Tuberculosis of the Urinary Tract

TUBERCULOSIS OF THE URINARY TRACT

Pathophysiology

Tuberculosis of the urinary tract is caused by the organism Myco-bacterium tuberculosis and is relatively rare in developed countries.The organism usually travels from the lungs by means of the blood-stream to the kidneys. On arrival in the kidney, the microorganism may lie dormant for years. After the organism reaches the kidney, a low-grade inflammation and the characteristic tubercles are seen.

If the organism continues to multiply, the tubercles enlarge to form cavities, with eventual destruction of parenchymal tissue. The or-ganism spreads down the urinary tract into the bladder and may also infect the prostate, epididymis, and testicles in men.

Clinical Manifestations

At first, the signs and symptoms of renal tuberculosis are mild; there is usually a slight afternoon fever, weight loss, night sweats, loss of appetite, and general malaise. Hematuria (microscopic or gross) and pyuria may be present. Pain, dysuria, and urinary fre-quency, when they occur, are due to bladder involvement. Cav-ity formations and calcifications may be noted on an intravenous urogram.

Assessment and Diagnostic Findings

A search for tuberculosis elsewhere in the body is conducted when tuberculosis of the kidney or urinary tract is found. The patient is asked about possible exposure to tuberculosis. Three or more clean-catch, first-morning urine specimens are obtained for culture for M. tuberculosis. The erythrocyte sedimentation rate is usually elevated and is helpful in monitoring response to treatment.

Other diagnostic studies include intravenous urography, bi-opsy, and urine culture for acid-fast bacilli. Recent studies have shown that the polymerase chain reaction (PCR) provides a much faster diagnosis of urinary M. tuberculosis. It is a rapid, sensitive, and specific diagnostic method and avoids a delay in starting treatment (Hemal, Gupta, Rajeev et al., 2000).

Medical Management

The goal of treatment is to eradicate the offending organism. Combinations of ethambutol, isoniazid, and rifampin are used to delay the emergence of resistant organisms. Shorter-course che-motherapy (4 months) has been effective in eradicating the or-ganism and in penetrating renal tissue. Surgical intervention may be necessary to treat obstruction and to remove an extensively dis-eased kidney. Because renal tuberculosis is a manifestation of a systemic disease, all measures to promote the general health of the patient are taken, including proper nutrition, adequate rest, and good hygiene practices. A scrotal support may be used by male patients with genital swelling.

Nursing Management

For the most part, nursing interventions focus on patient educa-tion to promote effective self-care at home and to prevent active recurrence or transmission of disease.

Instructions are provided about taking prescribed medications properly, recognizing adverse effects, and understanding the im-portance of completing the course of therapy. Instructions are also given regarding the nature of tuberculosis; its cause, spread, and treatment; and necessary follow-up care. Men are instructed to use condoms during sexual intercourse to prevent spread of the organisms; those with penile or urethral tuberculosis are in-structed to abstain from intercourse during treatment. The patient is encouraged to maintain a healthy lifestyle with a well-balanced diet, adequate intake of fluids, and exercise.

Follow-up care is essential to reinforce the importance of tak-ing medications exactly as prescribed (many patients do not take them correctly). The patient is counseled about the need for follow-up examinations (urine cultures, intravenous urograms), usually for 1 year. Treatment is reinstituted if a relapse occurs and the tubercle bacilli again invade the genitourinary tract. Because ureteral stenosis or bladder contractures may develop during heal-ing, the patient is monitored for these complications.