泌尿、男生殖系结核课件

UrologicandMaleGenitalTuberculosisYiLinDepartmentofurologyTianjinMedicalUniversity3.泌尿、男生殖系结核概述泌尿、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3.泌尿、男生殖系结核概述原发性结核病:

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3.泌尿、男生殖系结核概述感染途径：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3.泌尿、男生殖系结核血行传播顺行传播逆行传播3.泌尿、男生殖系结核Etiology

Thekidneyandpossiblytheprostatearetheprimarysitesoftuberculousinfectioninthegenitourinarytract.Allothergenitourinaryorgansbecomeinvolvedbyeitherascent(prostatetobladder)ordescent(kidneytobladder,prostatetoepididymis).Thetestismaybecomeinvolvedbydirectextensionfromepididymalinfection.3.泌尿、男生殖系结核Pathogenesis

A.kidneyandureter:AshowerofTBhitstherenalcortex,theorganismsmaybedestroyedbynormaltissueresistance.Onlyscarsarefoundinthekidney.However,ifenoughbacteriaofsufficientvirulencebecomelodgedinthekidneyandarenotovercome,aclinicalinfectionisestablished.3.泌尿、男生殖系结核PathogenesisA.kidneyandureter:Tuberculosisofthekidneyprogressesslowly;itmaytake15~20yearstodestroyakidneyinapatientwhohasgoodresistancetotheinfection.Therefore,thereisnorenalpainandlittleornoclinicaldisturbanceofanytypeuntilthelesionhasinvolvedthecalycesorthepelvis.Itisonlyatthisstagethatsymptoms(ofcystitis)aremanifested.3.泌尿、男生殖系结核PathogenesisA.kidneyandureter:Asthediseaseprogress,acaseousbreakdownoftissueoccursuntiltheentirekidneyisreplacedbycheesymaterial.Calciummaybelaiddowninthereparativeprocess.Theureterundergoesfibrosisandtendstobeshortenedandstraightened.Thischangeleadstoa“golf-hole”(gaping)ureteralorifice,typicalofanincompetentvalve.3.泌尿、男生殖系结核Tuberculosisofkidneyandureter3.泌尿、男生殖系结核Tuberculosisofkidneyandureter3.泌尿、男生殖系结核Tuberculosisofkidney3.泌尿、男生殖系结核PathogenesisB.bladder:Vesicalirritabilitydevelopsasanearlyclinicalmanifestationofthediseaseasthebladderisbathedbyinfectedmaterial.Tuberclesformlater,usuallyintheregionoftheinvolvedureteralorifice,andulcerate—bleeding.Bladderbecomesfibrosedandcontracted,thisleadstomarkedfrequency.Ureteralrefluxorstenosisandhydronephrosis.3.泌尿、男生殖系结核PathogenesisC.Prostateandseminalvesicles:Thepassageofinfectedurinethroughtheprostaticurethraleadstoinvasionoftheprostateandoneorbothseminalvesicles.Thereisnolocalpain.Theprimaryhematogenouslesioninthegenitourinarytraceisintheprostate.Prostaticinfectioncanascendtothebladderanddescenttotheepididymis.3.泌尿、男生殖系结核PathogenesisD.Epididymisandtestis:Tuberculosisoftheprostatecanextendtheepididymis.Thisisaslowprocess,thereisusuallynopain.Iftheepididymalinfectionisextensiveandanabscessforms,itmayrupturethroughthescrotalskin,thusestablishingapermanentsinus,oritmayextendintothetesticle.3.泌尿、男生殖系结核Pathology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。3.泌尿、男生殖系结核Pathology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。3.泌尿、男生殖系结核Pathology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。3.泌尿、男生殖系结核Pathology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3.泌尿、男生殖系结核Pathology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。3.泌尿、男生殖系结核Pathology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。3.泌尿、男生殖系结核Pathology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3.泌尿、男生殖系结核Pathology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3.泌尿、男生殖系结核Clinicalfindings

Tuberculosisofthegenitourinarytractshouldbeconsideredinthepresenceofanyofthefollowingsituations:Chronicsystitisthatrefusestorespondtotherapy.Thefindingofwithoutbacteriaincultureoftheurinarysediment.Grossormicorscopichematuria.EnlargedepididymiswithabeadedorthickenedAchronicdrainingscrotalsinusIndurationornodulationoftheprostateandthickeningofoneorbothseminalvesicles.3.泌尿、男生殖系结核ClinicalfindingsThediagnosisrestsonthedemonstrationoftuberclebacilliintheurinebyculture.Theextentoftheinfectionisdeterminedby:1.Thepalpablefindingsintheepididymises,prostateandseminalvesiclesTherenalandureterallesionsasrevealedbyIVPinvolvementofthebladderasseenthroughthecystoscopeThedegreeofrenaldamageasmeasuredbylossoffunction.Thepresenceoftuberclebacilliinoneorbothkidneys.3.泌尿、男生殖系结核ClinicalfindingsA.Symptoms:ThereisnoclassicclinicalpictureofrenaltuberculosisMostsymptomsofthisdisease,arevesicalinorigin(cystitis)3.泌尿、男生殖系结核ClinicalfindingsA.Symptoms:Frequency:

theearliestsymptomsofrenaltuberculosismayarisefromsecondaryvesicalinvolvement.

Pyuria:

nobacteriaisfoundinthecultureofurine.Hematuria:

isoccasionallyfoundandisofeitherrenalorvesicalorigin.50~60%,grosshematuria:10%Painandmass:

dullacheintheflank.Thepassageofabloodclot,secondarycalculi,oramassofdebrismaycauserenalandureteralcolic.Someofthenonspecificcomplaints:

vaguegeneralizedmalaise,fatigability,low-gradebutpersistentfever,andnightsweats.3.泌尿、男生殖系结核ClinicalfindingsB.Signs:Evidenceofextragenitaltuberculosismaybefound(lungs,bone,lymphnodes)Kidney—usuallynoenlargementortendernessoftheinvolvedkidney.Externalgenitalia:athickened,nontenderepididymis,achronicdrainingsinusthroughthescrotalskin.Prostateandseminalvesicles:tuberculousprostateshowsareasofinduration,evennodulation.Theinvolvedseminalvesicleisindurated,enlarged,andfixed.3.泌尿、男生殖系结核ClinicalfindingsB.Signs:Laboratoryfindings:persistentpyuria(“sterile”pyuria)

culturesfortuberclebacillifromthefirstmorningurinearepositiveinaveryhighpercentageofcasesoftuberculousinfection.thebloodcountmaybenormaloranemia.Sedimentationrateisusuallyaccelerated.thetuberculintestshouldbeperformed.3.泌尿、男生殖系结核ClinicalfindingsB.Signs:X-Rayfindings:

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

3.泌尿、男生殖系结核ClinicalfindingsB.Signs:X-Rayfindings:

IVP—thetypicalchangesinclude:

a“moth-eaten”appearanceoftheulceratedcalyces.obliterationofoneormorecalyces.dilatationofthecalycesduetoureteralstenosisfromfibrosis.abscesscavitiesthatconnectwithcalyces.singleormultipleureteralstrictures.absenceoffunctionofthekidneyduetocomplete

ureteralocclusionandrenaldestruction

(Autonephrectomy)3.泌尿、男生殖系结核IVP3.泌尿、男生殖系结核IVP3.泌尿、男生殖系结核右肾不显影3.泌尿、男生殖系结核ClinicalfindingsB.Signs:CT:Ultrasound:Cystoscope:typicaltuberclesorulcersoftuberculosis.Biopsycanbedoneifnecessary.

“golf-hole”

(gaping)ureteralorifice.3.泌尿、男生殖系结核3.泌尿、男生殖系结核3.泌尿、男生殖系结核3.泌尿、男生殖系结核3.泌尿、男生殖系结核DifferentialdiagnosisChronicnonspecificcystitisorpyelonephritisAcuteorchronicnonspecificepididymitisMultiplesmallrenalstonesTumor3.泌尿、男生殖系结核Treatment

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

3.泌尿、男生殖系结核TreatmentMostauthoritiesadviseappropriatemedicationfor2years(orlongerifculturesispositive).Gow(1979)findsthata6-monthcourseofdrugsisadequate.Isoniazid,rifampin,pyrazinamideandvitaminCdailyfor2months.Followedbyisoniazid,rifampinandvitaminCfor4months.Theurinemustbestudiedbacteriologicallyevery6monthsduringtreatmentandtheneveryyearfor10year.3.泌尿、男生殖系结核Treatment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3.泌尿、男生殖系结核TreatmentForaseverelycontractedbladder,enterocystoplastywillincreasevesicalvolume．3.泌尿、男生殖系结核Treatment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。3.泌尿、男生殖系结核PrognosisInahighpercentageofcases,Cureisobtainedbymedicalmeans.Unilateralrenallesionshavethebestprognosis.3.泌尿、男生殖系结核Malegenitaltuberculosis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3.泌尿、男生殖系结核Tuberculosisofepididymis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。3.泌尿、男生殖系结核3.泌尿、男生殖系结核3.泌尿、男生殖系结核Tuberculosisofepididymis

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。3.泌尿、男生殖系结核TreatmentInunilateralepididymalinvolvement,epididymectomypluscontralateralvasectomyisindicatedtopreventdescentoftheinfectionfromtheprostatetothatorg