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1、 Urologic and Male Genital TuberculosisYi Lin Department of urologyTianjin Medical University概概 述述泌尿、男生殖系结核泌尿、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结核杆菌侵犯泌尿、男性生殖器官引起的慢性特异性感染。感染。约占全部肺外结合的约占全部肺外结合的14%与经济落后、医疗水平底有关与经济落后、医疗水平底有关好发年龄好发年龄2040岁青壮年岁青壮年男性大于女性，男性大于女性，2：1左右左右概概
2、述述原发性结核病原发性结核病: 首次感染结核菌首次感染结核菌, 引起的结核病引起的结核病-肺结肺结核核继发性结核病继发性结核病: 有结核菌感染后有结核菌感染后, 已建立细胞免疫和变已建立细胞免疫和变态反应后发生的结核病态反应后发生的结核病.发病机理发病机理人体首次感染结核菌人体首次感染结核菌机机体无免疫力体无免疫力巨巨噬细胞不能噬细胞不能杀死结核菌杀死结核菌结结核菌蔓延核菌蔓延经经淋巴或血液播散到全身淋巴或血液播散到全身在在各组织中着床各组织中着床潜潜伏灶伏灶一一般情况下不发病般情况下不发病机机体免疫力地下时或营养不良时体免疫力地下时或营养不良时潜潜伏菌大量繁殖伏菌大量繁殖发发病病概概 述述感
3、染途径：感染途径：4种种 1. 血性感染：最常见血性感染：最常见 2. 接触感染：通过性生活或污染物传播，少见接触感染：通过性生活或污染物传播，少见 3. 淋巴感染：罕见淋巴感染：罕见 4. 直接蔓延：罕见直接蔓延：罕见 泌尿、男生殖系统内部传播：泌尿、男生殖系统内部传播： 1. 顺行蔓延：肾顺行蔓延：肾输输尿管尿管膀膀胱胱 2. 逆行蔓延：膀胱逆行蔓延：膀胱健健侧输尿管侧输尿管健健侧肾脏侧肾脏血行传播血行传播顺行传播顺行传播逆行传播逆行传播Etiology The kidney and possibly the prostate are the primary sites of tuberc
4、ulous 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:
5、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. PathogenesisA. kidney and ure
6、ter: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 only at
7、 this stage that symptoms ( of cystitis) are manifested.PathogenesisA. 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 and tends to
8、be shortened and straightened. This change leads to a “golf-hole” (gaping) ureteral orifice, typical of an incompetent valve.Tuberculosis of kidney and ureterTuberculosis of kidney and ureterTuberculosis of kidneyPathogenesisB. bladder:Vesical irritability develops as an early clinical manifestation
9、 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. PathogenesisC. Pro
10、state 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 can ascend to the bladde
11、r and descent to the epididymis.PathogenesisD. 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 skin, thus establishing a per
12、manent sinus, or it may extend into the testicle.Pathology病理型肾结核病理型肾结核: 结核早期病变结核早期病变, 结核菌通过血行传播至肾皮质结核菌通过血行传播至肾皮质结结核核结节和结核肉芽肿形成。结节和结核肉芽肿形成。结核结节结核结节: 类上皮细胞、多核巨细胞、淋巴细胞、浆细类上皮细胞、多核巨细胞、淋巴细胞、浆细胞、成纤维细胞等组成。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，虽然有镜下血尿、可找到结核菌，但无临床症状，IVP正常。正常。80%累及双肾，但大多数能自行愈合，形成斑痕或钙累及双肾，但大多数能自行愈合，
13、形成斑痕或钙化。化。Pathology临床型肾结核临床型肾结核: 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，患者出现临床症状出现临床症状。从病理型肾结核从病理型肾结核临临床型肾结核床型肾结核病史长，一般病史长，一般 5 年年90%为单侧。为单侧。左、右侧发病率无差别。左、右侧发病率无差别。Pathology肾积脓肾积脓:结核菌到达肾髓质后大量繁殖，破坏肾实质。结核结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。节相
14、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、膀胱脓肿向伸盏破溃，进入肾盂、输尿管、膀胱导致继导致继发性结核。发性结核。脓肿也可局限在肾实质，形成闭合性浓重。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，极少数情况下，肾实质大部或全部被脓肿取代， 形成形成结核型脓肾或肾积脓。结核型脓肾或肾积脓。Pathology输尿管结核输尿管结核 :输尿管结核最常见于下段，其次上段。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病变由粘膜向全层侵犯导致输尿管壁增厚、变硬、导致输尿管壁增厚、变硬、输尿管缩短、狭窄、收缩功能下降。输尿管缩短、
15、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（肾自截（autonephrectomy) :输尿管结核的严重表现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，功能损害至全但坏死物质不能排除，肾脏广泛破坏，功能损害至全部丧失。部丧失。Pathology膀胱结核膀胱结核 :同侧输尿管开口同侧输尿管开口粘膜充血、水肿等改变粘膜充血、水肿等改变形成结核形成结核结节结节膀胱挛缩膀胱挛缩纤维组织增生纤维组织增生-对侧输尿管口狭窄，对侧输尿管口狭窄，闭合不全闭合不全引起梗阻积水并感染健肾。引起梗阻积水并感染健肾
16、。膀胱结核溃疡向外穿透膀胱结核溃疡向外穿透可可形成膀胱阴道瘘或膀胱直形成膀胱阴道瘘或膀胱直肠瘘。肠瘘。前列腺结核和附睾结核前列腺结核和附睾结核 :少见。少见。Pathology泌尿系结核的病理特点：泌尿系结核的病理特点：组织破坏和修复混合存在。组织破坏和修复混合存在。机体低抗力低时：以破坏为主机体低抗力低时：以破坏为主溃溃疡和脓肿疡和脓肿 机体低抗力高时：以修复反应为主机体低抗力高时：以修复反应为主纤纤维化和钙化维化和钙化Pathology病理型肾结核病理型肾结核临床型肾结核临床型肾结核肾积脓肾积脓输尿管结核输尿管结核肾自截肾自截膀胱结核膀胱结核前列腺结核前列腺结核附睾结核附睾结核Clinic
17、al findings Tuberculosis of the genitourinary tract should be considered in the presence of any of the following situations: 1.Chronic systitis that refuses to respond to therapy. 2.The finding of without bacteria in culture of the urinary sediment.3.Gross or micorscopic hematuria.4.Enlarged epididy
18、mis with a beaded or thickened5.A chronic draining scrotal sinus6.Induration or nodulation of the prostate and thickening of one or both seminal vesicles.Clinical findingsThe diagnosis rests on the demonstration of tubercle bacilli in the urine by culture.The extent of the infection is determined by
19、:1. The palpable findings in the epididymises, prostate and seminal vesicles2.The renal and ureteral lesions as revealed by IVP3. involvement of the bladder as seen through the cystoscope4.The degree of renal damage as measured by loss of function.5.The presence of tubercle bacilli in one or both ki
20、dneys.Clinical findingsA. Symptoms:There is no classic clinical picture of renal tuberculosis Most symptoms of this disease, are vesical in origin (cystitis)Clinical findingsA. Symptoms:1.Frequency: the earliest symptoms of renal tuberculosis may arise from secondary vesical involvement. 2.Pyuria: n
21、o bacteria is found in the culture of urine.3.Hematuria: is occasionally found and is of either renal or vesical origin. 5060%, gross hematuria: 10%4.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.5.Some o
22、f the nonspecific complaints: vague generalized malaise, fatigability, low-grade but persistent fever, and night sweats.Clinical findingsB. Signs:1.Evidence of extragenital tuberculosis may be found (lungs, bone, lymph nodes)2.Kidneyusually no enlargement or tenderness of the involved kidney.3.Exter
23、nal genitalia: a thickened, nontender epididymis, a chronic draining sinus through the scrotal skin.4.Prostate and seminal vesicles: tuberculous prostate shows areas of induration, even nodulation. The involved seminal vesicleis indurated, enlarged, and fixed.Clinical findingsB. Signs:5.Laboratory f
24、indings: 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 perfor
25、med.Clinical findingsB. Signs:6.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 findingsB. Signs:6.
26、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 fu
27、nction of the kidney due to complete ureteral occlusion and renal destruction (Autonephrectomy)IVPIVP右右肾肾不不显显影影Clinical findingsB. Signs:7.CT: 8.Ultrasound:9.Cystoscope: typical tubercles or ulcers of tuberculosis. Biopsy can be done if necessary. “golf-hole” (gaping) ureteral orifice.Differential d
28、iagnosis1.Chronic nonspecific cystitis or pyelonephritis 2.Acute or chronic nonspecific epididymitis3.Multiple small renal stones 4.Tumor Treatment The following drugs are usually considered as the first-line drugs “*”:*Isoniazid: 300mg/d*Rifampin : 450mg/d *Pyrazinamide: 1500mg/dStreptomycin: 1g/d,
29、 intramuscularly Ethambutol: 25mg/kg TreatmentMost 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
30、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手术治疔手术治疔 1.肾肾切切除除:无无功功能能肾肾结结核核；肾肾实实质质破破坏坏2/3个个大大盏盏以以上上，合并有难以控制的高血压；伴输尿管严重梗阻。合并有难以控制的高血压；伴输尿管严重梗阻。2.部分肾切除：部分肾切除：局限在一极的病变。局限在一极的病变。3.病灶清除术病灶清除术: 适合于结核脓肿，一般穿刺解
31、决。适合于结核脓肿，一般穿刺解决。4.整形手术：整形手术： 矫正输尿管狭窄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膀胱挛缩可采用回肠或乙状结肠膀胱扩大术 尿路改道尿路改道TreatmentFor a severely contracted bladder, , enterocystoplasty will increase vesical volumeTreatment一侧肾结核（功能已丧失），对侧肾积水如何处理？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！根据积水侧功能情况进行治疔！1.功能尚佳者可先切除结核病肾，再解除积水梗阻。功能尚佳者
32、可先切除结核病肾，再解除积水梗阻。2.若积水严重，肾功能不良则应先解除若积水严重，肾功能不良则应先解除梗阻，然后切除梗阻，然后切除无功能的结核肾脏。无功能的结核肾脏。PrognosisIn a high percentage of cases, Cure is obtained by medical means. Unilateral renal lesions have the best prognosis.Male genital tuberculosis主要来源于其他部位的结核病灶，经血行感染而来。主要来源于其他部位的结核病灶，经血行感染而来。5070%合并男生殖器结核合并男生殖器结核附
33、睾和前列腺结核常同时存在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。大多为单侧，起病缓慢。多从尾部开始发病。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。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。输精管增粗，呈串珠伏。直肠指检，前列腺有硬结。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附睾结核应与慢性附睾炎鉴别. 治疔原则治疔原则 1.与肾结核相同，
34、早期可采用药物治疗。与肾结核相同，早期可采用药物治疗。2.如如治治疗疗效效果果不不明明显显或或病病变变较较大大，有有脓脓肿肿形形成成，则则可可行附睾切除，术时应尽量保留睾丸。行附睾切除，术时应尽量保留睾丸。3.若若睾睾丸丸有有病病变变，病病变变靠靠近近附附睾睾，则则可可连连同同附附睾睾将将睾睾丸部分切除。丸部分切除。TreatmentIn unilateral epididymal involvement, epididymectomy plus contralateral vasectomy is indicated to prevent descent of the infection f
35、rom the prostate to that organ bilateral epididymectomy should be done if both sides are involvedTuberculosis of epididymisTuberculosis of prostate常无自觉症状。常无自觉症状。有时有血精，射精痛有时有血精，射精痛DRE：前列腺表面有结节，无明显触痛前列腺表面有结节，无明显触痛Tuberculosis of prostate诊断：诊断：反复的血精或其它部位有结核病变反复的血精或其它部位有结核病变警警惕结核。惕结核。鉴别诊断：鉴别诊断：前列腺炎前列腺炎普
36、普通抗菌素有效通抗菌素有效前列腺癌前列腺癌老老年，年，DRE, PSA治疗：治疗：采用药物治疗为主，一般不采用手术治疗。采用药物治疗为主，一般不采用手术治疗。ConclusionsTuberculosis is the most important, most commonly missed type of specific genitourinary infectionIt should always be considered in any case of pyuria without bacteriuria or in any resistant urinary tract infect
37、ion that does not respond to treatmentConclusionsGenitourinary tuberculosis is always secondary to pulmonary infection，though in many cases，the primary focus has already healed or is in a subclinical formInfection occurs via the hematogenous routeConclusionsThe kidneys and (less commonly) the prostate are principal sites of urinary tract involvement, though all other segments of the genitourinary system can be affected
