Understanding the Clinical Presentation of Patients with Urogenital Tuberculosis in a Sub- Saharan Tertiary Care Setting

Understanding the Clinical Presentation of Patients with Urogenital Tuberculosis in a Sub- Saharan Tertiary Care Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Understanding the Clinical Presentation of Patients with Urogenital Tuberculosis in a Sub- Saharan Tertiary Care Setting Edouard Ngendahayo, Charles Niyotwiringiye, Nyamwasa Umunyurwa, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8138737/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Introduction: Tuberculosis remains the second leading infectious killer worldwide. Extrapulmonary tuberculosis represents 15%-40% of all cases, with urogenital tuberculosis (UG-TB) as the second most common form. UG-TB can cause severe urologic complications - including obstructive uropathy, renal failure, and infertility - due to inflammation and scarring. This study describes the presentation of UG-TB at a tertiary hospital in a low- and middle-income country (LMIC), aiming to raise clinical suspicion among providers. Methods We conducted a retrospective, cross-sectional study of patients diagnosed with UG-TB at a semi-private, tertiary referral hospital with a 160-bed capacity in Kigali, Rwanda between 2015 and 2023. We collated patient logs from the hospital’s inpatient and laboratory's tuberculosis registry to identify all cases of UG-TB. Results 32 patients were diagnosed and treated for UG-TB. Nearly all were male (96.9%), Rwandan nationals (90.6%), and younger than 55 years old (90.6%). Most had no known medical comorbidities (87.5%) and none were HIV positive. The majority (75%) presented with a scrotal mass, typically a unilateral epididymal nodule (83%); and the remaining presented with upper urinary tract and/or bladder TB. Nearly half (41%) of the patients required surgical intervention for their disease. Three patients required nephrectomy, one underwent bladder augmentation with bilateral ureteroneocystostomy, and one required unilateral nephroureterectomy with contralateral ileal ureter. Conclusion UG-TB imposes a high surgical burden in otherwise young, healthy men. Expanding subspecialty training in complex urinary reconstruction is essential to equip urologists to manage these challenging cases. Uro-genital tuberculosis Mycobacterium tuberculosis granulomatous inflammation Gene Xpert-MTB/RIF assay. Introduction Tuberculosis (TB) remains the second leading infectious killer worldwide, despite the global efforts such as the “World Health Organization End TB Strategy.” ( 1 , 2 ) In 2022, the World Health Organization (WHO) recorded 7.5 million newly diagnosed TB cases, the highest annual number since 1995. ( 1 ) Extrapulmonary TB (EPTB) is known to represent 15%-40% of all TB cases ( 3 ), of which urogenital tuberculosis (UG-TB) represents 15–20%. ( 3 , 4 ) UG-TB is the second most common form of EPTB, after TB involving lymph nodes. ( 5 , 6 ) Mycobacterium tuberculosis (Mtb) inhalation, Mycobacterium bovis ingestion in dairy products, and Bacillus Calmette-Guerin intravesical instillation during treatment of non-muscle invasive bladder cancer have all been implicated in transmission. ( 3 , 4 , 7 ). In UG-TB, Mtb is believed to spread hematogenously from its primary pulmonary focus to kidneys, ureters, the urinary bladder and to male genitalia through the ejaculatory ducts. ( 4 ) However, the exact mechanism has not been confirmed with contemporary studies. The latency period for UG-TB onset is thought to be very long, averaging 22 years. ( 8 ) The reactivation of Mtb takes advantage of the host’s immunosuppression to proliferate, leading to clinical disease. UG-TB can cause severe and highly morbid urologic complications, including obstructive uropathy, hydronephrosis, renal failure, and infertility, due to granulomatous inflammation and scarring of the urinary tract and the genital tract. A high index of suspicion and appropriate diagnostic tools are required to diagnose UG-TB. While treatment always starts with standard antituberculosis therapy, advanced cases may require surgical intervention. UG-TB challenges clinicians from all over the world because of its protean presentation and challenges with diagnostic instruments. In particular, the global health disparities with limited access to rapid and quality diagnostic facilities in low- and middle-income countries (LMIC) makes the diagnosis of UG-TB particularly difficult in this part of the world. ( 9 ) In addition, the index of clinical suspicion of UG-TB is likely even lower in high-income countries, the part of the world with the lowest rate of TB. However, with an increasing immigration of populations from endemic regions to high-income countries (HICs) and increasing rates of pulmonary TB in HICs, UG-TB may become more clinically relevant in these settings. ( 10 ) Further, surgical treatment of UG-TB can be complex, requiring surgical subspecialty care often unavailable in LMICs. Given this context, understanding how UG-TB presents in settings where TB remains prevalent may offer valuable insights for improving early recognition and diagnosis. The purpose of the current study was to evaluate and describe the pattern of presentation of UG-TB at a LMIC tertiary hospital, with an ultimate goal to contribute to raising the index of suspicion of UG-TB among clinicians. Methodology Study design and setting This was a retrospective cross-sectional study of patients who were diagnosed with UG-TB at King Faisal hospital, Rwanda (KFH), between 2015 and 2023. KFH is a semi-private tertiary hospital with a 160-bed capacity. It is the top referral national hospital, currently undergoing an extensive infrastructure development and subspecialty development. The readily available imaging and laboratory facilities play a major role in the diagnosis and management of UG-TB. Once the diagnosis of UG-TB is made, patients are internally transferred to the hospital’s TB unit, within the Internal Medicine department, for education and initiation of the six-month anti-TB treatment, as per the national guidelines. For patients that require surgery, intervention is offered within the first two months of initiating medical treatment. Data collection and analysis All cases of TB, including UG-TB, are recorded prospectively, per national policy. We retrospectively reviewed and collated patient logs from the hospital’s inpatient TB registry as well as the laboratory’s TB registry, to identify all cases of UG-TB over the eight-year study period. The data extraction sheet developed in Kobocollect was used to collect relevant clinical information. Demographic data included age, gender, residence, and health insurance. Clinical information focused on chief complaint, comorbidities, affected organs, diagnostic and treatment modalities and their outcomes. Ethical approval This study was approved by the Institutional Review Board of King Faisal Hospital, Rwanda Table 1: Cohort Characteristics (N=32) N=32 (%) Age (years) 18-55 29 (90.6) >55 3 (9.4) Gender Male 31 (96.9) Female 1 (3.1) Origin Urban (national) 20 (62.5) Rural (national) 9 (28.1) Foreigner 3 (9.4) Insurance Community-based 22 (68.8) Formal insurance 5 (15.6) Private 5 (15.6) Comorbidities None 28 (87.5) Yes (prostate cancer, DM, HTN and asthma) 4 (12.5) HIV Status Positive 0 (0.0) Table 2: Scrotal TB – Patient Characteristics and Surgical Management (n=24) Affected organ # of cases Physical finding Surgical Treatment Epididymal Unilateral 20 Epididymal nodule Epididymectomy (n= 2) Unilateral with ipsilateral non-functioning kidney 1 Epididymal nodule Nephrectomy Bilateral 1 B/L epididymal nodule Unilateral epididymectomy Unilateral with ipsilateral testicular TB 1 Testicular mass mimicking cancer Radical orchiectomy Unilateral with ipsilateral testicular TB 1 Fournier’s Gangrene with fistula between epididymis and testicle Fournier’s gangrene debridement, orchi-epididymectomy Table 3: Urinary TB - Patient Characteristics and management (n=8) Chief complaint # of cases Imaging modality Imaging findings Final surgical management Unilateral flank pain 1 CT-IVU Unilateral renal calyces scarring and distal ureter tight strictures Nephrectomy Unilateral flank pain 2 CT-IVU Partial ureteral strictures Ureteral stents Bilateral flank pain 1 CT-IVU Bilateral hydronephrosis and ureteric strictures Unilateral nephrectomy, ureteral stent in contralateral side Bilateral flank pain 1 CT-IVU Bilateral ureteral strictures and unilateral atrophic kidney Right nephroureterectomy and left ureterectomy with ileal ureteral interposition Renal failure 1 MRI Bilateral pyonephrosis Unilateral nephrectomy LUTS/CPPS 1 CT-IVU Diffuse bladder mucosal inflammation on cystoscopy None – medical treatment alone LUTS/OAB 1 CUG Small bladder capacity with bilateral distal ureteral strictures Bladder augmentation and bilateral ureteroneocystostomy Results Over a period of eight years (2015-2023), there were 612 TB cases and 382 extrapulmonary TB. Of the EPTB cases, 32 (8.37%) patients were diagnosed and treated for UG-TB (Table 1). Almost all UG-TB patients were male (96.9%), Rwandan nationals (90.6%) and young (90.6% under 55 years old, mean age 40.3, SD +/- 13.7). The majority of patients had no known medical comorbidities (87.5%). None of the patients was HIV positive and none of them had a history of pulmonary TB. Nearly half (41%) of patients underwent a surgical intervention for their UG-TB disease. One patient (3.1%) died during their hospital admission of complications related to their UG-TB. The majority of patients (68.8%) were insured with community-based health insurance (CBHI). The majority of cases (39.5%) were diagnosed using smear microscopy (Ziehl-Neelsen strain/auramine stain), followed by GeneXpert of urine or epididymal aspirate (27.9%), culture on Lowenstein–Jensen medium (21.0%), and organism visualization on histopathology (11.6%). The most common disease presentation involved the scrotum and/or testicles. Twenty-four patients (75%) presented with a scrotal mass. Of these, 20 (83%) presented with a unilateral epididymal nodule, of which 18 were treated medically and 2 were treated surgically with an epididymectomy. The additional four patients with scrotal pathology presented differently. One presented with a unilateral epididymal nodule and an ipsilateral non-functioning kidney, one presented with bilateral epididymal nodules, one presented with a testicular mass mimicking testis cancer on exam, and one presented with Fournier’s gangrene and a fistula between the epididymis and testicle. The management of each of these patients is displayed in Table 2. One-quarter of patients (n=8; 25%) presented with upper urinary tract and bladder TB. CT urography was the main imaging diagnostic modality for these cases. Five of these patients (62%) presented with flank pain, one with renal failure, and three with lower urinary tract symptoms – including chronic pelvic pain syndrome and overactive bladder (Table 3). Three patients required nephrectomy, one underwent bladder augmentation with bilateral ureteroneocystostomy, and one required unilateral nephroureterectomy and contralateral ileal ureteral interposition. Discussion Tuberculosis remains one of the world’s most serious infectious diseases, posing a significant global health threat due to its persistent prevalence, rising drug resistance, and potential for severe complications if left untreated (1). Treating pulmonary tuberculosis poses a substantial clinical and public health challenge; however, extrapulmonary manifestations, often more insidious and difficult to diagnose, tend to receive less attention despite their complexity and potential severity (2-3). Despite UG-TB being the second most common EPTB, there exists limited research and guidance on its diagnosis, treatment, and pathophysiology, specifically in Sub-Saharan Africa. In our cohort of patients at King Faisal Hospital (KFH) in Rwanda, UG-TB was notably a disease of primarily young and healthy men, with patient ages ranging from 20 to 55 years. None of our patients had a history of HIV co-infection and 87.5% were without major medical comorbidities. These results are unique compared to prior research. Globally, 12% of patients infected with TB are co-infected with HIV (11), and in areas of the world like sub-Saharan Africa, up to 60% to 90% of those with extrapulmonary disease will test positive for HIV. (12) In a study of 57 patients with UG-TB in Taiwan, notably 89% had comorbid conditions ranging from diabetes mellitus type II to chronic kidney disease. (13) Despite our cohort of healthier, younger men, a significant portion of these patients underwent surgical interventions for their disease. Thirteen of the 32 patients (41%) underwent surgery – ranging from epididymectomy and orchiectomy to nephrectomy, bladder augmentation, ureteroneocystostomy and ileal ureter creation. Of the patients that presented with UG-TB outside the scrotum, 6 patients (66%) required major intra-abdominal urologic surgery. These surgeries are complex and may require sub-specialty training to perform. They also carry a significant risk of morbidity, even in high-income settings, which is substantially compounded in low-income countries. A 2018 study published in the Lancet evaluated 7-day surgical outcomes of 11,422 patients in 25 African countries and found that despite a low-risk profile and few postoperative complications, patients in LMICs were twice as likely to die after surgery when compared to the global average. (14) Similarly, in a large international, prospective, multi-centre study evaluating patients undergoing elective or emergency intestinal surgery within a two-week period, countries with a low Human Development Index (HDI) carried a disproportionately greater burden of surgical site infections as compared to middle or high HDI countries. (15) UG-TB carries an even greater potential burden of morbidity in LMICs, where limited subspecialty expertise, resource constraints, and higher postoperative complication rates compound the risks of already complex urologic surgeries, making the disease uniquely devastating in these settings. Accurate diagnosis presents a further challenge of UG-TB. UG-TB can present with non-specific lower urinary tract symptoms, sterile pyuria, or abnormalities in semen analyses (4). Urine culture on Lowenstein-Jensen medium is considered the gold standard for diagnosing UG-TB. (16) However, cultures take six to eight weeks to result and have sensitivity ranging from 24 to 56.4% for a single urine culture sample. (16) Although the sensitivity can improve with multiple samples, this is not often feasible in LMIC settings. One faster and more cost-effective option for diagnosing UG-TB is smear microscopy using Ziehl–Neelsen (ZN) or auramine staining showing acid-fast bacilli (AFB) in urine samples, semen, tissue, prostatic fluid or pus. While this test has 97% specificity, the sensitivity is only 20%. (17) In recent years, nucleic acid amplification tests (NAATs) have become commercially available for diagnosing pulmonary tuberculosis. The readily available Gene Xpert MTB/RIF that can provide results for sputum samples in 24-48 hours (18). Although not originally designed for urine samples, various protocols have been developed to reappropriate the test for cases of suspected UG-TB. One meta-analysis of 12 unique studies reported a pooled sensitivity and specificity of Gene Xpert of 89% and 95%, respectively, for detecting UG-TB when compared to mycobacterial culture; and 55% and 99%, respectively, when compared to the composite reference standard. (19) In our cohort, the majority of patients (39%) were diagnosed using smear microscopy, the diagnostic test with the lowest reported sensitivity for the disease. While 28% were diagnosed using a locally developed protocol for Gene Xpert testing of either urine samples or epididymal aspirate, we suspect that the overall case number in our cohort is an under-estimation of the true incidence of UG-TB in our hospital setting because of the high frequency of false negatives with single agent testing, for each diagnostic modality. This is a limitation of our study, but it also highlights the difficulty of diagnosing UG-TB appropriately and the need for future studies to improve diagnostic testing for the disease. Our study has several additional limitations. First, KFH is a relatively small and semi-private hospital. Although the majority of patients in our cohort (68.8%) were enrolled in community-based health insurance (CBHI), KFH does not readily accept CBHI or provide care for uninsured patients, unless the patient is willing to pay for care out-of-pocket or they are transferred to the facility for clinical complexity. This creates an inherent selection bias in our sample. We suspect that our cohort likely under-represents the true annual burden of UG-TB cases in Rwanda. In addition, because most of our patients carried CBHI, it suggests that UG-TB may disproportionately affect poorer populations, which is consistent with other TB literature (20), and therefore we suspect that the burden of disease is likely much higher at public hospitals that routinely accept these patients. Second, while we included men with TB of their reproductive organs, we did not include female patients with genital TB in this study. Only female cases with urinary TB were included. Since it is estimated that the ratio of men to women with UG-TB is 2:1, we suspect that inclusion of female genital TB may have increased our cohort size by as much as 50% (6). Further research is needed to investigate the presentations of genital TB among women in Rwanda. Conclusion This study contributes to the limited but growing body of literature on urogenital tuberculosis, highlighting the significant surgical burden in a group of otherwise young, healthy men. Our findings underscore that UG-TB has the potential to be highly morbid in LMICs, where limited access to advanced diagnostics, delayed recognition, and constrained surgical capacity amplify its impact. Given the complexity of the surgical procedures often required, there is a critical need to expand subspecialty training in complex urinary reconstruction to equip urologists with the skills necessary to manage these challenging cases. At the same time, current diagnostic strategies for UG-TB remain outdated and insufficiently sensitive, and the pathophysiology of the disease is still poorly understood. Future efforts must therefore prioritize both capacity-building in surgical training and research aimed at developing more accurate diagnostic tools and deepening our understanding of disease mechanisms. Expanding such efforts across Rwanda’s public hospitals and community health settings will be essential to capture the true burden and clinical presentations of UG-TB and to design interventions that reduce its significant morbidity for LMICs where TB remains endemic. Abbreviations 1. TB Tuberculosis 2. EPTB Extrapulmonary TB 3. UG-TB urogenital tuberculosis 4. Mtb Mycobacterium tuberculosis 5. LMICs Low- and middle-income countries 6. HICs High-income countries 7. KFH King Faisal hospital, Rwanda 8. CBHI Community-based health insurance 9. HDI Human Development Index 10. ZN Ziehl–Neelsen 11. AFB Acid-fast bacilli 12. NAATs Nucleic acid amplification tests Declarations Ethical approval This study was approved by the Institutional Review Board of King Faisal Hospital, Rwanda Ethics approval and consent to participate: This study was conducted in accordance with the principles of the Declaration of Helsinki. This is a retrospective chart review study that was approved by the relevant ethical review boards in Rwanda with an IRB from KFH, and individual patient consent was not determined to be needed Consent for publication: All the authors agreed to publication of this article. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Author Contribution -EN: Conceptualization, supervision, methodology, data curation, writing - original draft. -TN: Conceptualization, supervision, methodology, data curation, writing - reviewing and editing- NU/FR/CN/PM: Data curation and input- JK: Supervision, methodology, writing - reviewing and editing- FK: writing - reviewing and editing Acknowledgement We thank all participants and the staff at King Faisal Hospital in Rwanda for their support. Data Availability The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. References World Health Organization. Global tuberculosis report 2023. Geneva; 2023. Villar-Hernandez R, Ghodousi A, Konstantynovska O, Duarte R, Lange C, Raviglione M. Tuberculosis: current challenges and beyond. Breathe (Sheff). 2023;19(1):220166. Muneer A, Macrae B, Krishnamoorthy S, Zumla A. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. 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10:37:51","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68243,"visible":true,"origin":"","legend":"","description":"","filename":"601e197cbbbe48d583e1b655b9de9bfa1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8138737/v1/a0c65b237b8ebe18ce91e058.xml"},{"id":100358423,"identity":"923373a7-5afc-4b22-9cbf-01f02d0c5e6f","added_by":"auto","created_at":"2026-01-16 07:21:03","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67014,"visible":true,"origin":"","legend":"","description":"","filename":"601e197cbbbe48d583e1b655b9de9bfa1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8138737/v1/eb2e40a7244d60df5e7f7046.xml"},{"id":99877838,"identity":"f7b6b460-88ed-464e-b3fa-a733c93551f3","added_by":"auto","created_at":"2026-01-09 10:37:51","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74604,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8138737/v1/1ee11d168ecefbfb38fa2b33.html"},{"id":100377261,"identity":"232883e3-51bb-4150-b9f5-985ae91a7fa3","added_by":"auto","created_at":"2026-01-16 08:47:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":596691,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8138737/v1/f00754a3-2786-4860-b539-d4115f846194.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the Clinical Presentation of Patients with Urogenital Tuberculosis in a Sub- Saharan Tertiary Care Setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculosis (TB) remains the second leading infectious killer worldwide, despite the global efforts such as the \u0026ldquo;World Health Organization End TB Strategy.\u0026rdquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) In 2022, the World Health Organization (WHO) recorded 7.5\u0026nbsp;million newly diagnosed TB cases, the highest annual number since 1995. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Extrapulmonary TB (EPTB) is known to represent 15%-40% of all TB cases (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), of which urogenital tuberculosis (UG-TB) represents 15\u0026ndash;20%. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) UG-TB is the second most common form of EPTB, after TB involving lymph nodes. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) \u003cem\u003eMycobacterium tuberculosis (Mtb)\u003c/em\u003e inhalation, \u003cem\u003eMycobacterium bovis\u003c/em\u003e ingestion in dairy products, and Bacillus Calmette-Guerin intravesical instillation during treatment of non-muscle invasive bladder cancer have all been implicated in transmission. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In UG-TB, \u003cem\u003eMtb\u003c/em\u003e is believed to spread hematogenously from its primary pulmonary focus to kidneys, ureters, the urinary bladder and to male genitalia through the ejaculatory ducts. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) However, the exact mechanism has not been confirmed with contemporary studies. The latency period for UG-TB onset is thought to be very long, averaging 22 years. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The reactivation of \u003cem\u003eMtb\u003c/em\u003e takes advantage of the host\u0026rsquo;s immunosuppression to proliferate, leading to clinical disease. UG-TB can cause severe and highly morbid urologic complications, including obstructive uropathy, hydronephrosis, renal failure, and infertility, due to granulomatous inflammation and scarring of the urinary tract and the genital tract.\u003c/p\u003e \u003cp\u003eA high index of suspicion and appropriate diagnostic tools are required to diagnose UG-TB. While treatment always starts with standard antituberculosis therapy, advanced cases may require surgical intervention. UG-TB challenges clinicians from all over the world because of its protean presentation and challenges with diagnostic instruments. In particular, the global health disparities with limited access to rapid and quality diagnostic facilities in low- and middle-income countries (LMIC) makes the diagnosis of UG-TB particularly difficult in this part of the world. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) In addition, the index of clinical suspicion of UG-TB is likely even lower in high-income countries, the part of the world with the lowest rate of TB. However, with an increasing immigration of populations from endemic regions to high-income countries (HICs) and increasing rates of pulmonary TB in HICs, UG-TB may become more clinically relevant in these settings. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) Further, surgical treatment of UG-TB can be complex, requiring surgical subspecialty care often unavailable in LMICs.\u003c/p\u003e \u003cp\u003eGiven this context, understanding how UG-TB presents in settings where TB remains prevalent may offer valuable insights for improving early recognition and diagnosis. The purpose of the current study was to evaluate and describe the pattern of presentation of UG-TB at a LMIC tertiary hospital, with an ultimate goal to contribute to raising the index of suspicion of UG-TB among clinicians.\u003c/p\u003e "},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy design and setting\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a retrospective cross-sectional study of patients who were diagnosed with UG-TB \u0026nbsp; \u0026nbsp; \u0026nbsp;at King Faisal hospital, Rwanda (KFH), between 2015 and 2023. KFH is a semi-private \u0026nbsp; \u0026nbsp; \u0026nbsp;tertiary hospital with a 160-bed capacity. It is the top referral national hospital, currently undergoing an extensive infrastructure development and subspecialty development. The readily available imaging and laboratory facilities play a major role in the diagnosis and management of UG-TB. Once the diagnosis of UG-TB is made, patients are internally transferred to the hospital\u0026rsquo;s TB unit, within the Internal Medicine department, for education and initiation of the six-month anti-TB treatment, as per the national guidelines. For patients that require surgery, intervention is offered within the first two months of initiating medical treatment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection and analysis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll cases of TB, including UG-TB, are recorded prospectively, per national policy. We retrospectively reviewed and collated patient logs from the hospital\u0026rsquo;s inpatient TB registry as well as the laboratory\u0026rsquo;s TB registry, to identify all cases of UG-TB over the eight-year study period. The data extraction sheet developed in Kobocollect was used to collect relevant clinical information. Demographic data included age, gender, residence, and health insurance. Clinical information focused on chief complaint, comorbidities, affected organs, diagnostic and treatment modalities and their outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of King Faisal Hospital, Rwanda\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTable 1:\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cu\u003eCohort Characteristics (N=32)\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"560\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=32 (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e18-55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e29 (90.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u0026gt;55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e31 (96.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (3.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eOrigin\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eUrban (national)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eRural (national)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eForeigner\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eInsurance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eCommunity-based\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e22 (68.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eFormal insurance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003ePrivate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eNone\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e28 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003eYes (prostate cancer, DM, HTN and asthma)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eHIV Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 306px;\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTable 2:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;Scrotal TB \u0026ndash; Patient Characteristics and Surgical Management (n=24)\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAffected organ\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of cases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical finding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical Treatment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEpididymal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEpididymal nodule\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEpididymectomy (n= 2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral with ipsilateral non-functioning kidney\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eEpididymal nodule\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNephrectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eB/L epididymal nodule\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral epididymectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral with ipsilateral testicular TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eTesticular mass mimicking cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eRadical orchiectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral with ipsilateral testicular TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eFournier\u0026rsquo;s Gangrene with fistula between epididymis and testicle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eFournier\u0026rsquo;s gangrene debridement, orchi-epididymectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTable 3:\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u003cu\u003eUrinary TB\u003cstrong\u003e\u0026nbsp;-\u0026nbsp;\u003c/strong\u003ePatient Characteristics and management (n=8)\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChief complaint\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ecases\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImaging modality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImaging findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFinal surgical management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral flank pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCT-IVU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral renal calyces scarring and distal ureter tight strictures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNephrectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral flank pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCT-IVU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003ePartial ureteral strictures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUreteral stents \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral flank pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCT-IVU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral hydronephrosis and ureteric strictures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral nephrectomy, ureteral stent in contralateral side\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral flank pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCT-IVU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral ureteral strictures and unilateral atrophic kidney\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eRight nephroureterectomy and left ureterectomy with ileal ureteral interposition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eRenal failure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eMRI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBilateral pyonephrosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eUnilateral nephrectomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eLUTS/CPPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCT-IVU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eDiffuse bladder mucosal inflammation on cystoscopy \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eNone \u0026ndash; medical\u003c/p\u003e\n \u003cp\u003etreatment alone \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eLUTS/OAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eCUG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eSmall bladder capacity with bilateral distal ureteral strictures\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003eBladder augmentation and bilateral ureteroneocystostomy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Results","content":"\u003cp\u003eOver a period of eight years (2015-2023), there were 612 TB cases and 382 extrapulmonary TB. Of the EPTB cases, 32 (8.37%) patients were diagnosed and treated for UG-TB (Table 1). Almost all UG-TB patients were male (96.9%), Rwandan nationals (90.6%) and young (90.6% under 55 years old, mean age 40.3, SD +/- 13.7). The majority of patients had no known medical comorbidities (87.5%). None of the patients was HIV positive and none of them had a history of pulmonary TB. Nearly half (41%) of patients underwent a surgical intervention for their UG-TB disease. One patient (3.1%) died during their hospital admission of complications related to their UG-TB. The majority of patients (68.8%) were insured with community-based health insurance (CBHI).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of cases (39.5%) were diagnosed using smear microscopy (Ziehl-Neelsen strain/auramine stain), followed by GeneXpert of urine or epididymal aspirate (27.9%), culture on Lowenstein\u0026ndash;Jensen medium (21.0%), and organism visualization on histopathology (11.6%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe most common disease presentation involved the scrotum and/or testicles. Twenty-four patients (75%) presented with a scrotal mass. Of these, 20 (83%) presented with a unilateral epididymal nodule, of which 18 were treated medically and 2 were treated surgically with an epididymectomy. The additional four patients with scrotal pathology presented differently. One presented with a unilateral epididymal nodule and an ipsilateral non-functioning kidney, one presented with bilateral epididymal nodules, one presented with a testicular mass mimicking testis cancer on exam, and one presented with Fournier\u0026rsquo;s gangrene and a fistula between the epididymis and testicle. The management of each of these patients is displayed in Table 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne-quarter of patients (n=8; 25%) presented with upper urinary tract and bladder TB. CT urography was the main imaging diagnostic modality for these cases. Five of these patients (62%) presented with flank pain, one with renal failure, and three with lower urinary tract symptoms \u0026ndash; including chronic pelvic pain syndrome and overactive bladder (Table 3). Three patients required nephrectomy, one underwent bladder augmentation with bilateral ureteroneocystostomy, and one required unilateral nephroureterectomy and contralateral ileal ureteral interposition.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTuberculosis remains one of the world\u0026rsquo;s most serious infectious diseases, posing a significant global health threat due to its persistent prevalence, rising drug resistance, and potential for severe complications if left untreated (1). Treating pulmonary tuberculosis poses a substantial clinical and public health challenge; however, extrapulmonary manifestations, often more insidious and difficult to diagnose, tend to receive less attention despite their complexity and potential severity (2-3). Despite UG-TB being the second most common EPTB, there exists limited research and guidance on its diagnosis, treatment, and pathophysiology, specifically in Sub-Saharan Africa.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our cohort of patients at King Faisal Hospital (KFH) in Rwanda, UG-TB was notably a disease of primarily young and healthy men, with patient ages ranging from 20 to 55 years. None of our patients had a history of HIV co-infection and 87.5% were without major medical comorbidities. These results are unique compared to prior research. Globally, 12% of patients infected with TB are co-infected with HIV (11), and\u003cem\u003e\u0026nbsp;\u003c/em\u003ein areas of the world like sub-Saharan Africa, up to 60% to 90% of those with extrapulmonary disease will test positive for HIV. (12) In a study of 57 patients with UG-TB in Taiwan, notably 89% had comorbid conditions ranging from diabetes mellitus type II to chronic kidney disease. (13)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite our cohort of healthier, younger men, a significant portion of these patients underwent surgical interventions for their disease. Thirteen of the 32 patients (41%) underwent surgery \u0026ndash; ranging from epididymectomy and orchiectomy to nephrectomy, bladder augmentation, ureteroneocystostomy and ileal ureter creation. Of the patients that presented with UG-TB outside the scrotum, 6 patients (66%) required major intra-abdominal urologic surgery. These surgeries are complex and may require sub-specialty training to perform. They also carry a significant risk of morbidity, even in high-income settings, which is substantially compounded in low-income countries. A 2018 study published in the Lancet evaluated 7-day surgical outcomes of 11,422 patients in 25 African countries and found that despite a low-risk profile and few postoperative complications, patients in LMICs were twice as likely to die after surgery when compared to the global average. (14) Similarly, in a large international, prospective, multi-centre study evaluating patients undergoing elective or emergency intestinal surgery within a two-week period, countries with a low Human Development Index (HDI) carried a disproportionately greater burden of surgical site infections as compared to middle or high HDI countries. (15) UG-TB carries an even greater potential burden of morbidity in LMICs, where limited subspecialty expertise, resource constraints, and higher postoperative complication rates compound the risks of already complex urologic surgeries, making the disease uniquely devastating in these settings.\u003c/p\u003e\n\u003cp\u003eAccurate diagnosis presents a further challenge of UG-TB. UG-TB can present with non-specific lower urinary tract symptoms, sterile pyuria, or abnormalities in semen analyses (4). Urine culture on Lowenstein-Jensen medium is considered the gold standard for diagnosing UG-TB. (16) However, cultures take six to eight weeks to result and have sensitivity ranging from 24 to 56.4% for a single urine culture sample. (16) Although the sensitivity can improve with multiple samples, this is not often feasible in LMIC settings. One faster and more cost-effective option for diagnosing UG-TB is smear microscopy using Ziehl\u0026ndash;Neelsen (ZN) or auramine staining showing acid-fast bacilli (AFB) in urine samples, semen, tissue, prostatic fluid or pus. While this test has 97% specificity, the sensitivity is only 20%. (17) In recent years, nucleic acid amplification tests (NAATs) have become commercially available for diagnosing pulmonary tuberculosis. The readily available Gene Xpert MTB/RIF that can provide results for sputum samples in 24-48 hours (18). Although not originally designed for urine samples, various protocols have been developed to reappropriate the test for cases of suspected UG-TB. One meta-analysis of 12 unique studies reported a pooled sensitivity and specificity of Gene Xpert of 89% and 95%, respectively, for detecting UG-TB when compared to mycobacterial culture; and 55% and 99%, respectively, when compared to the composite reference standard. (19)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our cohort, the majority of patients (39%) were diagnosed using smear microscopy, the diagnostic test with the lowest reported sensitivity for the disease. While 28% were diagnosed using a locally developed protocol for Gene Xpert testing of either urine samples or epididymal aspirate, we suspect that the overall case number in our cohort is an under-estimation of the true incidence of UG-TB in our hospital setting because of the high frequency of false negatives with single agent testing, for each diagnostic modality. This is a limitation of our study, but it also highlights the difficulty of diagnosing UG-TB appropriately and the need for future studies to improve diagnostic testing for the disease.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study has several additional limitations. First, KFH is a relatively small and semi-private hospital. Although the majority of patients in our cohort (68.8%) were enrolled in community-based health insurance (CBHI), KFH does not readily accept CBHI or provide care for uninsured patients, unless the patient is willing to pay for care out-of-pocket or they are transferred to the facility for clinical complexity. This creates an inherent selection bias in our sample. We suspect that our cohort likely under-represents the true annual burden of UG-TB cases in Rwanda. In addition, because most of our patients carried CBHI, it suggests that UG-TB may disproportionately affect poorer populations, which is consistent with other TB literature (20), and therefore we suspect that the burden of disease is likely much higher at public hospitals that routinely accept these patients. Second, while we included men with TB of their reproductive organs, we did not include female patients with genital TB in this study. Only female cases with urinary TB were included. Since it is estimated that the ratio of men to women with UG-TB is 2:1, we suspect that inclusion of female genital TB may have increased our cohort size by as much as 50% (6). Further research is needed to investigate the presentations of genital TB among women in Rwanda. \u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study contributes to the limited but growing body of literature on urogenital tuberculosis, highlighting the significant surgical burden in a group of otherwise young, healthy men. Our findings underscore that UG-TB has the potential to be highly morbid in LMICs, where limited access to advanced diagnostics, delayed recognition, and constrained surgical capacity amplify its impact. Given the complexity of the surgical procedures often required, there is a critical need to expand subspecialty training in complex urinary reconstruction to equip urologists with the skills necessary to manage these challenging cases. At the same time, current diagnostic strategies for UG-TB remain outdated and insufficiently sensitive, and the pathophysiology of the disease is still poorly understood. Future efforts must therefore prioritize both capacity-building in surgical training and research aimed at developing more accurate diagnostic tools and deepening our understanding of disease mechanisms. Expanding such efforts across Rwanda\u0026rsquo;s public hospitals and community health settings will be essential to capture the true burden and clinical presentations of UG-TB and to design interventions that reduce its significant morbidity for LMICs where TB remains endemic.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e1. TB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e2. EPTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtrapulmonary TB\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e3. UG-TB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eurogenital tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e4. Mtb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMycobacterium tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e5. LMICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and middle-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e6. HICs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHigh-income countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e7. KFH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKing Faisal hospital, Rwanda\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e8. CBHI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCommunity-based health insurance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e9. HDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Development Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e10. ZN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eZiehl\u0026ndash;Neelsen\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e11. AFB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcid-fast bacilli\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e12. NAATs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNucleic acid amplification tests\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical approval\u003c/h2\u003e \u003cp\u003eThis study was approved by the Institutional Review Board of King Faisal Hospital, Rwanda\u003c/p\u003e \u003ch2\u003eEthics approval and consent to participate:\u003c/h2\u003e \u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. This is a retrospective chart review study that was approved by the relevant ethical review boards in Rwanda with an IRB from KFH, and individual patient consent was not determined to be needed\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eAll the authors agreed to publication of this article.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e-EN: Conceptualization, supervision, methodology, data curation, writing - original draft. -TN: Conceptualization, supervision, methodology, data curation, writing - reviewing and editing- NU/FR/CN/PM: Data curation and input- JK: Supervision, methodology, writing - reviewing and editing- FK: writing - reviewing and editing\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank all participants and the staff at King Faisal Hospital in Rwanda for their support.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global tuberculosis report 2023. Geneva; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVillar-Hernandez R, Ghodousi A, Konstantynovska O, Duarte R, Lange C, Raviglione M. Tuberculosis: current challenges and beyond. Breathe (Sheff). 2023;19(1):220166.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuneer A, Macrae B, Krishnamoorthy S, Zumla A. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019;16(10):573\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoddy K, Tobin E, Leslie S, Rathish B. Genitourinary Tuberculosis. StatPearls [internet[Treasure Island (FL): StatPearls Publishing; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueiredo AA, Lucon AM, Srougi M. Urogenital Tuberculosis. Microbiol Spectr. 2017;5(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueiredo AA, Lucon AM. Urogenital tuberculosis: update and review of 8961 cases from the world literature. Rev Urol. 2008;10(3):207\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMukhopadhyay D, Booth S, Sbitli T, Shiley KT, Pomakova D. Invasive Mycobacterium bovis Infection Outside the Genitourinary Tract Following Bacille Calmette-Guerin Therapy for Non-muscle Invasive Bladder Cancer. Cureus. 2024;16(7):e63613.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristensen WI. Genitourinary tuberculosis: review of 102 cases. Med (Baltim). 1974;53(5):377\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeghji J, Mortimer K, Agusti A, Allwood BW, Asher I, Bateman ED, et al. Improving lung health in low-income and middle-income countries: from challenges to solutions. Lancet. 2021;397(10277):928\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeaza A, Tola HH, Eshetu K, Mindaye T, Medhin G, Gumi B. Tuberculosis among refugees and migrant populations: Systematic review. PLoS ONE. 2022;17(6):e0268696.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBausch K, Mantica G, Smith EJ, Bartoletti R, Bruyere F, Cai T, et al. Genitourinary Tuberculosis: A Brief Manual for Urologists on Diagnosis and Treatment from the European Association of Urology Urological Infections Panel. Eur Urol Focus. 2024;10(1):77\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatters DA. Surgery for tuberculosis before and after human immunodeficiency virus infection: a tropical perspective. Br J Surg. 1997;84(1):8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang TY, Hung CH, Hsu WH, Peng KT, Hung MS, Lai LJ, et al. Genitourinary tuberculosis in Taiwan: A 15-year experience at a teaching hospital. J Microbiol Immunol Infect. 2019;52(2):312\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiccard BM, Madiba TE, Kluyts HL, Munlemvo DM, Madzimbamuto FD, Basenero A, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet. 2018;391(10130):1589\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlobalSurg C. Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study. Lancet Infect Dis. 2018;18(5):516\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFigueiredo AA, Truzzi JC, Barreto AA, Siqueira EC, Lucon M, Broglio M et al. Urogenital Tuberculosis: A Narrative Review and recommendations for diagnosis and treatment. Int Braz J Urol. 2025;51(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewinsohn DM, Leonard MK, LoBue PA, Cohn DL, Daley CL, Desmond E, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017;64(2):111\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteingart KR, Schiller I, Horne DJ, Pai M, Boehme CC, Dendukuri N. Xpert\u0026reg; MTB/RIF assay for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev. 2014;1:CD009593. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD009593.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD009593.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen K, Malik AA, Nantasenamat C, Ahmed S, Chaudhary O, Sun C, et al. Clinical validation of urine-based Xpert(R) MTB/RIF assay for the diagnosis of urogenital tuberculosis: A systematic review and meta-analysis. Int J Infect Dis. 2020;95:15\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMishra KG, Ahmad A, Singh G, et al. Current status of genitourinary tuberculosis: presentation, diagnostic approach and management\u0026mdash;single centre experience at IGIMS (Patna, Bihar, India). Indian J Surg. 2020;82:817\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12262-020-02115-z\u003c/span\u003e\u003cspan address=\"10.1007/s12262-020-02115-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Uro-genital tuberculosis, Mycobacterium tuberculosis, granulomatous inflammation, Gene Xpert-MTB/RIF assay.","lastPublishedDoi":"10.21203/rs.3.rs-8138737/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8138737/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eTuberculosis remains the second leading infectious killer worldwide. Extrapulmonary tuberculosis represents 15%-40% of all cases, with urogenital tuberculosis (UG-TB) as the second most common form. UG-TB can cause severe urologic complications - including obstructive uropathy, renal failure, and infertility - due to inflammation and scarring. This study describes the presentation of UG-TB at a tertiary hospital in a low- and middle-income country (LMIC), aiming to raise clinical suspicion among providers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWe conducted a retrospective, cross-sectional study of patients diagnosed with UG-TB at a semi-private, tertiary referral hospital with a 160-bed capacity in Kigali, Rwanda between 2015 and 2023. We collated patient logs from the hospital\u0026rsquo;s inpatient and laboratory's tuberculosis registry to identify all cases of UG-TB.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003e32 patients were diagnosed and treated for UG-TB. Nearly all were male (96.9%), Rwandan nationals (90.6%), and younger than 55 years old (90.6%). Most had no known medical comorbidities (87.5%) and none were HIV positive. The majority (75%) presented with a scrotal mass, typically a unilateral epididymal nodule (83%); and the remaining presented with upper urinary tract and/or bladder TB. Nearly half (41%) of the patients required surgical intervention for their disease. Three patients required nephrectomy, one underwent bladder augmentation with bilateral ureteroneocystostomy, and one required unilateral nephroureterectomy with contralateral ileal ureter.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eUG-TB imposes a high surgical burden in otherwise young, healthy men. Expanding subspecialty training in complex urinary reconstruction is essential to equip urologists to manage these challenging cases.\u003c/p\u003e","manuscriptTitle":"Understanding the Clinical Presentation of Patients with Urogenital Tuberculosis in a Sub- Saharan Tertiary Care Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-09 10:37:46","doi":"10.21203/rs.3.rs-8138737/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-03-10T08:54:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"218937180344858078077872158458120196956","date":"2026-01-23T08:22:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-20T18:07:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150110007715470410570539094792207995311","date":"2026-01-15T04:01:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T20:07:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"139961764153790386597527074659499316373","date":"2026-01-07T23:52:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T21:07:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T12:29:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-12T21:08:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-11T15:15:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-12-11T14:59:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e9d48934-d1d6-48bf-8779-7ee6142b45a2","owner":[],"postedDate":"January 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-09T10:37:46+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-09 10:37:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8138737","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8138737","identity":"rs-8138737","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}