tuberculosis(tb) of the genitourinary tract 泌尿生殖系结核
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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Tuberculosis(TB) of the Genitourinary Tract
泌尿生殖系结核瑞金医院泌尿外科
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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
•
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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
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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.
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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.
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Pathology( 病理 )
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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 ).
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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.
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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 ).
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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%.
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• Left kidney: autonephrectomy
• Right Kidney: hydronephrosis & ureteral reflux ( 肾积水 & 输尿管返流 )
• Contraction of the bladder ( 膀胱孪缩 )
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左肾萎缩
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萎缩肾外观
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Caseation & Fibrosis
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Lt Renal Dysfunction on Radioisotope Scan( 同位素扫描 )
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Calcification ( 钙化 )
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Bladder
• Tubercle form: white/yellow raised
nodules( 结节 ) surrounded by a halo of
hyperremia( 充血 ).
• Tubercles break downdeep ragged
ulcers bladder irritable.
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膀胱结核,多个粟粒样黄色小结节
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膀胱结核,结核性溃疡
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Diagnosis( 诊断 )
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• 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.
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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 )
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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 )
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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.
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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%
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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.
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• Excretory urograms:
• Ureteral stricture with secondary dilatation.
• Absence of function of the kidney.
• Retrograde Urography
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MRU or CT
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Diagnosis: Instrumental Exams
• Cystoscope(膀胱镜 ):
• Tubercles & ulcers, contraction( 孪缩 )
• Cystogram(膀胱造影 ):
• Ureteral reflux( 输尿管返流 )
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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.
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Treatment ( 治疗 )
TB must be treated as a generalized disease!
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• Basic treatment——Medical 药物
• Surgical excision( 外科切除 ) —— merely adjunct
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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
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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 )
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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.
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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 )
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Treatment: General Measures
• Optimal nutrition: important
• Irritable bladder: bladder sedatives( 镇静剂 )
• tolterodine, oxybutynin
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Prognosis( 预后 )
• Relapse( 复发 ):
• Ureteral stenosis; • Vesical contraction
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Prognosis
• Overall control rate: 98% at 5 years
• Urine study: every 6 m during treatment; every year for 10 years.
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Case Report
• A 56y male with left abdominal mass & anemia( 贫血 ).
• X-ray showed a large stone in Lt kidney with severe hydronephrosis.
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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!
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谢 谢