泌尿、男生殖系結(jié)核課件

UrologicandMaleGenitalTuberculosisYiLinDepartmentofurologyTianjinMedicalUniversity3.泌尿、男生殖系結(jié)核概述泌尿、男生殖系結(jié)核(urologicandmalegenitaltuberculosis)結(jié)核桿菌侵犯泌尿、男性生殖器官引起的慢性特異性感染。約占全部肺外結(jié)合的14%與經(jīng)濟(jì)落后、醫(yī)療水平底有關(guān)好發(fā)年齡20~40歲青壯年男性大于女性，2：1左右3.泌尿、男生殖系結(jié)核概述原發(fā)性結(jié)核病:

首次感染結(jié)核菌,引起的結(jié)核病-肺結(jié)核繼發(fā)性結(jié)核病:

有結(jié)核菌感染后,已建立細(xì)胞免疫和變態(tài)反應(yīng)后發(fā)生的結(jié)核病.發(fā)病機(jī)理人體首次感染結(jié)核菌—機(jī)體無免疫力—巨噬細(xì)胞不能殺死結(jié)核菌—結(jié)核菌蔓延—經(jīng)淋巴或血液播散到全身—在各組織中著床—潛伏灶—一般情況下不發(fā)病—機(jī)體免疫力地下時(shí)或營養(yǎng)不良時(shí)—潛伏菌大量繁殖—發(fā)病3.泌尿、男生殖系結(jié)核概述感染途徑：4種1.血性感染：最常見2.接觸感染：通過性生活或污染物傳播，少見3.淋巴感染：罕見4.直接蔓延：罕見

泌尿、男生殖系統(tǒng)內(nèi)部傳播：1.順行蔓延：腎—輸尿管—膀胱2.逆行蔓延：膀胱—健側(cè)輸尿管—健側(cè)腎臟3.泌尿、男生殖系結(jié)核血行傳播順行傳播逆行傳播3.泌尿、男生殖系結(jié)核Etiology

Thekidneyandpossiblytheprostatearetheprimarysitesoftuberculousinfectioninthegenitourinarytract.Allothergenitourinaryorgansbecomeinvolvedbyeitherascent(prostatetobladder)ordescent(kidneytobladder,prostatetoepididymis).Thetestismaybecomeinvolvedbydirectextensionfromepididymalinfection.3.泌尿、男生殖系結(jié)核Pathogenesis

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

結(jié)核早期病變,結(jié)核菌通過血行傳播至腎皮質(zhì)—結(jié)核結(jié)節(jié)和結(jié)核肉芽腫形成。結(jié)核結(jié)節(jié):類上皮細(xì)胞、多核巨細(xì)胞、淋巴細(xì)胞、漿細(xì)胞、成纖維細(xì)胞等組成。雖然有鏡下血尿、可找到結(jié)核菌，但無臨床癥狀，IVP正常。80%累及雙腎，但大多數(shù)能自行愈合，形成斑痕或鈣化。3.泌尿、男生殖系結(jié)核Pathology臨床型腎結(jié)核:

因細(xì)菌數(shù)量大，毒性高而機(jī)體抵抗力弱，結(jié)核結(jié)節(jié)融合、擴(kuò)大，逐漸向隋質(zhì)發(fā)展并在腎乳頭處破潰，患者出現(xiàn)臨床癥狀。從病理型腎結(jié)核—臨床型腎結(jié)核病史長，一般>5年90%為單側(cè)。左、右側(cè)發(fā)病率無差別。3.泌尿、男生殖系結(jié)核Pathology腎積膿:結(jié)核菌到達(dá)腎髓質(zhì)后大量繁殖，破壞腎實(shí)質(zhì)。結(jié)核結(jié)節(jié)相互融合，形成干洛樣壞死、液化，形成膿腫。膿腫向伸盞破潰，進(jìn)入腎盂、輸尿管、膀胱—導(dǎo)致繼發(fā)性結(jié)核。膿腫也可局限在腎實(shí)質(zhì)，形成閉合性濃重。極少數(shù)情況下，腎實(shí)質(zhì)大部或全部被膿腫取代，形成結(jié)核型膿腎或腎積膿。3.泌尿、男生殖系結(jié)核Pathology輸尿管結(jié)核:輸尿管結(jié)核最常見于下段，其次上段。病變由粘膜向全層侵犯—導(dǎo)致輸尿管壁增厚、變硬、輸尿管縮短、狹窄、收縮功能下降。輸尿管完全閉塞，尿液不能排入膀胱，臨床癥狀減輕3.泌尿、男生殖系結(jié)核Pathology腎自截（autonephrectomy):輸尿管結(jié)核的嚴(yán)重表現(xiàn)但壞死物質(zhì)不能排除，腎臟廣泛破壞，功能損害至全部喪失。3.泌尿、男生殖系結(jié)核Pathology膀胱結(jié)核:同側(cè)輸尿管開口—粘膜充血、水腫等改變—形成結(jié)核結(jié)節(jié)—膀胱攣縮—纖維組織增生--對側(cè)輸尿管口狹窄，閉合不全—引起梗阻積水并感染健腎。膀胱結(jié)核潰瘍向外穿透—可形成膀胱陰道瘺或膀胱直腸瘺。前列腺結(jié)核和附睪結(jié)核:少見。3.泌尿、男生殖系結(jié)核Pathology泌尿系結(jié)核的病理特點(diǎn)：組織破壞和修復(fù)混合存在。機(jī)體低抗力低時(shí)：以破壞為主—潰瘍和膿腫機(jī)體低抗力高時(shí)：以修復(fù)反應(yīng)為主—纖維化和鈣化3.泌尿、男生殖系結(jié)核Pathology病理型腎結(jié)核臨床型腎結(jié)核腎積膿輸尿管結(jié)核腎自截膀胱結(jié)核前列腺結(jié)核附睪結(jié)核3.泌尿、男生殖系結(jié)核Clinicalfindings

Tuberculosisofthegenitourinarytractshouldbeconsideredinthepresenceofanyofthefollowingsituations:Chronicsystitisthatrefusestorespondtotherapy.Thefindingofwithoutbacteriaincultureoftheurinarysediment.Grossormicorscopichematuria.EnlargedepididymiswithabeadedorthickenedAchronicdrainingscrotalsinusIndurationornodulationoftheprostateandthickeningofoneorbothseminalvesicles.3.泌尿、男生殖系結(jié)核ClinicalfindingsThediagnosisrestsonthedemonstrationoftuberclebacilliintheurinebyculture.Theextentoftheinfectionisdeterminedby:1.Thepalpablefindingsintheepididymises,prostateandseminalvesiclesTherenalandureterallesionsasrevealedbyIVPinvolvementofthebladderasseenthroughthecystoscopeThedegreeofrenaldamageasmeasuredbylossoffunction.Thepresenceoftuberclebacilliinoneorbothkidneys.3.泌尿、男生殖系結(jié)核ClinicalfindingsA.Symptoms:ThereisnoclassicclinicalpictureofrenaltuberculosisMostsymptomsofthisdisease,arevesicalinorigin(cystitis)3.泌尿、男生殖系結(jié)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、男生殖系結(jié)核ClinicalfindingsB.Signs:Evidenceofextragenitaltuberculosismaybefound(lungs,bone,lymphnodes)Kidney—usuallynoenlargementortendernessoftheinvolvedkidney.Externalgenitalia:athickened,nontenderepididymis,achronicdrainingsinusthroughthescrotalskin.Prostateandseminalvesicles:tuberculousprostateshowsareasofinduration,evennodulation.Theinvolvedseminalvesicleisindurated,enlarged,andfixed.3.泌尿、男生殖系結(jié)核ClinicalfindingsB.Signs:Laboratoryfindings:persistentpyuria(“sterile”pyuria)

culturesfortuberclebacillifromthefirstmorningurinearepositiveinaveryhighpercentageofcasesoftuberculousinfection.thebloodcountmaybenormaloranemia.Sedimentationrateisusuallyaccelerated.thetuberculintestshouldbeperformed.3.泌尿、男生殖系結(jié)核ClinicalfindingsB.Signs:X-Rayfindings:

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

3.泌尿、男生殖系結(jié)核ClinicalfindingsB.Signs:X-Rayfindings:

IVP—thetypicalchangesinclude:

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

ureteralocclusionandrenaldestruction

(Autonephrectomy)3.泌尿、男生殖系結(jié)核IVP3.泌尿、男生殖系結(jié)核IVP3.泌尿、男生殖系結(jié)核右腎不顯影3.泌尿、男生殖系結(jié)核ClinicalfindingsB.Signs:CT:Ultrasound:Cystoscope:typicaltuberclesorulcersoftuberculosis.Biopsycanbedoneifnecessary.

“golf-hole”

(gaping)ureteralorifice.3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核DifferentialdiagnosisChronicnonspecificcystitisorpyelonephritisAcuteorchronicnonspecificepididymitisMultiplesmallrenalstonesTumor3.泌尿、男生殖系結(jié)核Treatment

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

3.泌尿、男生殖系結(jié)核TreatmentMostauthoritiesadviseappropriatemedicationfor2years(orlongerifculturesispositive).Gow(1979)findsthata6-monthcourseofdrugsisadequate.Isoniazid,rifampin,pyrazinamideandvitaminCdailyfor2months.Followedbyisoniazid,rifampinandvitaminCfor4months.Theurinemustbestudiedbacteriologicallyevery6monthsduringtreatmentandtheneveryyearfor10year.3.泌尿、男生殖系結(jié)核Treatment手術(shù)治疔

腎切除:無功能腎結(jié)核；腎實(shí)質(zhì)破壞2/3個(gè)大盞以上，合并有難以控制的高血壓；伴輸尿管嚴(yán)重梗阻。部分腎切除：局限在一極的病變。病灶清除術(shù):

適合于結(jié)核膿腫，一般穿刺解決。整形手術(shù)：矯正輸尿管狹窄手術(shù)膀胱攣縮可采用回腸或乙狀結(jié)腸膀胱擴(kuò)大術(shù)尿路改道3.泌尿、男生殖系結(jié)核TreatmentForaseverelycontractedbladder,enterocystoplastywillincreasevesicalvolume．3.泌尿、男生殖系結(jié)核Treatment一側(cè)腎結(jié)核（功能已喪失），對側(cè)腎積水如何處理？根據(jù)積水側(cè)功能情況進(jìn)行治疔！功能尚佳者可先切除結(jié)核病腎，再解除積水梗阻。若積水嚴(yán)重，腎功能不良則應(yīng)先解除梗阻，然后切除無功能的結(jié)核腎臟。3.泌尿、男生殖系結(jié)核PrognosisInahighpercentageofcases,Cureisobtainedbymedicalmeans.Unilateralrenallesionshavethebestprognosis.3.泌尿、男生殖系結(jié)核Malegenitaltuberculosis主要來源于其他部位的結(jié)核病灶，經(jīng)血行感染而來。50~70%合并男生殖器結(jié)核附睪和前列腺結(jié)核常同時(shí)存在3.泌尿、男生殖系結(jié)核Tuberculosisofepididymis大多為單側(cè)，起病緩慢。多從尾部開始發(fā)病。附睪逐漸增大，多無明顯疼痛，腫大的附睪可與陰囊粘連或形成寒性膿腫、破潰成為竇道，經(jīng)久不愈。輸精管增粗，呈串珠伏。直腸指檢，前列腺有硬結(jié)。3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核3.泌尿、男生殖系結(jié)核Tuberculosisofepididymis

附睪結(jié)核應(yīng)與慢性附睪炎鑒別.

治疔原則

與腎結(jié)核相同，早期可采用藥物治療。如治療效果不明顯或病變較大，有膿腫形成，則可行附睪切除，術(shù)時(shí)應(yīng)盡量保留睪丸。若睪丸有病變，病變靠近附睪，則可連同附睪將睪丸部分切除。3.泌尿、男生殖系結(jié)核TreatmentInunilateralepididymalinvolvement,epididymectomypluscontralateralvasectomyisindicatedtopreventdescentoftheinfectionfromtheprostatetothatorg