Sexually Transmitted Diseases - I. I. Mavrov 2005

Genital Tuberculosis
Tuberculous diseases of the genital organs in men

This disease is frequently encountered in urological practice (5-10%). Tuberculosis can involve all Male reproductive Organs in the pathological process: the Penis, Urethra, Testes, epididymides, vas deferens, Prostate Gland, and Seminal Vesicles.

The infection often spreads to the reproductive tract from a tuberculous focus in the Kidney (urinogenic origin of Genital Tuberculosis). Within the Reproductive System, it can spread via both ascending and descending pathways (along the vas deferens). Lymphogenic spread of infection to the reproductive system may occur when the process extends from any adjacent focus, such as from an affected Urinary Bladder to the prostate or Seminal Vesicle.

However, intracanalicular penetration of Mycobacterium tuberculosis from the urethra cannot be ruled out either. Sexual transmission of the infection is also possible. This is indirectly supported by the fact that 70% of male patients with genital tuberculosis are between 20 and 40 years of age. Functional sexual inactivity significantly reduces the incidence of genital tuberculosis.

Tuberculosis of the penis is an extremely rare condition, presenting as dense, non-healing ulcers that may be accompanied by tuberous, nodular proliferations (see Plate XII, 5). Prior to the advent of modern pharmacotherapy, the disease in the vast majority of cases resulted from primary infection during ritual circumcision (removal of the prepuce). Other cases of primary penile tuberculosis can be attributed to sexual transmission. Sometimes the disease is the result of secondary spread of infection in extensive urethral lesions. Hematogenous dissemination to the corpora cavernosa is less common.

Tuberculous urethritis. It is characterized by nonspecific clinical manifestations. Dysuria, Urinary Incontinence, periurethral abscesses, or multiple urinary fistulae in the perineal region are noted. The disease is invariably associated with some form of tuberculous lesion in the urogenital tract. It frequently arises when preceded by underlying urethral pathology.

Unusual manifestations of genitourinary tuberculosis: tumor-like masses in the Perineum (likely resulting from secondary lymphatic spread of the infection); rectovesicocutaneous fistulae; hemospermia, and nephrobronchial fistulae (see Plate XII, 4, 5).

Prostatic tuberculosis. It has been established that the primary focus of tuberculous infection is located in the prostate gland more frequently than in other reproductive organs. This is explained by the rich Blood and Lymphatic supply of the prostate and its Location at the crossroads of the URINARY AND REPRODUCTIVE tracts, whereby mycobacteria from various foci easily enter the prostate gland. Involvement of this organ is detected in 45-50% of patients with genital tuberculosis.

Prostatic tuberculosis typically coexists with involvement of the seminal vesicles and epididymides. In Renal tuberculosis, the prostate is involved in more than 50% of cases, and in Pulmonary Tuberculosis, in 77% of patients.

Symptoms of prostatic tuberculosis are mild, especially in the Cytology/cytology/16.html">Early stages of the disease. Patient Complaints mainly boil down to discomfort in the perineal and anal regions. With more significant involvement, perineal pain during defecation and urethral pus discharge join the picture. A typical finding is the presence of Mycobacterium tuberculosis in the prostatic secretion.

If the tuberculous lesion is located closer to the urethra, dysuric symptoms occur: frequent, difficult urination, especially at night, and painful sensations at the end of or during urination (in 16.3% of patients). Terminal or initial Hematuria is occasionally observed, less frequently hemospermia (red or chocolate-colored semen), and more commonly pyospermia. Ejaculation becomes painful in prostatic tuberculosis. Hemospermia and pyospermia indicate involvement of the seminal vesicles, although they may occur even in their absence.

Of great importance in the Diagnosis OF GENITAL tuberculosis is the detection of aseptic pus in the semen (80-85% of cases). An especially crucial role is played by the analysis of prostatic secretion. Ascending and descending urethrography have a certain diagnostic value for prostatic tuberculosis.

The manifestations of tuberculosis of the prostate gland are often nonspecific, and physical examination findings may be similarly non-diagnostic. The affected prostate may be small and fibrotic, and in some cases soft due to the presence of a caseous focus. Occasionally, it presents with lateral nodular outgrowths. The course of prostatic tuberculosis is typically chronic with periodic exacerbations and prolonged remissions. The disease lasts for years and even decades.

Tuberculosis of the seminal vesicles. Seminal vesicles are involved in the process during Urogenital Tuberculosis more frequently (60-90% of cases) than commonly believed. A specific clinical picture is absent. Sometimes, tuberculosis of the seminal vesicles manifests as mild pain at the end of urination, urinary urgency, discomfort in the perineal region, or the appearance of blood in the semen. Ejaculation is painful in most cases.

A valuable objective diagnostic method is vesiculography. The most characteristic signs of tuberculosis are wrinkling and ulceration of The surface of the seminal vesicles. Tuberculous lesions of the seminal vesicles detected by vesiculography are observed in 60-65% of patients. The disadvantage of this method is that it requires a surgical Procedure, and patients are very reluctant to undergo it (puncture of the vas deferens requires its exposure). Vesiculography is used primarily in specialized medical institutions.

Tuberculosis of the testes, epididymides, and vas deferens. The disease occurs at any age—both in infants and the elderly—but in 50-70% of cases, it is observed in men aged 20-40 years.

Testicular tuberculosis without epididymal involvement is rarely noted (in young children, as well as in generalized Miliary tuberculosis). In 70-75% of cases, tuberculosis of the prostate and seminal vesicles is diagnosed alongside tuberculous epididymitis. In more than 90% of cases, the Epididymis of one Testis is initially affected, and only after some time (ranging from several months to several years) does the epididymis of the other testis become involved.

Isolated tuberculosis of the vas deferens does not occur. The tuberculous process extends to the duct from the epididymis or from the prostate gland and seminal vesicles. In the first case, tuberculous Changes in the duct are especially pronounced in its terminal segment adjacent to the epididymis; In the second case, in the pelvic segment. The middle portion is usually unaffected.

The wall of the duct is uniformly thickened and dense. Alternating thickened areas and unaffected segments of the duct are also observed. Tuberculosis of the vas deferens frequently leads to the obliteration of its lumen.

The most characteristic variant of genital tuberculosis is tuberculous epididymitis. Two Clinical forms of the disease are distinguished. In the first, chronic form (which is the most common), tuberculosis of the epididymis begins imperceptibly and runs an almost asymptomatic course. By the time a feeling of discomfort or mild soreness in the testicular region draws the patient's attention, a dense, nodular infiltrate of varying size or a localized node is already palpable in the epididymis. Such an onset of the disease is observed in the majority of cases. In 20-25% of cases, the disease develops acutely, presenting as acute epididymitis with severe pain, high fever, and a febrile state. The second form—acute inflammation of the epididymis—is accompanied by a hydrocele (effusion into the tunica vaginalis). The resulting Swelling exceeds the size of the testis several times over, the overlying Skin becomes swollen and reddened, and the volume of the corresponding hemiscrotum significantly increases.

In the first days, patients complain of pain along the Spermatic Cord and discomfort in the lumbar or iliac regions. The tumultuous course of the illness is short-lived; acute symptoms gradually subside—the skin pales, pain diminishes or ceases, and signs of periorchitis become less pronounced. By 10-15 days from the onset of the disease, its course assumes the same sluggish, chronic character as in the first form. Transitional forms exist between the two described clinical variants.

Tuberculosis of the epididymis is characterized by the absence of urethral discharge and clear, normal urine. An elevated leukocyte count in the urinary sediment sometimes points to tuberculosis of the prostate or seminal vesicles. More pronounced pyuria mostly indicates concomitant tuberculous involvement of the Urinary System.

Complications of urogenital tuberculosis are very diverse and depend on the intensity of the lesion and the localization of the process. Renal failure and Impairment of the self-regulatory capacity of the Kidneys are noted. Blood pressure in such cases is rarely elevated. Patients with genital tuberculosis are more susceptible to infection by other microorganisms due to anatomical lesions acting as entry gates for pathogens (N. Simon et al., 1977). With extensive lesions of the prostate gland and seminal vesicles, the majority of men experience Infertility; at the time of diagnosis, a reduced ejaculate volume, azoospermia, oligospermia, and/or decreased sperm motility are noted.