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Tuberculosis(TB) of the Genitourinary Tract 泌尿生殖系结核

Tuberculosis(TB) of the Genitourinary Tract 泌尿生殖系结核. 瑞金医院泌尿外科. Urinary TB. A disease of young adults. 60% between 20~40y. Infecting organism — Mycobacterium tuberculosis ( 结核分支杆菌，结核杆菌 ), Tubercle bacilli. Infecting Route( 感染途径 ). Hematogenous route( 血行途径 ) from the lungs.

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Tuberculosis(TB) of the Genitourinary Tract 泌尿生殖系结核

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  1. Tuberculosis(TB) of the Genitourinary Tract泌尿生殖系结核 瑞金医院泌尿外科

  2. Urinary TB A disease of young adults. 60% between 20~40y. Infecting organism — Mycobacterium tuberculosis (结核分支杆菌，结核杆菌), Tubercle bacilli

  3. Infecting Route(感染途径) Hematogenous route(血行途径) from the lungs. Primary sites(初发部位): Kidney, Prostate (前列腺) Other organs involved: direct extension

  4. Pathogenesis(发病机理) Tubercle bacilli hit the renal cortex(肾皮质): Normal resistance(抵抗力): organism destroyed Sufficient virulence(致病力): clinical infection established.

  5. Pathogenesis TB of kidney: progresses slowly, 15~20y to destroy a kidney with good resistance. No clinical disturbance until the calyces / pelvis(肾盏/肾盂) involved.

  6. Pathology(病理)

  7. Kidney & Ureter (输尿管) Grossly: a soft, yellowish localized bulge (隆起). On section: involved area filled with cheesy material (caseation, 干酪样物质).

  8. Kidney & Ureter Walls of pelvis, calyces and ureter thickened. Ulceration(溃疡形成) in calyces. Complete ureteral stenosis(输尿管狭窄) Autonephrectomy(肾自截). Bladder urine normal and symptom absent.

  9. Kidney & Ureter Basic lesion——Tubercle foci(结核结节) Epithelioid reticulum(上皮样网) Peripheral giant cells Heal by fibrosis(纤维化).

  10. Kidney & Ureter TB is a combination of caseation(干酪样变), cavitation(空洞形成) and healing by fibrosis &scarring(纤维化和疤痕愈合). Depending on virulence vs resistance. Calcification(钙化): strongly suggestive of TB. Secondary renal stones in 10%.

  11. Left kidney: autonephrectomy Right Kidney: hydronephrosis & ureteral reflux (肾积水&输尿管返流) Contraction of the bladder (膀胱孪缩)

  12. 左肾萎缩

  13. 萎缩肾外观

  14. Caseation & Fibrosis

  15. Lt Renal Dysfunction on Radioisotope Scan(同位素扫描)

  16. Calcification (钙化)

  17. Bladder Tubercle form: white/yellow raised nodules(结节) surrounded by a halo of hyperremia(充血). Tubercles break downdeep ragged ulcers bladder irritable.

  18. 膀胱结核，多个粟粒样黄色小结节

  19. 膀胱结核，结核性溃疡

  20. Diagnosis(诊断)

  21. Just saying you had turned a corner doesn’t make it so. Just saying there is massive destruction doesn’t make it so. __John Kerry Just saying there is TB also doesn’t make it so. We must provide…… Demonstration of tubercle bacilli in urine by culture.

  22. Diagnosis: Symptoms(症状) No classic clinical picture of renal TB. Most are vesical in-origin(膀胱起源): burning, frequency(尿频) & nocturia(夜尿), hematuria(血尿)

  23. Diagnosis: Signs(体征) Kidney——no enlargement / tenderness(触痛) External genitalia(外生殖器): thickened, nontender epididymis(附睾) chronic scrotal draining sinus(阴囊窦道) Induration/nodulationof prostate & seminal vesicles(前列腺/精囊硬结)

  24. Diagnosis: Lab Findings Persistent pyuria(脓尿) without organism on culture. But acid-fast stains: 60%(+).  Culture for TB (1st morning urine): (+) percentage very high. Tuberculin test(结核菌素试验): (-) against TB.

  25. Diagnosis: X-ray Findings Chest film Plain film(平片): Enlargement of 1 kidney Obliteration(消失) of the renal & psoas (腰大肌) shadow Renal stones(肾结石) 10%

  26. Diagnosis: X-ray Findings Excretory urograms(排泄性尿路造影): “Moth-eaten”(蚤咬) appearance of ulcerated calyces. Obliteration of 1/more calyces. Dilation of calyces. Abscess cavities connecting with calyces.

  27. Excretory urograms: Ureteral stricture with secondary dilatation. Absence of function of the kidney. Retrograde Urography

  28. MRU or CT

  29. Diagnosis: Instrumental Exams Cystoscope(膀胱镜): Tubercles & ulcers, contraction(孪缩) Cystogram(膀胱造影): Ureteral reflux(输尿管返流)

  30. Differential Diagnosis鉴别诊断 Chronic nonspecific cystitis 慢性膀胱炎 Epididymitis 附睾炎 Multiple small renal stones and medullary sponge kidneys(海绵肾) Urinary bilharziasis(血吸虫病) Bladder stones or cancer.

  31. Treatment (治疗) TB must be treated as a generalized disease!

  32. Basic treatment——Medical 药物 Surgical excision(外科切除) —— merely adjunct

  33. Treatment: Renal TB Combination of drugs(1st line): 1. Isoniazid (INH, 异烟肼) 200~300mg/d 2. Rifapin (RFP, 利福平) 450~600mg/d 3. Ethambutol (EMB, 乙胺丁醇) 15mg/kg/d 4. Streptomycin (STM, 链霉素) 1g/d im 5. Pyrazinamide (PZA, 吡嗪酰胺) 1.5~2g/d

  34. Treatment: Renal TB Prefer —— INH + RFP + EMB Resistance to 1st line drugs: Aminosalicylic acid (氨基水杨酸) Capreomycin (卷须霉素) Cycloserine (环丝氨酸) Ethionamide (乙硫异烟胺) Viomycin (紫霉素)

  35. Treatment: Renal TB Nephrectomy(肾切除) : 1. After 3 m, urine culture still (+) and gross involvement radiologically evident. 2. Severe sepsis(脓毒症), pain or bleeding from 1 kidney. 3. Marked advanced on 1 side and minimal damage on the other.

  36. Treatment: Vesical TB Tends to heal when treatment for the “primary” infection is given. Ulcers : trans-urethral electrocoagulation (经尿道电凝) Extreme bladder contraction: urinary diversion(尿流改道); augmentation cystoplasty(节段性膀胱成形术)

  37. Treatment: General Measures Optimal nutrition: important Irritable bladder: bladder sedatives(镇静剂) tolterodine, oxybutynin

  38. Prognosis(预后) Relapse(复发): Ureteral stenosis; Vesical contraction

  39. Prognosis Overall control rate: 98% at 5 years Urine study: every 6 m during treatment; every year for 10 years.

  40. Case Report A 56y male with left abdominal mass & anemia(贫血). X-ray showed a large stone in Lt kidney with severe hydronephrosis.

  41. Physician, Surgeon & Pathologist Physicians know everything but do nothing. Surgeons do everything but know nothing. Pathologists know everything and do everything BUT…… IT’S TOO LATE!

  42. 谢 谢

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