泌尿男生殖系结核课件

泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核1概述泌尿、男生殖系结核(urologicandmalegenitaltuberculosis)结核杆菌侵犯泌尿、男性生殖器官引起的慢性特异性感染。约占全部肺外结合的14%与经济落后、医疗水平底有关好发年龄20~40岁青壮年男性大于女性，2：1左右概述泌尿、男生殖系结核2概述原发性结核病:首次感染结核菌,引起的结核病-肺结核继发性结核病:有结核菌感染后,已建立细胞免疫和变态反应后发生的结核病.发病机理人体首次感染结核菌—机体无免疫力—巨噬细胞不能杀死结核菌—结核菌蔓延—经淋巴或血液播散到全身—在各组织中着床—潜伏灶—一般情况下不发病—机体免疫力地下时或营养不良时—潜伏菌大量繁殖—发病概述原发性结核病:首次感染结核菌,引起的结核病-肺结3概述感染途径：4种1.血性感染：最常见2.接触感染：通过性生活或污染物传播，少见3.淋巴感染：罕见4.直接蔓延：罕见泌尿、男生殖系统内部传播：1.顺行蔓延：肾—输尿管—膀胱2.逆行蔓延：膀胱—健侧输尿管—健侧肾脏概述感染途径：4种4血行传播顺行传播逆行传播血行传播顺行传播逆行传播5Etiology

Thekidneyandpossiblytheprostatearetheprimarysitesoftuberculousinfectioninthegenitourinarytract.Allothergenitourinaryorgansbecomeinvolvedbyeitherascent(prostatetobladder)ordescent(kidneytobladder,prostatetoepididymis).Thetestismaybecomeinvolvedbydirectextensionfromepididymalinfection.EtiologyThekidneyandpossib6Pathogenesis

A.kidneyandureter:AshowerofTBhitstherenalcortex,theorganismsmaybedestroyedbynormaltissueresistance.Onlyscarsarefoundinthekidney.However,ifenoughbacteriaofsufficientvirulencebecomelodgedinthekidneyandarenotovercome,aclinicalinfectionisestablished.PathogenesisA.kidneyandur7PathogenesisA.kidneyandureter:Tuberculosisofthekidneyprogressesslowly;itmaytake15~20yearstodestroyakidneyinapatientwhohasgoodresistancetotheinfection.Therefore,thereisnorenalpainandlittleornoclinicaldisturbanceofanytypeuntilthelesionhasinvolvedthecalycesorthepelvis.Itisonlyatthisstagethatsymptoms(ofcystitis)aremanifested.PathogenesisA.kidneyandure8PathogenesisA.kidneyandureter:Asthediseaseprogress,acaseousbreakdownoftissueoccursuntiltheentirekidneyisreplacedbycheesymaterial.Calciummaybelaiddowninthereparativeprocess.Theureterundergoesfibrosisandtendstobeshortenedandstraightened.Thischangeleadstoa“golf-hole”(gaping)ureteralorifice,typicalofanincompetentvalve.PathogenesisA.kidneyandure9TuberculosisofkidneyandureterTuberculosisofkidneyandure10TuberculosisofkidneyandureterTuberculosisofkidneyandure11TuberculosisofkidneyTuberculosisofkidney12PathogenesisB.bladder:Vesicalirritabilitydevelopsasanearlyclinicalmanifestationofthediseaseasthebladderisbathedbyinfectedmaterial.Tuberclesformlater,usuallyintheregionoftheinvolvedureteralorifice,andulcerate—bleeding.Bladderbecomesfibrosedandcontracted,thisleadstomarkedfrequency.Ureteralrefluxorstenosisandhydronephrosis.PathogenesisB.bladder:13PathogenesisC.Prostateandseminalvesicles:Thepassageofinfectedurinethroughtheprostaticurethraleadstoinvasionoftheprostateandoneorbothseminalvesicles.Thereisnolocalpain.Theprimaryhematogenouslesioninthegenitourinarytraceisintheprostate.Prostaticinfectioncanascendtothebladderanddescenttotheepididymis.PathogenesisC.Prostateands14PathogenesisD.Epididymisandtestis:Tuberculosisoftheprostatecanextendtheepididymis.Thisisaslowprocess,thereisusuallynopain.Iftheepididymalinfectionisextensiveandanabscessforms,itmayrupturethroughthescrotalskin,thusestablishingapermanentsinus,oritmayextendintothetesticle.PathogenesisD.Epididymisand15Pathology病理型肾结核:结核早期病变,结核菌通过血行传播至肾皮质—结核结节和结核肉芽肿形成。结核结节:类上皮细胞、多核巨细胞、淋巴细胞、浆细胞、成纤维细胞等组成。虽然有镜下血尿、可找到结核菌，但无临床症状，IVP正常。80%累及双肾，但大多数能自行愈合，形成斑痕或钙化。Pathology病理型肾结核:16Pathology临床型肾结核:

因细菌数量大，毒性高而机体抵抗力弱，结核结节融合、扩大，逐渐向隋质发展并在肾乳头处破溃，患者出现临床症状。从病理型肾结核—临床型肾结核病史长，一般>5年90%为单侧。左、右侧发病率无差别。Pathology临床型肾结核:17Pathology肾积脓:结核菌到达肾髓质后大量繁殖，破坏肾实质。结核结节相互融合，形成干洛样坏死、液化，形成脓肿。脓肿向伸盏破溃，进入肾盂、输尿管、膀胱—导致继发性结核。脓肿也可局限在肾实质，形成闭合性浓重。极少数情况下，肾实质大部或全部被脓肿取代，形成结核型脓肾或肾积脓。Pathology肾积脓:18Pathology输尿管结核:输尿管结核最常见于下段，其次上段。病变由粘膜向全层侵犯—导致输尿管壁增厚、变硬、输尿管缩短、狭窄、收缩功能下降。输尿管完全闭塞，尿液不能排入膀胱，临床症状减轻Pathology输尿管结核:19Pathology肾自截（autonephrectomy):输尿管结核的严重表现但坏死物质不能排除，肾脏广泛破坏，功能损害至全部丧失。Pathology肾自截（autonephrectomy)20Pathology膀胱结核:同侧输尿管开口—粘膜充血、水肿等改变—形成结核结节—膀胱挛缩—纤维组织增生--对侧输尿管口狭窄，闭合不全—引起梗阻积水并感染健肾。膀胱结核溃疡向外穿透—可形成膀胱阴道瘘或膀胱直肠瘘。前列腺结核和附睾结核:少见。Pathology膀胱结核:21Pathology泌尿系结核的病理特点：组织破坏和修复混合存在。机体低抗力低时：以破坏为主—溃疡和脓肿机体低抗力高时：以修复反应为主—纤维化和钙化Pathology泌尿系结核的病理特点：22Pathology病理型肾结核临床型肾结核肾积脓输尿管结核肾自截膀胱结核前列腺结核附睾结核Pathology病理型肾结核23Clinicalfindings

Tuberculosisofthegenitourinarytractshouldbeconsideredinthepresenceofanyofthefollowingsituations:Chronicsystitisthatrefusestorespondtotherapy.Thefindingofwithoutbacteriaincultureoftheurinarysediment.Grossormicorscopichematuria.EnlargedepididymiswithabeadedorthickenedAchronicdrainingscrotalsinusIndurationornodulationoftheprostateandthickeningofoneorbothseminalvesicles.ClinicalfindingsTuberculosis24ClinicalfindingsThediagnosisrestsonthedemonstrationoftuberclebacilliintheurinebyculture.Theextentoftheinfectionisdeterminedby:1.Thepalpablefindingsintheepididymises,prostateandseminalvesiclesTherenalandureterallesionsasrevealedbyIVPinvolvementofthebladderasseenthroughthecystoscopeThedegreeofrenaldamageasmeasuredbylossoffunction.Thepresenceoftuberclebacilliinoneorbothkidneys.ClinicalfindingsThediagnosis25ClinicalfindingsA.Symptoms:ThereisnoclassicclinicalpictureofrenaltuberculosisMostsymptomsofthisdisease,arevesicalinorigin(cystitis)ClinicalfindingsA.Symptoms:26ClinicalfindingsA.Symptoms:Frequency:theearliestsymptomsofrenaltuberculosismayarisefromsecondaryvesicalinvolvement.Pyuria:nobacteriaisfoundinthecultureofurine.Hematuria:isoccasionallyfoundandisofeitherrenalorvesicalorigin.50~60%,grosshematuria:10%Painandmass:dullacheintheflank.Thepassageofabloodclot,secondarycalculi,oramassofdebrismaycauserenalandureteralcolic.Someofthenonspecificcomplaints:vaguegeneralizedmalaise,fatigability,low-gradebutpersistentfever,andnightsweats.ClinicalfindingsA.Symptoms:27ClinicalfindingsB.Signs:Evidenceofextragenitaltuberculosismaybefound(lungs,bone,lymphnodes)Kidney—usuallynoenlargementortendernessoftheinvolvedkidney.Externalgenitalia:athickened,nontenderepididymis,achronicdrainingsinusthroughthescrotalskin.Prostateandseminalvesicles:tuberculousprostateshowsareasofinduration,evennodulation.Theinvolvedseminalvesicleisindurated,enlarged,andfixed.ClinicalfindingsB.Signs:28ClinicalfindingsB.Signs:Laboratoryfindings:persistentpyuria(“sterile”pyuria)

culturesfortuberclebacillifromthefirstmorningurinearepositiveinaveryhighpercentageofcasesoftuberculousinfection.thebloodcountmaybenormaloranemia.Sedimentationrateisusuallyaccelerated.thetuberculintestshouldbeperformed.ClinicalfindingsB.Signs:29ClinicalfindingsB.Signs:X-Rayfindings:

Achestfilm:evidenceoftuberculosisAplainfilmofabdomen:enlargementofonekidneyofobliterationoftherenalshadowsduetoabscess.Renalstonesarefoundin10%ofcases.Calcificatinoftheuretermaybenoted.

ClinicalfindingsB.Signs:30ClinicalfindingsB.Signs:X-Rayfindings:IVP—thetypicalchangesinclude:

a“moth-eaten”appearanceoftheulceratedcalyces.obliterationofoneormorecalyces.dilatationofthecalycesduetoureteralstenosisfromfibrosis.abscesscavitiesthatconnectwithcalyces.singleormultipleureteralstrictures.absenceoffunctionofthekidneyduetocompleteureteralocclusionandrenaldestruction(Autonephrectomy)ClinicalfindingsB.Signs:31IVPIVP32IVPIVP33右肾不显影右肾不显影34ClinicalfindingsB.Signs:CT:Ultrasound:Cystoscope:typicaltuberclesorulcersoftuberculosis.Biopsycanbedoneifnecessary.“golf-hole”(gaping)ureteralorifice.ClinicalfindingsB.Signs:35泌尿男生殖系结核课件36泌尿男生殖系结核课件37泌尿男生殖系结核课件38泌尿男生殖系结核课件39DifferentialdiagnosisChronicnonspecificcystitisorpyelonephritisAcuteorchronicnonspecificepididymitisMultiplesmallrenalstonesTumorDifferentialdiagnosisChronic40Treatment

Thefollowingdrugsareusuallyconsideredasthefirst-linedrugs“*”:*Isoniazid:300mg/d*Rifampin:450mg/d*Pyrazinamide:1500mg/dStreptomycin:1g/d,intramuscularlyEthambutol:25mg/kg

TreatmentThefollowingdrugs41TreatmentMostauthoritiesadviseappropriatemedicationfor2years(orlongerifculturesispositive).Gow(1979)findsthata6-monthcourseofdrugsisadequate.Isoniazid,rifampin,pyrazinamideandvitaminCdailyfor2months.Followedbyisoniazid,rifampinandvitaminCfor4months.Theurinemustbestudiedbacteriologicallyevery6monthsduringtreatmentandtheneveryyearfor10year.TreatmentMostauthoritiesadvi42Treatment手术治疔肾切除:无功能肾结核；肾实质破坏2/3个大盏以上，合并有难以控制的高血压；伴输尿管严重梗阻。部分肾切除：局限在一极的病变。病灶清除术:适合于结核脓肿，一般穿刺解决。整形手术：矫正输尿管狭窄手术膀胱挛缩可采用回肠或乙状结肠膀胱扩大术尿路改道Treatment手术治疔43TreatmentForaseverelycontractedbladder,enterocystoplastywillincreasevesicalvolume．TreatmentForaseverelycontra44Treatment一侧肾结核（功能已丧失），对侧肾积水如何处理？根据积水侧功能情况进行治疔！功能尚佳者可先切除结核病肾，再解除积水梗阻。若积水严重，肾功能不良则应先解除梗阻，然后切除无功能的结核肾脏。Treatment一侧肾结核（功能已丧失），对侧肾积水如何处45PrognosisInahighpercentageofcases,Cureisobtainedbymedicalmeans.Unilateralrenallesionshavethebestprognosis.PrognosisInahighpercentage46Malegenitaltuberculosis主要来源于其他部位的结核病灶，经血行感染而来。50~70%合并男生殖器结核附睾和前列腺结核常同时存在Malegenitaltuberculosis主要来源于47Tuberculosisofepididymis大多为单侧，起病缓慢。多从尾部开始发病。附睾逐渐增大，多无明显疼痛，肿大的附睾可与阴囊粘连或形成寒性脓肿、破溃成为窦道，经久不愈。输精管增粗，呈串珠伏。直肠指检，前列腺有硬结。Tuberculosisofepididymis大多为单48泌尿男生殖系结核课件49泌尿男生殖系结核课件50Tuberculosisofepididymis附睾结核应与慢性附睾炎鉴别.

治疔原则

与肾结核相同，早期可采用药物治疗。如治疗效果不明显或病变较大，有脓肿形成，则可行附睾切除，术时应尽量保留睾丸。若睾丸有病变，病变靠近附睾，则可连同附睾将睾丸部分切除。Tuberculosisofepididymis附睾结51TreatmentInunilateralepididymalinvolvement,epididymectomypluscontralateralvasectomyisindicatedtopreventdescentoftheinfectionfromtheprostatetothatorganbilateralepididymectomyshouldbedoneifbothsidesareinvolved．TreatmentInunilateralepidid52TuberculosisofepididymisTuberculosisofepididymis53泌尿男生殖系结核课件54泌尿男生殖系结核课件55Tuberculosisofprostate常无自觉症状。有时有血精，射精痛DRE：前列腺表面有结节，无明显触痛Tuberculosisofprostate常无自觉症状56Tuberculosisofprostate诊断：反复的血精或其它部位有结核病变—警惕结核。鉴别诊断：前列腺炎—普通抗菌素有效前列腺癌—老年，DRE,PSA治疗：采用药物治疗为主，一般不采用手术治疗。Tuberculosisofprostate诊断：57ConclusionsTuberculosisisthemostimportant,mostcommonlymissedtypeofspecificgenitourinaryinfection．Itshouldalwaysbeconsideredinanycaseofpyuriawithoutbacteriuriaorinanyresistanturinarytractinfectionthatdoesnotrespondtotreatment．ConclusionsTuberculosisisthe58ConclusionsGenitourinarytuberculosisisalwayssecondarytopulmonaryinfection，thoughinmanycases，theprimaryfocushasalreadyhealedorisinasubclinicalform．Infectionoccursviathehematogenousroute．ConclusionsGenitourinarytuber59ConclusionsThekidneysand(lesscommonly)theprostateareprincipalsitesofurinarytractinvolvement,thoughallothersegmentsofthegenitourinarysystemcanbeaffected．ConclusionsThekidneysand(le60ThankYouVeryMuch!!!ThankYouVeryMuch!!!61谢谢！谢谢！62泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核泌尿男生殖系结核63概述泌尿、男生殖系结核(urologicandmalegenitaltuberculosis)结核杆菌侵犯泌尿、男性生殖器官引起的慢性特异性感染。约占全部肺外结合的14%与经济落后、医疗水平底有关好发年龄20~40岁青壮年男性大于女性，2：1左右概述泌尿、男生殖系结核64概述原发性结核病:首次感染结核菌,引起的结核病-肺结核继发性结核病:有结核菌感染后,已建立细胞免疫和变态反应后发生的结核病.发病机理人体首次感染结核菌—机体无免疫力—巨噬细胞不能杀死结核菌—结核菌蔓延—经淋巴或血液播散到全身—在各组织中着床—潜伏灶—一般情况下不发病—机体免疫力地下时或营养不良时—潜伏菌大量繁殖—发病概述原发性结核病:首次感染结核菌,引起的结核病-肺结65概述感染途径：4种1.血性感染：最常见2.接触感染：通过性生活或污染物传播，少见3.淋巴感染：罕见4.直接蔓延：罕见泌尿、男生殖系统内部传播：1.顺行蔓延：肾—输尿管—膀胱2.逆行蔓延：膀胱—健侧输尿管—健侧肾脏概述感染途径：4种66血行传播顺行传播逆行传播血行传播顺行传播逆行传播67Etiology

Thekidneyandpossiblytheprostatearetheprimarysitesoftuberculousinfectioninthegenitourinarytract.Allothergenitourinaryorgansbecomeinvolvedbyeitherascent(prostatetobladder)ordescent(kidneytobladder,prostatetoepididymis).Thetestismaybecomeinvolvedbydirectextensionfromepididymalinfection.EtiologyThekidneyandpossib68Pathogenesis

A.kidneyandureter:AshowerofTBhitstherenalcortex,theorganismsmaybedestroyedbynormaltissueresistance.Onlyscarsarefoundinthekidney.However,ifenoughbacteriaofsufficientvirulencebecomelodgedinthekidneyandarenotovercome,aclinicalinfectionisestablished.PathogenesisA.kidneyandur69PathogenesisA.kidneyandureter:Tuberculosisofthekidneyprogressesslowly;itmaytake15~20yearstodestroyakidneyinapatientwhohasgoodresistancetotheinfection.Therefore,thereisnorenalpainandlittleornoclinicaldisturbanceofanytypeuntilthelesionhasinvolvedthecalycesorthepelvis.Itisonlyatthisstagethatsymptoms(ofcystitis)aremanifested.PathogenesisA.kidneyandure70PathogenesisA.kidneyandureter:Asthediseaseprogress,acaseousbreakdownoftissueoccursuntiltheentirekidneyisreplacedbycheesymaterial.Calciummaybelaiddowninthereparativeprocess.Theureterundergoesfibrosisandtendstobeshortenedandstraightened.Thischangeleadstoa“golf-hole”(gaping)ureteralorifice,typicalofanincompetentvalve.PathogenesisA.kidneyandure71TuberculosisofkidneyandureterTuberculosisofkidneyandure72TuberculosisofkidneyandureterTuberculosisofkidneyandure73TuberculosisofkidneyTuberculosisofkidney74PathogenesisB.bladder:Vesicalirritabilitydevelopsasanearlyclinicalmanifestationofthediseaseasthebladderisbathedbyinfectedmaterial.Tuberclesformlater,usuallyintheregionoftheinvolvedureteralorifice,andulcerate—bleeding.Bladderbecomesfibrosedandcontracted,thisleadstomarkedfrequency.Ureteralrefluxorstenosisandhydronephrosis.PathogenesisB.bladder:75PathogenesisC.Prostateandseminalvesicles:Thepassageofinfectedurinethroughtheprostaticurethraleadstoinvasionoftheprostateandoneorbothseminalvesicles.Thereisnolocalpain.Theprimaryhematogenouslesioninthegenitourinarytraceisintheprostate.Prostaticinfectioncanascendtothebladderanddescenttotheepididymis.PathogenesisC.Prostateands76PathogenesisD.Epididymisandtestis:Tuberculosisoftheprostatecanextendtheepididymis.Thisisaslowprocess,thereisusuallynopain.Iftheepididymalinfectionisextensiveandanabscessforms,itmayrupturethroughthescrotalskin,thusestablishingapermanentsinus,oritmayextendintothetesticle.PathogenesisD.Epididymisand77Pathology病理型肾结核:结核早期病变,结核菌通过血行传播至肾皮质—结核结节和结核肉芽肿形成。结核结节:类上皮细胞、多核巨细胞、淋巴细胞、浆细胞、成纤维细胞等组成。虽然有镜下血尿、可找到结核菌，但无临床症状，IVP正常。80%累及双肾，但大多数能自行愈合，形成斑痕或钙化。Pathology病理型肾结核:78Pathology临床型肾结核:

因细菌数量大，毒性高而机体抵抗力弱，结核结节融合、扩大，逐渐向隋质发展并在肾乳头处破溃，患者出现临床症状。从病理型肾结核—临床型肾结核病史长，一般>5年90%为单侧。左、右侧发病率无差别。Pathology临床型肾结核:79Pathology肾积脓:结核菌到达肾髓质后大量繁殖，破坏肾实质。结核结节相互融合，形成干洛样坏死、液化，形成脓肿。脓肿向伸盏破溃，进入肾盂、输尿管、膀胱—导致继发性结核。脓肿也可局限在肾实质，形成闭合性浓重。极少数情况下，肾实质大部或全部被脓肿取代，形成结核型脓肾或肾积脓。Pathology肾积脓:80Pathology输尿管结核:输尿管结核最常见于下段，其次上段。病变由粘膜向全层侵犯—导致输尿管壁增厚、变硬、输尿管缩短、狭窄、收缩功能下降。输尿管完全闭塞，尿液不能排入膀胱，临床症状减轻Pathology输尿管结核:81Pathology肾自截（autonephrectomy):输尿管结核的严重表现但坏死物质不能排除，肾脏广泛破坏，功能损害至全部丧失。Pathology肾自截（autonephrectomy)82Pathology膀胱结核:同侧输尿管开口—粘膜充血、水肿等改变—形成结核结节—膀胱挛缩—纤维组织增生--对侧输尿管口狭窄，闭合不全—引起梗阻积水并感染健肾。膀胱结核溃疡向外穿透—可形成膀胱阴道瘘或膀胱直肠瘘。前列腺结核和附睾结核:少见。Pathology膀胱结核:83Pathology泌尿系结核的病理特点：组织破坏和修复混合存在。机体低抗力低时：以破坏为主—溃疡和脓肿机体低抗力高时：以修复反应为主—纤维化和钙化Pathology泌尿系结核的病理特点：84Pathology病理型肾结核临床型肾结核肾积脓输尿管结核肾自截膀胱结核前列腺结核附睾结核Pathology病理型肾结核85Clinicalfindings

Tuberculosisofthegenitourinarytractshouldbeconsideredinthepresenceofanyofthefollowingsituations:Chronicsystitisthatrefusestorespondtotherapy.Thefindingofwithoutbacteriaincultureoftheurinarysediment.Grossormicorscopichematuria.EnlargedepididymiswithabeadedorthickenedAchronicdrainingscrotalsinusIndurationornodulationoftheprostateandthickeningofoneorbothseminalvesicles.ClinicalfindingsTuberculosis86ClinicalfindingsThediagnosisrestsonthedemonstrationoftuberclebacilliintheurinebyculture.Theextentoftheinfectionisdeterminedby:1.Thepalpablefindingsintheepididymises,prostateandseminalvesiclesTherenalandureterallesionsasrevealedbyIVPinvolvementofthebladderasseenthroughthecystoscopeThedegreeofrenaldamageasmeasuredbylossoffunction.Thepresenceoftuberclebacilliinoneorbothkidneys.ClinicalfindingsThediagnosis87ClinicalfindingsA.Symptoms:ThereisnoclassicclinicalpictureofrenaltuberculosisMostsymptomsofthisdisease,arevesicalinorigin(cystitis)ClinicalfindingsA.Symptoms:88ClinicalfindingsA.Symptoms:Frequency:theearliestsymptomsofrenaltuberculosismayarisefromsecondaryvesicalinvolvement.Pyuria:nobacteriaisfoundinthecultureofurine.Hematuria:isoccasionallyfoundandisofeitherrenalorvesicalorigin.50~60%,grosshematuria:10%Painandmass:dullacheintheflank.Thepassageofabloodclot,secondarycalculi,oramassofdebrismaycauserenalandureteralcolic.Someofthenonspecificcomplaints:vaguegeneralizedmalaise,fatigability,low-gradebutpersistentfever,andnightsweats.ClinicalfindingsA.Symptoms:89ClinicalfindingsB.Signs:Evidenceofextragenitaltuberculosismaybefound(lungs,bone,lymphnodes)Kidney—usuallynoenlargementortendernessoftheinvolvedkidney.Externalgenitalia:athickened,nontenderepididymis,achronicdrainingsinusthroughthescrotalskin.Prostateandseminalvesicles:tuberculousprostateshowsareasofinduration,evennodulation.Theinvolvedseminalvesicleisindurated,enlarged,andfixed.ClinicalfindingsB.Signs:90ClinicalfindingsB.Signs:Laboratoryfindings:persistentpyuria(“sterile”pyuria)

culturesfortuberclebacillifromthefirstmorningurinearepositiveinaveryhighpercentageofcasesoftuberculousinfection.thebloodcountmaybenormaloranemia.Sedimentationrateisusuallyaccelerated.thetuberculintestshouldbeperformed.ClinicalfindingsB.Signs:91ClinicalfindingsB.Signs:X-Rayfindings:

Achestfilm:evidenceoftuberculosisAplainfilmofabdomen:enlargementofonekidneyofobliterationoftherenalshadowsduetoabscess.Renalstonesarefoundin10%ofcases.Calcificatinoftheuretermaybenoted.

ClinicalfindingsB.Signs:92ClinicalfindingsB.Signs:X-Rayfindings:IVP—thetypicalchangesinclude:

a“moth-eaten”appearanceoftheulceratedcalyces.obliterationofoneormorecalyces.dilatationofthecalycesduetoureteralstenosisfromfibrosis.abscesscavitiesthatconnectwithcalyces.singleormultipleureteralstrictures.absenceoffunctionofthekidneyduetocompleteureteralocclusionandrenaldestruction(Autonephrectomy)ClinicalfindingsB.Signs:93IVPIVP94IVPIVP95右肾不显影右肾不显影96ClinicalfindingsB.Signs:CT:Ultrasound:Cystoscope:typicaltuberclesorulcersoftuberculosis.Biopsycanbedoneifnecessary.“golf-hole”(gaping)ureteralorifice.ClinicalfindingsB.Signs:97泌尿男生殖系结核课件98泌尿男生殖系结核课件99泌尿男生殖系结核课件100泌尿男生殖系结核课件101DifferentialdiagnosisChronicnonspecificcystitisorpyelonephritisAcuteorchronicnonspecificepididymitisMultiplesmallrenalstonesTumorDifferentialdiagnosisChronic102Treatment

Thefollowingdrugsareusuallyconsideredasthefirst-linedrugs“*”:*Isoniazid:300mg/d*Rifampin:450mg/d*Pyrazinamide:1500mg/dStreptomycin:1g/d,intramuscularlyEthambutol:25mg/kg

TreatmentThefollowingdrugs103TreatmentMostauthoritiesadviseappropriatemedicationfor2years(orlongerifculturesispositive).Gow(1979)findsthata6-monthcourseofdrugsisadequate.Isoniazid,rifampin,pyrazinamideandvitaminCdailyfor2months.Followedbyisoniazid,rifampinandvitaminCfor4months.Theurinemustbestudiedbacteriologicallyevery6monthsduringtreatmentandtheneveryyearfor10year.TreatmentMostauthoritiesadvi104Treatment手术治疔肾切除:无功能肾结核；肾实质破坏2/3个大盏以上，合并有难以控制的高血压；伴输尿管严重梗阻。部分肾切除：局限在一极的病变。病灶清除术:适合于结核脓肿，一般穿刺解决。整形手术：矫正输尿管狭窄手术膀胱挛缩可采用回肠或乙状结肠膀胱扩大术尿路改道Treatment手术治疔