yasuda M, Deguchi T et al. Nationwide survey of urogenital tuberculosis in Japan. Int. J. Urol. 2014; doi: 10.1111/iju.12549. 4 Figueiredo AA, Lucon AM, Falci Junior R, Srougi M. Epidemiology of urogenital tuberculosis worldwide. Int. J. Urol. 2008; 15: 827–32.
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