What is the management of a tuberculated bladder?

Management of Tuberculated Bladder

The standard treatment for tuberculated bladder is a 6-month regimen of anti-tuberculosis drugs, consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for the first 2 months, followed by isoniazid and rifampicin for 4 months. 1

Medical Management

First-Line Treatment

• A standard 6-month regimen is recommended for genitourinary tuberculosis, including tuberculated bladder 1
• Initial phase (first 2 months): Four drugs - isoniazid, rifampicin, pyrazinamide, and ethambutol 1
• Continuation phase (next 4 months): Two drugs - isoniazid and rifampicin 1
• Recommended adult dosages: isoniazid 5 mg/kg (up to 300 mg) daily, rifampicin 10 mg/kg (up to 600 mg) daily, pyrazinamide 35 mg/kg (up to 2.0 g) daily, and ethambutol 15 mg/kg daily 2

Monitoring During Treatment

• Liver function should be evaluated before starting treatment 2, 3
• Regular monitoring is not necessary for patients without pre-existing liver disease but should be repeated if symptoms such as fever, malaise, vomiting, jaundice, or unexplained deterioration occur 2, 3
• If liver enzymes (AST/ALT) increase to five times normal or bilirubin increases, rifampicin, isoniazid, and pyrazinamide should be discontinued 2, 3
• Renal function should be evaluated before starting treatment with ethambutol 2, 3
• Visual acuity should be tested using the Snellen chart before prescribing ethambutol 2, 3

Management of Complications

• If ureteral obstruction occurs, procedures to relieve the obstruction are indicated 1
• In cases of hydronephrosis and progressive renal insufficiency due to obstruction, renal drainage by stenting or nephrostomy is advised 1
• Nephrectomy is considered when there is a nonfunctioning or poorly functioning kidney, particularly if hypertension or continuous flank pain is present 1
• Dose adjustment is required in patients with coexisting renal failure 1

Special Considerations

Drug Resistance

• If multidrug-resistant tuberculosis is suspected, treatment should include at least five medications in the intensive phase and four medications in the continuation phase 4
• For patients with pre-XDR and XDR tuberculosis, a total treatment duration of 15 to 24 months after culture conversion is suggested 4
• While waiting for drug susceptibility test results, the therapeutic regimen should include 5 to 7 drugs selected based on the patient's characteristics 5

Compliance Issues

• Combined drug preparations (e.g., Rifinah, Rimactazid, Rifater) can be used to improve compliance 1, 2
• Directly observed therapy (DOT) is recommended for patients who are unlikely to comply with self-medication, including homeless individuals, alcoholics, drug abusers, seriously mentally ill patients, and those with a history of non-compliance 1

Management of Hepatotoxicity

• If hepatotoxicity develops during treatment, suspend treatment until liver function normalizes 3
• Reintroduce drugs sequentially, starting with isoniazid at 50 mg/day, increasing to 300 mg/day after 2-3 days 3
• Add rifampicin at 75 mg/day after 2-3 days without reaction and increase to full dose 3
• Add pyrazinamide at 250 mg/day and increase to full dose 3

Surgical Management

• Tuberculosis of the genitourinary tract responds well to standard chemotherapy, but surgery may be indicated in specific cases 1
• Surgical intervention is necessary for complications such as ureteral obstruction, hydronephrosis, or non-functioning kidneys 1, 6
• Procedures may include stenting, nephrostomy, or nephrectomy depending on the extent of damage 1, 6

By following this comprehensive approach to managing tuberculated bladder, clinicians can effectively treat the infection while minimizing complications and preventing drug resistance.