泌尿生殖系结核

1、泌尿生殖系结核泌尿生殖系结核第1页Urinary TBA disease of young adults. 60% between 2040y.Infecting organism Mycobacterium tuberculosis (结核分支杆菌，结核杆菌), Tubercle bacilli 泌尿生殖系结核第2页Infecting Route(感染路径)Hematogenous route(血行路径) from the lungs.Primary sites(初发部位): Kidney, Prostate (前列腺)Other organs involved: direct extens

2、ion 泌尿生殖系结核第3页Pathogenesis(发病机理)Tubercle bacilli hit the renal cortex(肾皮质):Normal resistance(抵抗力): organism destroyedSufficient virulence(致病力): clinical infection established.泌尿生殖系结核第4页PathogenesisTB of kidney: progresses slowly, 1520y to destroy a kidney with good resistance.No clinical disturbance

3、 until the calyces / pelvis(肾盏/肾盂) involved.泌尿生殖系结核第5页Pathology(病理)泌尿生殖系结核第6页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).泌尿生殖系结核第7页Kidney & UreterWalls of pelvis, calyces and ureter thickened. Ulceratio

4、n(溃疡形成) in calyces.Complete ureteral stenosis(输尿管狭窄) Autonephrectomy(肾自截). Bladder urine normal and symptom absent.泌尿生殖系结核第8页Kidney & UreterBasic lesionTubercle foci(结核结节) Epithelioid reticulum(上皮样网) Peripheral giant cellsHeal by fibrosis(纤维化).泌尿生殖系结核第9页Kidney & UreterTB is a combination of caseatio

5、n(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%.泌尿生殖系结核第10页Left kidney: autonephrectomyRight Kidney: hydronephrosis & ureteral reflux (肾积水&输尿管返流)Contraction of the b

6、ladder (膀胱孪缩) 泌尿生殖系结核第11页左肾萎缩泌尿生殖系结核第12页萎缩肾外观泌尿生殖系结核第13页Caseation & Fibrosis泌尿生殖系结核第14页Lt Renal Dysfunction on Radioisotope Scan(同位素扫描)泌尿生殖系结核第15页Calcification (钙化)泌尿生殖系结核第16页BladderTubercle form: white/yellow raised nodules(结节) surrounded by a halo of hyperremia(充血).Tubercles break downdeep ragged

7、ulcers bladder irritable. 泌尿生殖系结核第17页膀胱结核，多个粟粒样黄色小结节泌尿生殖系结核第18页膀胱结核，结核性溃疡泌尿生殖系结核第19页Diagnosis(诊疗)泌尿生殖系结核第20页Just saying you had turned a corner doesnt make it so.Just saying there is massive destruction doesnt make it so. _John KerryJust saying there is TB also doesnt make it so.We must provideDemon

8、stration of tubercle bacilli in urine by culture.泌尿生殖系结核第21页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)泌尿生殖系结核第22页Diagnosis: Signs(体征)Kidneyno enlargement / tenderness(触痛)External genitalia(外生殖器

9、): 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) 泌尿生殖系结核第23页Diagnosis: Lab FindingsPersistent pyuria(脓尿) without organism on culture. But acid-fast stains: 60%(+). Culture for TB (1st morning urine): (+) percent

10、age very high.Tuberculin test(结核菌素试验): (-) against TB.泌尿生殖系结核第24页Diagnosis: X-ray FindingsChest filmPlain film(平片): Enlargement of 1 kidney Obliteration(消失) of the renal & psoas (腰大肌) shadow Renal stones(肾结石) 10%泌尿生殖系结核第25页Diagnosis: X-ray FindingsExcretory urograms(排泄性尿路造影): “Moth-eaten”(蚤咬) appear

11、ance of ulcerated calyces. Obliteration of 1/more calyces. Dilation of calyces. Abscess cavities connecting with calyces.泌尿生殖系结核第26页Excretory urograms: Ureteral stricture with secondary dilatation. Absence of function of the kidney.Retrograde Urography泌尿生殖系结核第27页泌尿生殖系结核第28页泌尿生殖系结核第29页MRU or CT泌尿生殖系结

12、核第30页泌尿生殖系结核第31页Diagnosis: Instrumental ExamsCystoscope(膀胱镜): Tubercles & ulcers, contraction(孪缩)Cystogram(膀胱造影): Ureteral reflux(输尿管返流)泌尿生殖系结核第32页Differential Diagnosis判别诊疗Chronic nonspecific cystitis 慢性膀胱炎Epididymitis 附睾炎Multiple small renal stones and medullary sponge kidneys(海绵肾)Urinary bilharzi

13、asis(血吸虫病)Bladder stones or cancer. 泌尿生殖系结核第33页Treatment (治疗)TB must be treated as a generalized disease!泌尿生殖系结核第34页Basic treatmentMedical 药品Surgical excision(外科切除) merely adjunct泌尿生殖系结核第35页Treatment: Renal TBCombination of drugs(1st line):1. Isoniazid (INH, 异烟肼) 200300mg/d2. Rifapin (RFP, 利福平) 4506

14、00mg/d3. Ethambutol (EMB, 乙胺丁醇) 15mg/kg/d4. Streptomycin (STM, 链霉素) 1g/d im5. Pyrazinamide (PZA, 吡嗪酰胺) 1.52g/d泌尿生殖系结核第36页Treatment: Renal TBPrefer INH + RFP + EMBResistance 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)泌尿生殖系结核第37页Tr

15、eatment: Renal TBNephrectomy(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. 泌尿生殖系结核第38页Treatment: Vesical TBTends to heal when treatment for t

16、he “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)泌尿生殖系结核第39页Treatment: General MeasuresOptimal nutrition: importantIrritable bladder: bladder sedatives(镇静剂) tolterodine, oxybutyni

17、n泌尿生殖系结核第40页Prognosis(预后)Relapse(复发): Ureteral stenosis; Vesical contraction 泌尿生殖系结核第41页PrognosisOverall control rate: 98% at 5 yearsUrine study: every 6 m during treatment; every year for 10 years.泌尿生殖系结核第42页Case ReportA 56y male with left abdominal mass & anemia(贫血).X-ray showed a large stone in Lt kidney with severe h