A 76-year-old man with diabetes and a 2-year history of mediastinal lymphadenopathy of unknown cause presented with fever and fatigue. Pyuria was seen on urinalysis. Contrast-enhanced computed tomography (CT) of the abdomen showed mild dilatation of the left renal pelvis and thickening of the ipsilateral ureteral wall (Panels A and B, arrows); the excretory phase on CT showed mild narrowing of the left ureter (Panel C, arrows). He was treated with a beta-lactam antibiotic, but pyuria and fever persisted. The results of a urine culture were negative. Urinary acid-fast staining revealed the presence of acid-fast bacilli (Panel D). A polymerase-chain-reaction assay for Mycobacterium tuberculosis was positive. Patients with urinary tract tuberculosis can present with dysuria and hematuria, though many patients are asymptomatic, with only sterile pyuria, with or without microscopic hematuria. Urogenital tuberculosis may cause complications, such as ureteral strictures, oligospermia in men, and vaginal bleeding in women. The patient was treated with multiple-drug therapy for tuberculosis, and his symptoms abated.