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1、Urologic and Male Genital Tuberculosis,Yi Lin Department of urology Tianjin Medical University,概 述,泌尿、男生殖系结核 (urologic and male genital tuberculosis) 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2040岁青壮年 男性大于女性，2：1左右,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.
2、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,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,血行传播,顺行传播,逆行传播,Etiology,The kidney and possibly the prostate are the primary sites of tubercu
3、lous infection in the genitourinary tract. All other genitourinary organs become involved by either ascent ( prostate to bladder ) or descent ( kidney to bladder, prostate to epididymis). The testis may become involved by direct extension from epididymal infection.,Pathogenesis,A. kidney and ureter:
4、 A shower of TB hits the renal cortex, the organisms may be destroyed by normal tissue resistance. Only scars are found in the kidney. However, if enough bacteria of sufficient virulence become lodged in the kidney and are not overcome, a clinical infection is established.,Pathogenesis,A. kidney and
5、 ureter: Tuberculosis of the kidney progresses slowly; it may take 1520 years to destroy a kidney in a patient who has good resistance to the infection. Therefore, there is no renal pain and little or no clinical disturbance of any type until the lesion has involved the calyces or the pelvis. It is
6、only at this stage that symptoms ( of cystitis) are manifested.,Pathogenesis,A. kidney and ureter: As the disease progress, a caseous breakdown of tissue occurs until the entire kidney is replaced by cheesy material. Calcium may be laid down in the reparative process. The ureter undergoes fibrosis a
7、nd tends to be shortened and straightened. This change leads to a “golf-hole” (gaping) ureteral orifice, typical of an incompetent valve.,Tuberculosis of kidney and ureter,Tuberculosis of kidney and ureter,Tuberculosis of kidney,Pathogenesis,B. bladder: Vesical irritability develops as an early clin
8、ical manifestation of the disease as the bladder is bathed by infected material. Tubercles form later, usually in the region of the involved ureteral orifice, and ulceratebleeding. Bladder becomes fibrosed and contracted, this leads to marked frequency. Ureteral reflux or stenosis and hydronephrosis
9、.,Pathogenesis,C. Prostate and seminal vesicles: The passage of infected urine through the prostatic urethra leads to invasion of the prostate and one or both seminal vesicles. There is no local pain. The primary hematogenous lesion in the genitourinary trace is in the prostate. Prostatic infection
10、can ascend to the bladder and descent to the epididymis.,Pathogenesis,D. Epididymis and testis: Tuberculosis of the prostate can extend the epididymis. This is a slow process, there is usually no pain. If the epididymal infection is extensive and an abscess forms, it may rupture through the scrotal
11、skin, thus establishing a permanent sinus, or it may extend into the testicle.,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。,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
12、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,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,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,肾自截（a
13、utonephrectomy) : 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,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,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,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
14、核 附睾结核,Clinical findings,Tuberculosis of the genitourinary tract should be considered in the presence of any of the following situations: Chronic systitis that refuses to respond to therapy. The finding of without bacteria in culture of the urinary sediment. Gross or micorscopic hematuria. Enlarged
15、epididymis with a beaded or thickened A chronic draining scrotal sinus Induration or nodulation of the prostate and thickening of one or both seminal vesicles.,Clinical findings,The diagnosis rests on the demonstration of tubercle bacilli in the urine by culture. The extent of the infection is deter
16、mined by: 1. The palpable findings in the epididymises, prostate and seminal vesicles The renal and ureteral lesions as revealed by IVP involvement of the bladder as seen through the cystoscope The degree of renal damage as measured by loss of function. The presence of tubercle bacilli in one or bot
17、h kidneys.,Clinical findings,A. Symptoms: There is no classic clinical picture of renal tuberculosis Most symptoms of this disease, are vesical in origin (cystitis),Clinical findings,A. Symptoms: Frequency: the earliest symptoms of renal tuberculosis may arise from secondary vesical involvement. Pyu
18、ria: no bacteria is found in the culture of urine. Hematuria: is occasionally found and is of either renal or vesical origin. 5060%, gross hematuria: 10% Pain and mass: dull ache in the flank. The passage of a blood clot, secondary calculi, or a mass of debris may cause renal and ureteral colic. Som
19、e of the nonspecific complaints: vague generalized malaise, fatigability, low-grade but persistent fever, and night sweats.,Clinical findings,B. Signs: Evidence of extragenital tuberculosis may be found (lungs, bone, lymph nodes) Kidneyusually no enlargement or tenderness of the involved kidney. Ext
20、ernal genitalia: a thickened, nontender epididymis, a chronic draining sinus through the scrotal skin. Prostate and seminal vesicles: tuberculous prostate shows areas of induration, even nodulation. The involved seminal vesicleis indurated, enlarged, and fixed.,Clinical findings,B. Signs: Laboratory
21、 findings: persistent pyuria ( “sterile” pyuria) cultures for tubercle bacilli from the first morning urine are positive in a very high percentage of cases of tuberculous infection. the blood count may be normal or anemia. Sedimentation rate is usually accelerated. the tuberculin test should be perf
22、ormed.,Clinical findings,B. Signs: X-Ray findings: A chest film: evidence of tuberculosis A plain film of abdomen: enlargement of one kidney of obliteration of the renal shadows due to abscess. Renal stones are found in 10% of cases. Calcificatin of the ureter may be noted.,Clinical findings,B. Sign
23、s: X-Ray findings: IVPthe typical changes include: a “moth-eaten” appearance of the ulcerated calyces. obliteration of one or more calyces. dilatation of the calyces due to ureteral stenosis from fibrosis. abscess cavities that connect with calyces. single or multiple ureteral strictures. absence of
24、 function of the kidney due to complete ureteral occlusion and renal destruction (Autonephrectomy),IVP,IVP,右肾不显影,Clinical findings,B. Signs: CT: Ultrasound: Cystoscope: typical tubercles or ulcers of tuberculosis. Biopsy can be done if necessary. “golf-hole” (gaping) ureteral orifice.,Differential d
25、iagnosis,Chronic nonspecific cystitis or pyelonephritis Acute or chronic nonspecific epididymitis Multiple small renal stones Tumor,Treatment,The following drugs are usually considered as the first-line drugs “*”: *Isoniazid: 300mg/d *Rifampin : 450mg/d *Pyrazinamide: 1500mg/d Streptomycin: 1g/d, in
26、tramuscularly Ethambutol: 25mg/kg,Treatment,Most authorities advise appropriate medication for 2 years (or longer if cultures is positive). Gow (1979) finds that a 6-month course of drugs is adequate. Isoniazid, rifampin, pyrazinamide and vitamin C daily for 2 months. Followed by isoniazid, rifampin
27、 and vitamin C for 4 months. The urine must be studied bacteriologically every 6 months during treatment and then every year for 10 year.,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,Treatment,For a seve
28、rely contracted bladder, enterocystoplasty will increase vesical volume,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。,Prognosis,In a high percentage of cases, Cure is obtained by medical means. Unilateral renal lesions have the best prognosi
29、s.,Male genital tuberculosis,主要来源于其他部位的结核病灶，经血行感染而来。 5070%合并男生殖器结核 附睾和前列腺结核常同时存在,Tuberculosis of epididymis,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。,Tuberculosis of epididymis,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
30、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。,Treatment,In unilateral epididymal involvement, epididymectomy plus contralateral vasectomy is indicated to prevent descent of the infection from the prostate to that organ bilateral epididymectomy should be done if both sides are involved,Tuberculosis of epididymis
31、,Tuberculosis of prostate,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,Tuberculosis of prostate,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。,Conclusions,Tuberculosis is the most important, most commonly missed type of specific genitourinary infection It should always be
32、 considered in any case of pyuria without bacteriuria or in any resistant urinary tract infection that does not respond to treatment,Conclusions,Genitourinary tuberculosis is always secondary to pulmonary infection，though in many cases，the primary focus has already healed or is in a subclinical form Infection occurs via the hematogenous route,Conclusions,The kidneys and (less commonly) the prostate are principal sites of urinary tract involvement, though all other segments of the genitourinary system can be affected,Thank You Very Much !,