Clinical Classification of Bladder Tuberculosis | Surgsci

Overview:

Bladder tuberculosis, also known as tuberculosis of the bladder, is a chronic, progressive, and destructive condition caused by infection with Mycobacterium tuberculosis. It often occurs as a secondary infection following renal tuberculosis, and in rare cases, it can spread from prostatic tuberculosis. Initial symptoms include urinary frequency, which gradually worsens along with urgency, dysuria, and hematuria. Systemic symptoms such as low-grade fever and night sweats may also be present. Clinically, treatment primarily involves adequate and prolonged administration of anti-tuberculosis drugs, with surgical intervention if necessary.

Epidemiology:

Infectiousness: Bladder tuberculosis is considered non-infectious in most cases, as it is an extrapulmonary form of tuberculosis. However, if a patient has concurrent pulmonary tuberculosis, transmission can occur through respiratory routes.

High-Risk Groups:

Young adults with a history of pulmonary or renal tuberculosis.

Immunocompromised individuals.

Trends in Incidence: While authoritative data on the incidence trend of bladder tuberculosis is lacking, it is worth noting that overall tuberculosis rates have decreased due to improved living standards, environmental awareness, and vaccine promotion. However, recent increases in drug-resistant Mycobacterium tuberculosis, population mobility, and HIV prevalence have led to a resurgence of global tuberculosis cases.

Basic Etiology:

Pathogen: Bladder tuberculosis results from invasion by Mycobacterium tuberculosis, the causative agent of tuberculosis. These slender, slightly curved acid-fast bacilli are obligate aerobes with an optimal growth temperature of 37°C. Although they can affect various organs, pulmonary tuberculosis remains the most common form.

Route of Infection: Mycobacterium tuberculosis enters the bladder via the respiratory tract and subsequently disseminates through the bloodstream to the kidneys, eventually reaching the bladder via urine flow.

Risk Factors:

Poor living conditions and economic disadvantage increase the risk of infection.

Individuals with underlying conditions such as diabetes, silicosis, or whooping cough are at higher risk.

Immunosuppressed individuals or those receiving steroid or immunosuppressive therapy are also more susceptible to infection.

Typical Symptoms:

Bladder Irritation Symptoms:

Initial symptoms include urinary frequency, urgency, and dysuria.

Nocturia increases gradually, with nighttime voiding occurring 3–5 times initially and later escalating to 10–20 times.

Severe bladder mucosal damage may cause burning or painful sensations during urination.

Hematuria:

Hematuria is usually microscopic or occasionally visible as gross hematuria with clots.

Bladder contraction during voiding leads to ulceration and bleeding.

Terminal hematuria is common.

Pyuria:

Severe cases may exhibit urine containing cheesy material, appearing turbid like rice soup.

Occasionally, blood-tinged or purulent urine may be present.

Systemic Symptoms:

Patients with active systemic tuberculosis may experience fatigue, low-grade fever, and night sweats.

Complications:

Bladder Contraction:

Tuberculous bladder contraction results from severe fibrosis due to involvement of the bladder muscle layer.

Hydronephrosis:

Tuberculosis-related bladder narrowing and contraction can obstruct urine flow, leading to hydronephrosis.

Spontaneous Rupture of Tuberculous Bladder:

A late-stage complication characterized by full-thickness bladder wall involvement, resulting in caseous necrosis and thinning of affected tissue.

Patients may experience sudden abdominal pain without external trauma.

Genitourinary Tuberculosis:

Mycobacterium tuberculosis can enter the male reproductive system via the prostatic ducts, ejaculatory ducts, causing prostatitis, seminal vesiculitis, epididymitis, and orchitis.

Diagnostic Workup:

Laboratory Tests:

Urinalysis reveals acidic urine, positive urine protein, and increased red and white blood cells.

Acid-fast staining of urine sediment detects mycobacteria in approximately 50%–70% of cases.

Urine culture for tuberculous bacilli (takes 4–8 weeks) is crucial for diagnosing renal tuberculosis.

Tuberculin Skin Test:

Evaluates type IV hypersensitivity response to tuberculin antigen, indicating exposure to tuberculosis or response to BCG vaccination.

Urinary Tract Plain Film + Intravenous Urography (IVU):

Urinary Tract Plain Film (UTPF): UTPF is useful for observing bladder calcifications.

Intravenous Urography (IVU): IVU provides information about renal function, the extent of lesions, and the affected areas.

MRI:

MRI with water imaging is particularly valuable for diagnosing concurrent renal tuberculosis and assessing the presence of hydronephrosis.

Other Examinations:

Cystoscopy:

A specialized procedure involving the insertion of an instrument with a light source through the urethra to visualize changes within the bladder. Cystoscopy allows observation of bladder mucosal lesions, measurement of bladder volume, and collection of clean urine samples for further examination. Typical findings of tuberculous cystitis during cystoscopy include the formation of tuberculous nodules or varying-sized ulcerated areas on the mucosa.