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.

• Primary sites( 初发部位 ): Kidney, Prostate ( 前列腺 )

• Other organs involved: direct extension

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.

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.

Pathology( 病理 )

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 ).

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.

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 ).

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%.

• Left kidney: autonephrectomy

• Right Kidney: hydronephrosis & ureteral reflux ( 肾积水 & 输尿管返流 )

• Contraction of the bladder ( 膀胱孪缩 )

左肾萎缩

萎缩肾外观

Caseation & Fibrosis

Lt Renal Dysfunction on Radioisotope Scan( 同位素扫描 )

Calcification ( 钙化 )

Bladder

• Tubercle form: white/yellow raised

nodules( 结节 ) surrounded by a halo of

hyperremia( 充血 ).

• Tubercles break downdeep ragged

ulcers bladder irritable.

膀胱结核，多个粟粒样黄色小结节

膀胱结核，结核性溃疡

Diagnosis( 诊断 )

• 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.

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 )

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 )

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.

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%

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.

• Excretory urograms:

• Ureteral stricture with secondary dilatation.

• Absence of function of the kidney.

• Retrograde Urography

MRU or CT

Diagnosis: Instrumental Exams

• Cystoscope(膀胱镜 ):

• Tubercles & ulcers, contraction( 孪缩 )

• Cystogram(膀胱造影 ):

• Ureteral reflux( 输尿管返流 )

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.

Treatment ( 治疗 )

TB must be treated as a generalized disease!

• Basic treatment——Medical 药物

• Surgical excision( 外科切除 ) —— merely adjunct

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

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 )

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.

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 )

Treatment: General Measures

• Optimal nutrition: important

• Irritable bladder: bladder sedatives( 镇静剂 )

• tolterodine, oxybutynin

Prognosis( 预后 )

• Relapse( 复发 ):

• Ureteral stenosis; • Vesical contraction

Prognosis

• Overall control rate: 98% at 5 years

• Urine study: every 6 m during treatment; every year for 10 years.

Case Report

• A 56y male with left abdominal mass & anemia( 贫血 ).

• X-ray showed a large stone in Lt kidney with severe hydronephrosis.

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!

谢 谢