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Genitourinary Tuberculosis Today
THE JOURNAL OF UROLOGY
Vol. 82, No. 3, September 1959 Printed in U.S.A.
GENITOURINARY TUBERCULOSIS TODAY CONRAD A. KUEHN
AND
WILLIAM H. GEHRON, JR.*
From the Urology Service, Veterans Administration Hospital, Butler, Pa., and the Department of Surgery of the University of Pittsburgh School of lVIeclicine, Pittsburgh, Pa.
There is no unanimity of opinion in the current literature as to the actual incidence of genitourinary tuberculosis. Lattimer,1 in 1955, stated that he had been unable to measure any conclusive decline in the incidence of renal tuberculosis with the advent of the drugs used in the present treatment of the disease. Statistics from the postmortem findings at the Sea View Hospital 2 for tuberculosis from 1930 to 1955 showed that prior to the use of present day antituberculous drugs, 117 out of 736 male patients autopsied (16 per cent) revealed genitourinary tuberculosis. In 219 consecutive autopsies performed on patients with prolonged antituberculous therapy, only 17 (7 per cent) had evidence of genitourinary involvement. This problem is not a new one, for in his book Young 3 made the following statement, "vVe have, therefore, no accurate statistics as to the proportion of all tuberculous patients having genitourinary involvement." Because of the profound change in the clinical picture that has resulted from the use of streptomycin, para-aminosalicylic acid and isoniazid, their combinations and their derivatives, a reevaluation of the present incidence of genitourinary tuberculosis in patients who are under treatment for active pulmonary tuberculosis should be made. To this end, an evaluation of the problem was made from the study of 100 consecutive patients under drug therapy for active pulmonary tuberculosis at the Veterans Administration Hospital, Butler, Pa., a center for the treatment of this disease. The clinical study of the 100 patients comprised only those with clinical, radiologic and bacterioAccepted for publication March 26, 1959.
* Present address, 416 Pine St., Williamsport, Pa.
1 Lattimer, J. K.: Symposium on pediatric urology; kidney tuberculosis in children. Pediat. Clin. North Amer., 2: 793-801, 1955. 2 Sporer, A. and Greenberger, M. E.: Genitourinary tuberculosis. Sea View Hospital, 19301955. Sea View Hosp. Bull., 16: 95-100, 1956. 3 Young, H. H. and Davis, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.
380
logic evidence of active pulmonary tuberculosis who were under antituberculous therapy for their pulmonary disease. The examination of each patient began with an intensive and exhaustive history regarding symptoms that would suggest a genitourinary localization of tuberculosis. The patient was questioned concerning frequency of urination, nocturia, dysuria, the passage of visible blood, or cloudy urine. A history of pain in the scrotum, swelling of the testicles or any unusual symptom that would suggest involvement of the genitalia was sought. A complete physical examination of these 10n patients was made, special attention being directed to palpation of the scrotum and its contents as well as a digital evaluation of the prostate and seminal vesicles. The freshly voided urine was centrifuged in the genitourinary clinic and the sediment examined by the urologist. A methylene blue stained specimen was then made of the sediment to determine the presence or absence of organisms other than the tubercle bacillus. The patients with abnormal cellular elements in the urine or those whose urine was free from organisms and cellular elements but whose symptoms or physical findings even suggested a remote possibility of genitourinary tuberculosis had cultures made of 24 hour urine concentrates. Culture of the 24 hour urine for tuberculosis was made on 53 of these patients. From one to six urine specimens were inoculated for a total of 153 cultures. Guinea pig inoculations were not made because the urine cultures did not suggest the need for animal inoculation. The following nontuberculous diseases of the genitourinary tract were found in these patients: 2 cases of benign prostatic enlargement, one bladder calculus, one ureteral calculus, two urethral strictures, one hydrocele and one papillary carcinoma of the bladder. Four patients had an undescended testicle and 10, atrophic testes. The diseases not related to the genitourinary tract were one case of amyloidosis, three of Laennec's cirrhosis, two of diabetes mellitus.
GENITOURINARY TUBERCULOSIS
There were two hernias, one rectal fistula, and one healed case of tuberculosis of the rectum. One patient had syphilis. Seventy-five per cent of the patients in this group had no red blood cells in the urine. Nineteen per cent had an occasional red blood cell; 4 per cent, :five to nine; and 3 per cent, over 20 cells per high power :field. One patient with 20 red blood cells per field had a ureteral calculus; a second, amyloidosis; and a third, colon bacilluria. White blood cells were absent in the freshly centrifuged specimen of urine in 43 per cent. Thirty-nine per cent had an occasional white blood cell. Ten per cent had five to nine and 4 per cent had 10 to 19; four, over 20 per high power field. The same nontuberculous diseases previously mentioned were considered as the cause of the pyuria. The microscopic study of the urinary sediment did not permit a diagnosis of genitourinary tuberculosis to be established in this study. The cultures were most interesting. There was not one positive culture in the entire group. To reiterate, 53 patients had from one to six 24 hour urine concentrations for culture with a total of 153 examinations, and not one was positive for Koch's bacillus. Only two patients had evidence of genitourinary tuberculosis. The first, M. J., No. 20953, was a 63-year-old negro who had been admitted to Fort Howard Veterans Administration Hospital for the first time on May 29, 1946 with the chief complaint of hemoptysis. The diagnosis of far advanced pulmonary tuberculosis, bilateral, was established. The only treatment he received was bed rest until December 5, 1947 at which time he was discharged as apparently an arrested case of tuberculosis. He had no positive sputum examinations after March 1947. His total hospitalization at the first admission was 535 days. In April 1950 he was rehospitalized with positive sputum, weakness and 12 pounds' weight loss. On this admission, he was treated with streptomycin and para-aminosalicylic acid from November 1950 to June 1952. In November 1950, because of a constant filling defect in his transverse colon, laparotomy and colotomy were done. The biopsy was diagnosed as tuberculosis of the colon. In April 1951 the patient was seen by the genitourinary department and a diagnosis of tuberculosis of the right epididymis made. This
381
diagnosis was verified following surgical removal of the right epididymis. At the time of this examination the patient had no symptoms or positive findings of genitourinary tuberculosis. The second patient, T. C., Jr., No. 19032, was admitted to the Butler Veterans Administration Hospital on September 24, 1956 with the chief complaints of cough, chest pain and weight loss since January 1956. His history further revealed that in April 1956 he began to notice a gradual increase in the size of his right testicle. There was no pain or discharge from the scrotum. Physical examination at the time of consultation by the genitourinary department was negative except for an indurated, thickened, slightly tender right epididymis. The laboratory data revealed no abnormalities including three 24 hour urine concentrates for tubercle bacilli. The sputum was positive for tubercle bacillus and the roentgenograms of the chest were compatible with a diagnosis of moderately advanced, active, bilateral pulmonary tuberculosis. At Butler Veterans Administration Hospital, the patient was started on isoniazid 300 mg. daily and para-aminosalicylic acid 12 gm. daily on October 6, 1956. Following consultation by the urologist, the patient was transferred to the Veterans Administration Hospital, Pittsburgh on October 11, 1956 and on October 22, a right orchiectomy and epididymectomy accomplished. The pathology department reported the specimen as being tuberculous orchitis and epididymitis. The patient had an uneventful postoperative course and he was transferred to the Butler Veterans Administration Hospital on November 1, 1956 to continue treatment for pulmonary tuberculosis. The essential facts in the natural history of tuberculosis have been known for approximately 75 years. During that time the reported mortality of the disease has decreased about 95 per cent. However, a little progress has been made in identifying and controlling specific causes responsible for this change in the mortality rate. It has been pointed out that the tubercle bacillus is not the cause of tuberculosis but really only one of the causes. The importance of environmental factors upon morbidity and mortality, even the clinical form the disease may assume, has long been recognized. In a disease where the invasive powers of the
382
C. A. KUEHN AND W. H. GEHRON, JR.
agent are in such delicate balance with the resistance of the host, factors which substantially augment the virulence of the causative organism, or depress the resistance of the host, determine the trends of the disease. There is evidence that the general improvements in the standards of living in Western civilization during the past 100 years have played an important role in the decline of tuberculosis. Better nutrition, reduction in overcrowding, shorter hours of work and less physical labor have done a great deal to lessen the physical stress and strain of living. Needless to say, the present day chemotherapeutic treatment and early case finding of pulmonary tuberculosis have materially changed the course of the disease as well as the incidence of genitourinary tuberculosis. While the ecological factors that operate and their relative importance in the course of tuberculosis in the human population are still a major problem facing the epidemiologist, the urologist too, must re-evaluate his previous concepts of this disease. It is obvious that there can be no tuberculosis without the tubercle bacillus. The genitourinary system must be involved bdore a urological disease can be established. Of the new tuberculosis picture the U. S. Public Health Service says, "In the past 15 years, the tuberculosis problem has changed radically. Some areas of the country are now practically free of active cases of the disease. For other areas, it continues to be a problem within certain groups." 1Yhile the number of active cases has declined nearly 30 per cent in the last 5 years, it is estimated that there are still about 250,000 patients with active tuberculosis in the United States today. If the incidence of genitourinary tuberculosis is 2 per cent in patients who have active pulmonary tuberculosis, it is of statistical and clinical significance that perhaps some 5,000 patients in the United States could be expected to have genitourinary tuberculosis. This study demonstrated that no patient under active prolonged chemotherapy for pulmonary tuberculosis was found to have demonstrable (clinical) genitourinary tuberculosis. Thus, it could be assumed that not only has the incidence of genitourinary tuberculosis declined precipitously, but the morbidity and the total clinical picture of the disease too have been altered. Only a few years ago, it can be recalled how
these chronically ill, extremely uncomfortable patients suffered from their disease for years and then died of inanition, exhaustion, and spread of the tuberculosis. Even today there appear articles in the foreign literature"- 7 describing surgical techniques for the enlargement of the contracted tuberculous bladder, segmental resection of the kidneys and mutilating operations on the external genitalia. There are no means to determine the number of genitourinary operations that are being done for the surgical cure of tuberculosis at this time. It is of significance to note that in a general medical and surgical hospital (Veterans Administration Hospital, Pittsburgh, Pa.) that averages a yearly admission of 8,000 patients, only three nephrectomies have been done for tuberculosis in the past 10 years. Not only has the morbidity, mortality, incidence and clinical picture of tuberculosis changed, but the organism itself has been subject to alteration. The bacteriologists have shown that it is difficult indeed to find the organism in the urine of patients under active therapy for tuberculosis. At the Butler Veterans Administration Hospital, there has not been a microscopic identification in the 24 hour concentrated urine in nearly three years. At the same hospital the urine cultures have failed to grow the organism in approximately 500 cultures. Staining and morphological characteristics too have been altered. Instead of the faggot pile of short red rods in a field of green or blue as defined by the counterstain, the organisms have become short and stubby with many dub shaped forms. The tubercle bacillus under chemotherapy does not appl'ar to be as virulent to the guinea pig, for urine known to contain tubercle bacilli injected into the guinea pig Yvill often not be lethal to the animal. In other words the organism is so changed or attenuated that variation and 4 Cibert, J., Durl1nd, L., Gerdil, R., Bl1nic, Er., Ortegl1, G. l1nd DeMiguel, S.: L'ileocystopll1stie dans le traitement des seqnelles de ll1 cystite tuberculeuse, resultl1ts; d'l1pres 60 observl1tions. J. urol., Pl1ris, 62: 185-224, 1956. 5 K,nss, R., Legrain, M., Eitker, M. l1nd Perrin, C.: Etude du Retentissement sur ll1 fonction renl1le des plasties intestinl1les de b voie excretrice urinaire apropos de 42 observl1tions. J. urol., Paris, 64: 187-200, 1958. 6 Eocquentin, Ch.: Le reflux vesico-ureteral dans la tuberculose urinl1ire. J. urol., Paris, 61: 849870, 1955. 7 Cimadevila Covelo, A.: Les cystoenteroplasties et Jes vessies de substitution. J. urol., Paris,
61: 7.54-769, 1955.
383
GENITOURINARY TUBERCULOSIS
possible mutation forms of the Koch bacillus may be no longer virulent enough to cause the death of the animals. In some areas that have an untreated reserve of pulmonary tuberculosis, the incidence of genitourinary tuberculosis may appear to remain the same as it was before advent of the present therapeutic regimen. However, when this reservoir of untreated pulmonary tuberculosis has been reduced, it is possible that unless there is a radical change in the over-all picture of the disease in the United States, the incidence of genitourinary tuberculosis in all areas in this country would be as low as this study would indicate. Tubercle bacilli obtained from the urine of patients treated with antituberculous drugs can have their virulence to guinea pigs altered, mutant strains can develop and changes in staining properties can occur. Therefore, a plea is made to take special precautions to identify the organism and to establish a definite clinical diag-
,1
nosis of genitourinary tuberculosis before a patient is started on long term therapy for this disease. SUMMARY
From the clinical and laboratory examination of 100 patients with active pulmonary tuberculosis, we have found 2 cases, or an incidence of 2 per cent, with genitourinary involvement. This study would seem to indicate that with the clinical and laboratory studies available, the diagnosis of genitourinary tuberculosis in patients with active pulmonary disease under therapy is most difficult to make. The possibility that the present day combinations of therapy have markedly diminished the incidence of this aspect of the disease is presented. A corollary to the foregoing is the fact that these drugs should not be used until irrefutable bacteriological evidence of genitourinary tuberculosis is present.
Vol. 82, No. 3, September 1959 Printed in U.S.A.
GENITOURINARY TUBERCULOSIS TODAY CONRAD A. KUEHN
AND
WILLIAM H. GEHRON, JR.*
From the Urology Service, Veterans Administration Hospital, Butler, Pa., and the Department of Surgery of the University of Pittsburgh School of lVIeclicine, Pittsburgh, Pa.
There is no unanimity of opinion in the current literature as to the actual incidence of genitourinary tuberculosis. Lattimer,1 in 1955, stated that he had been unable to measure any conclusive decline in the incidence of renal tuberculosis with the advent of the drugs used in the present treatment of the disease. Statistics from the postmortem findings at the Sea View Hospital 2 for tuberculosis from 1930 to 1955 showed that prior to the use of present day antituberculous drugs, 117 out of 736 male patients autopsied (16 per cent) revealed genitourinary tuberculosis. In 219 consecutive autopsies performed on patients with prolonged antituberculous therapy, only 17 (7 per cent) had evidence of genitourinary involvement. This problem is not a new one, for in his book Young 3 made the following statement, "vVe have, therefore, no accurate statistics as to the proportion of all tuberculous patients having genitourinary involvement." Because of the profound change in the clinical picture that has resulted from the use of streptomycin, para-aminosalicylic acid and isoniazid, their combinations and their derivatives, a reevaluation of the present incidence of genitourinary tuberculosis in patients who are under treatment for active pulmonary tuberculosis should be made. To this end, an evaluation of the problem was made from the study of 100 consecutive patients under drug therapy for active pulmonary tuberculosis at the Veterans Administration Hospital, Butler, Pa., a center for the treatment of this disease. The clinical study of the 100 patients comprised only those with clinical, radiologic and bacterioAccepted for publication March 26, 1959.
* Present address, 416 Pine St., Williamsport, Pa.
1 Lattimer, J. K.: Symposium on pediatric urology; kidney tuberculosis in children. Pediat. Clin. North Amer., 2: 793-801, 1955. 2 Sporer, A. and Greenberger, M. E.: Genitourinary tuberculosis. Sea View Hospital, 19301955. Sea View Hosp. Bull., 16: 95-100, 1956. 3 Young, H. H. and Davis, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., 1926.
380
logic evidence of active pulmonary tuberculosis who were under antituberculous therapy for their pulmonary disease. The examination of each patient began with an intensive and exhaustive history regarding symptoms that would suggest a genitourinary localization of tuberculosis. The patient was questioned concerning frequency of urination, nocturia, dysuria, the passage of visible blood, or cloudy urine. A history of pain in the scrotum, swelling of the testicles or any unusual symptom that would suggest involvement of the genitalia was sought. A complete physical examination of these 10n patients was made, special attention being directed to palpation of the scrotum and its contents as well as a digital evaluation of the prostate and seminal vesicles. The freshly voided urine was centrifuged in the genitourinary clinic and the sediment examined by the urologist. A methylene blue stained specimen was then made of the sediment to determine the presence or absence of organisms other than the tubercle bacillus. The patients with abnormal cellular elements in the urine or those whose urine was free from organisms and cellular elements but whose symptoms or physical findings even suggested a remote possibility of genitourinary tuberculosis had cultures made of 24 hour urine concentrates. Culture of the 24 hour urine for tuberculosis was made on 53 of these patients. From one to six urine specimens were inoculated for a total of 153 cultures. Guinea pig inoculations were not made because the urine cultures did not suggest the need for animal inoculation. The following nontuberculous diseases of the genitourinary tract were found in these patients: 2 cases of benign prostatic enlargement, one bladder calculus, one ureteral calculus, two urethral strictures, one hydrocele and one papillary carcinoma of the bladder. Four patients had an undescended testicle and 10, atrophic testes. The diseases not related to the genitourinary tract were one case of amyloidosis, three of Laennec's cirrhosis, two of diabetes mellitus.
GENITOURINARY TUBERCULOSIS
There were two hernias, one rectal fistula, and one healed case of tuberculosis of the rectum. One patient had syphilis. Seventy-five per cent of the patients in this group had no red blood cells in the urine. Nineteen per cent had an occasional red blood cell; 4 per cent, :five to nine; and 3 per cent, over 20 cells per high power :field. One patient with 20 red blood cells per field had a ureteral calculus; a second, amyloidosis; and a third, colon bacilluria. White blood cells were absent in the freshly centrifuged specimen of urine in 43 per cent. Thirty-nine per cent had an occasional white blood cell. Ten per cent had five to nine and 4 per cent had 10 to 19; four, over 20 per high power field. The same nontuberculous diseases previously mentioned were considered as the cause of the pyuria. The microscopic study of the urinary sediment did not permit a diagnosis of genitourinary tuberculosis to be established in this study. The cultures were most interesting. There was not one positive culture in the entire group. To reiterate, 53 patients had from one to six 24 hour urine concentrations for culture with a total of 153 examinations, and not one was positive for Koch's bacillus. Only two patients had evidence of genitourinary tuberculosis. The first, M. J., No. 20953, was a 63-year-old negro who had been admitted to Fort Howard Veterans Administration Hospital for the first time on May 29, 1946 with the chief complaint of hemoptysis. The diagnosis of far advanced pulmonary tuberculosis, bilateral, was established. The only treatment he received was bed rest until December 5, 1947 at which time he was discharged as apparently an arrested case of tuberculosis. He had no positive sputum examinations after March 1947. His total hospitalization at the first admission was 535 days. In April 1950 he was rehospitalized with positive sputum, weakness and 12 pounds' weight loss. On this admission, he was treated with streptomycin and para-aminosalicylic acid from November 1950 to June 1952. In November 1950, because of a constant filling defect in his transverse colon, laparotomy and colotomy were done. The biopsy was diagnosed as tuberculosis of the colon. In April 1951 the patient was seen by the genitourinary department and a diagnosis of tuberculosis of the right epididymis made. This
381
diagnosis was verified following surgical removal of the right epididymis. At the time of this examination the patient had no symptoms or positive findings of genitourinary tuberculosis. The second patient, T. C., Jr., No. 19032, was admitted to the Butler Veterans Administration Hospital on September 24, 1956 with the chief complaints of cough, chest pain and weight loss since January 1956. His history further revealed that in April 1956 he began to notice a gradual increase in the size of his right testicle. There was no pain or discharge from the scrotum. Physical examination at the time of consultation by the genitourinary department was negative except for an indurated, thickened, slightly tender right epididymis. The laboratory data revealed no abnormalities including three 24 hour urine concentrates for tubercle bacilli. The sputum was positive for tubercle bacillus and the roentgenograms of the chest were compatible with a diagnosis of moderately advanced, active, bilateral pulmonary tuberculosis. At Butler Veterans Administration Hospital, the patient was started on isoniazid 300 mg. daily and para-aminosalicylic acid 12 gm. daily on October 6, 1956. Following consultation by the urologist, the patient was transferred to the Veterans Administration Hospital, Pittsburgh on October 11, 1956 and on October 22, a right orchiectomy and epididymectomy accomplished. The pathology department reported the specimen as being tuberculous orchitis and epididymitis. The patient had an uneventful postoperative course and he was transferred to the Butler Veterans Administration Hospital on November 1, 1956 to continue treatment for pulmonary tuberculosis. The essential facts in the natural history of tuberculosis have been known for approximately 75 years. During that time the reported mortality of the disease has decreased about 95 per cent. However, a little progress has been made in identifying and controlling specific causes responsible for this change in the mortality rate. It has been pointed out that the tubercle bacillus is not the cause of tuberculosis but really only one of the causes. The importance of environmental factors upon morbidity and mortality, even the clinical form the disease may assume, has long been recognized. In a disease where the invasive powers of the
382
C. A. KUEHN AND W. H. GEHRON, JR.
agent are in such delicate balance with the resistance of the host, factors which substantially augment the virulence of the causative organism, or depress the resistance of the host, determine the trends of the disease. There is evidence that the general improvements in the standards of living in Western civilization during the past 100 years have played an important role in the decline of tuberculosis. Better nutrition, reduction in overcrowding, shorter hours of work and less physical labor have done a great deal to lessen the physical stress and strain of living. Needless to say, the present day chemotherapeutic treatment and early case finding of pulmonary tuberculosis have materially changed the course of the disease as well as the incidence of genitourinary tuberculosis. While the ecological factors that operate and their relative importance in the course of tuberculosis in the human population are still a major problem facing the epidemiologist, the urologist too, must re-evaluate his previous concepts of this disease. It is obvious that there can be no tuberculosis without the tubercle bacillus. The genitourinary system must be involved bdore a urological disease can be established. Of the new tuberculosis picture the U. S. Public Health Service says, "In the past 15 years, the tuberculosis problem has changed radically. Some areas of the country are now practically free of active cases of the disease. For other areas, it continues to be a problem within certain groups." 1Yhile the number of active cases has declined nearly 30 per cent in the last 5 years, it is estimated that there are still about 250,000 patients with active tuberculosis in the United States today. If the incidence of genitourinary tuberculosis is 2 per cent in patients who have active pulmonary tuberculosis, it is of statistical and clinical significance that perhaps some 5,000 patients in the United States could be expected to have genitourinary tuberculosis. This study demonstrated that no patient under active prolonged chemotherapy for pulmonary tuberculosis was found to have demonstrable (clinical) genitourinary tuberculosis. Thus, it could be assumed that not only has the incidence of genitourinary tuberculosis declined precipitously, but the morbidity and the total clinical picture of the disease too have been altered. Only a few years ago, it can be recalled how
these chronically ill, extremely uncomfortable patients suffered from their disease for years and then died of inanition, exhaustion, and spread of the tuberculosis. Even today there appear articles in the foreign literature"- 7 describing surgical techniques for the enlargement of the contracted tuberculous bladder, segmental resection of the kidneys and mutilating operations on the external genitalia. There are no means to determine the number of genitourinary operations that are being done for the surgical cure of tuberculosis at this time. It is of significance to note that in a general medical and surgical hospital (Veterans Administration Hospital, Pittsburgh, Pa.) that averages a yearly admission of 8,000 patients, only three nephrectomies have been done for tuberculosis in the past 10 years. Not only has the morbidity, mortality, incidence and clinical picture of tuberculosis changed, but the organism itself has been subject to alteration. The bacteriologists have shown that it is difficult indeed to find the organism in the urine of patients under active therapy for tuberculosis. At the Butler Veterans Administration Hospital, there has not been a microscopic identification in the 24 hour concentrated urine in nearly three years. At the same hospital the urine cultures have failed to grow the organism in approximately 500 cultures. Staining and morphological characteristics too have been altered. Instead of the faggot pile of short red rods in a field of green or blue as defined by the counterstain, the organisms have become short and stubby with many dub shaped forms. The tubercle bacillus under chemotherapy does not appl'ar to be as virulent to the guinea pig, for urine known to contain tubercle bacilli injected into the guinea pig Yvill often not be lethal to the animal. In other words the organism is so changed or attenuated that variation and 4 Cibert, J., Durl1nd, L., Gerdil, R., Bl1nic, Er., Ortegl1, G. l1nd DeMiguel, S.: L'ileocystopll1stie dans le traitement des seqnelles de ll1 cystite tuberculeuse, resultl1ts; d'l1pres 60 observl1tions. J. urol., Pl1ris, 62: 185-224, 1956. 5 K,nss, R., Legrain, M., Eitker, M. l1nd Perrin, C.: Etude du Retentissement sur ll1 fonction renl1le des plasties intestinl1les de b voie excretrice urinaire apropos de 42 observl1tions. J. urol., Paris, 64: 187-200, 1958. 6 Eocquentin, Ch.: Le reflux vesico-ureteral dans la tuberculose urinl1ire. J. urol., Paris, 61: 849870, 1955. 7 Cimadevila Covelo, A.: Les cystoenteroplasties et Jes vessies de substitution. J. urol., Paris,
61: 7.54-769, 1955.
383
GENITOURINARY TUBERCULOSIS
possible mutation forms of the Koch bacillus may be no longer virulent enough to cause the death of the animals. In some areas that have an untreated reserve of pulmonary tuberculosis, the incidence of genitourinary tuberculosis may appear to remain the same as it was before advent of the present therapeutic regimen. However, when this reservoir of untreated pulmonary tuberculosis has been reduced, it is possible that unless there is a radical change in the over-all picture of the disease in the United States, the incidence of genitourinary tuberculosis in all areas in this country would be as low as this study would indicate. Tubercle bacilli obtained from the urine of patients treated with antituberculous drugs can have their virulence to guinea pigs altered, mutant strains can develop and changes in staining properties can occur. Therefore, a plea is made to take special precautions to identify the organism and to establish a definite clinical diag-
,1
nosis of genitourinary tuberculosis before a patient is started on long term therapy for this disease. SUMMARY
From the clinical and laboratory examination of 100 patients with active pulmonary tuberculosis, we have found 2 cases, or an incidence of 2 per cent, with genitourinary involvement. This study would seem to indicate that with the clinical and laboratory studies available, the diagnosis of genitourinary tuberculosis in patients with active pulmonary disease under therapy is most difficult to make. The possibility that the present day combinations of therapy have markedly diminished the incidence of this aspect of the disease is presented. A corollary to the foregoing is the fact that these drugs should not be used until irrefutable bacteriological evidence of genitourinary tuberculosis is present.