Genital Tuberculosis - Scrotal Swelling with Two Sinuses (TB Epididymitis + Funiculitis)

Clinical Picture You're Describing

"A chronic draining sinus through the scrotal skin is almost pathognomonic of tuberculous epididymitis." "Tuberculosis of the epididymis usually presents as a painless or only mildly painful swelling. An abscess may drain spontaneously through the scrotal wall."

Diagnosis Workup First

Treatment

1. Medical Treatment (PRIMARY - the foundation)

• Isoniazid: 300 mg/day orally; always give with pyridoxine 25-50 mg/day to prevent peripheral neuropathy
• Rifampicin: 600 mg/day (or 450 mg if <50 kg); potent CYP450 inducer - check for drug interactions
• Pyrazinamide: 1500-2000 mg/day; can worsen gout (raises uric acid)
• Ethambutol: 800-1200 mg/day; monitor for optic neuritis (check visual acuity)

2. Adjunctive Medical Measures

• Nutritional optimization: Important for recovery and immune function
• Anticholinergic medications: If there is associated bladder irritability/cystitis

Surgical Treatment

"The ducts of the involved epididymis become occluded. If this is bilateral, sterility results. Abscesses of the epididymis may invade the testes and even involve the scrotal skin."

Complications to Monitor

• Bilateral involvement - leads to obstructive azoospermia and infertility
• Testicular invasion - orchitis, abscess
• Scrotal skin involvement - multiple sinuses (like your case)
• Concurrent upper urinary tract TB - always image kidneys/ureters; involvement ranges up to 10% in men with genital TB

Summary Algorithm

Scrotal swelling + chronic draining sinus(es) + painless/mildly painful
       ↓
Suspect TB epididymitis (± funiculitis)
       ↓
Workup: Urine cultures x3, AFB smear, sinus discharge culture, USS scrotum, CXR
       ↓
Confirm → Start HRZE x 2 months + HR x 4 months (total 6 months)
+ Pyridoxine 25 mg/day with INH
       ↓
Surgery ONLY if: abscess not resolving, persistent sinus, diagnostic doubt
(always pre-treat with 4-6 weeks ATT before surgery)
       ↓
Follow up: clinical exam, sinus healing, serial USS if needed

• Smith and Tanagho's General Urology, 19th Edition, pp. 245-248
• Harrison's Principles of Internal Medicine, 22nd Edition, p. 1465
• Katzung's Basic and Clinical Pharmacology, 16th Edition

What to Avoid During TB Treatment (Genital TB / HRZE Regimen)

1. Alcohol - STRICTLY AVOID

• Isoniazid + Rifampicin are both independently hepatotoxic. Alcohol dramatically multiplies this risk.
• Alcohol + isoniazid combination causes severe drug-induced hepatitis - one of the leading causes of treatment failure and fatalities on ATT.
• Even "social" drinking is dangerous. Complete abstinence for the entire 6-month course.
• Watch for warning signs of liver damage: yellow eyes/skin (jaundice), dark urine, nausea, right-sided abdominal pain - report immediately if these appear.

2. Missing Doses - NEVER Skip

• TB bacilli develop drug resistance rapidly when doses are missed. Once MDR-TB develops, treatment becomes far longer (18-24 months), more toxic, and less effective.
• This is why DOTS (Directly Observed Therapy) is standard - a healthcare worker watches you swallow each dose.
• If you miss a dose, do not double up the next day - just resume the normal schedule.

3. Food and Timing Interactions

4. Drugs and Medications to Avoid or Be Careful With

5. Self-Medicating / Herbal Remedies

• Avoid any liver-stressing herbal supplements: kava, comfrey, large doses of Vitamin A, traditional herbal preparations used for "liver cleansing."
• Many herbal products are hepatotoxic on their own and combined with ATT can cause acute liver failure.
• Do not start any new medication without telling your TB doctor - interactions are common.

6. Sun Exposure (Pyrazinamide)

• Pyrazinamide causes photosensitivity - skin becomes unusually sensitive to sunlight.
• Avoid prolonged sun exposure without sunscreen or protective clothing during the 2-month intensive phase.
• Also raises uric acid - avoid high-purine foods (red meat, organ meats, shellfish, beer) if you have gout or joint pains develop.

7. Eye-Straining Activities Without Monitoring (Ethambutol)

• Ethambutol causes optic neuritis - loss of red-green color discrimination is the earliest sign.
• Get a baseline eye test before starting.
• Report any visual changes immediately - blurred vision, difficulty distinguishing colors.
• Avoid delaying eye checkups if vision changes occur.

8. Sexual Activity Precautions

• During the active phase (especially the first 2 months when bacterial load is highest), use condoms - TB can theoretically be transmitted sexually in genital TB.
• Also relevant because rifampicin makes oral contraceptives ineffective (see above).

9. What NOT to Do If You Feel Better Early

• Many patients feel significantly better within 4-6 weeks and stop treatment.
• Do not stop ATT early - TB bacilli are still alive but "dormant" in caseous tissue. Stopping early causes relapse and drug resistance.
• Complete the full 6 months regardless of how well you feel.

Monitoring Schedule During Treatment

• Comprehensive Clinical Nephrology, 7th Edition, Table 54.3
• Harrison's Principles of Internal Medicine, 22nd Edition, p. 1465
• Smith and Tanagho's General Urology, 19th Edition, p. 247