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

首次感染結核菌,引起的結核病-肺結核繼發性結核病:

有結核菌感染后,已建立細胞免疫和變態反應后發生的結核病.發病機理人體首次感染結核菌—機體無免疫力—巨噬細胞不能殺死結核菌—結核菌蔓延—經淋巴或血液播散到全身—在各組織中著床—潛伏灶—一般情況下不發病—機體免疫力地下時或營養不良時—潛伏菌大量繁殖—發病3.泌尿、男生殖系結核概述感染途徑：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、男生殖系統內部傳播：1.順行蔓延：腎—輸尿管—膀胱2.逆行蔓延：膀胱—健側輸尿管—健側腎臟3.泌尿、男生殖系結核血行傳播順行傳播逆行傳播3.泌尿、男生殖系結核Etiology

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

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

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

因細菌數量大，毒性高而機體抵抗力弱，結核結節融合、擴大，逐漸向隋質發展并在腎乳頭處破潰，患者出現臨床癥狀。從病理型腎結核—臨床型腎結核病史長，一般>5年90%為單側。左、右側發病率無差別。3.泌尿、男生殖系結核Pathology腎積膿:結核菌到達腎髓質后大量繁殖，破壞腎實質。結核結節相互融合，形成干洛樣壞死、液化，形成膿腫。膿腫向伸盞破潰，進入腎盂、輸尿管、膀胱—導致繼發性結核。膿腫也可局限在腎實質，形成閉合性濃重。極少數情況下，腎實質大部或全部被膿腫取代，形成結核型膿腎或腎積膿。3.泌尿、男生殖系結核Pathology輸尿管結核:輸尿管結核最常見于下段，其次上段。病變由粘膜向全層侵犯—導致輸尿管壁增厚、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、男生殖系結核Pathology腎自截（autonephrectomy):輸尿管結核的嚴重表現但壞死物質不能排除，腎臟廣泛破壞，功能損害至全部喪失。3.泌尿、男生殖系結核Pathology膀胱結核:同側輸尿管開口—粘膜充血、水腫等改變—形成結核結節—膀胱攣縮—纖維組織增生--對側輸尿管口狹窄，閉合不全—引起梗阻積水并感染健腎。膀胱結核潰瘍向外穿透—可形成膀胱陰道瘺或膀胱直腸瘺。前列腺結核和附睪結核:少見。3.泌尿、男生殖系結核Pathology泌尿系結核的病理特點：組織破壞和修復混合存在。機體低抗力低時：以破壞為主—潰瘍和膿腫機體低抗力高時：以修復反應為主—纖維化和鈣化3.泌尿、男生殖系結核Pathology病理型腎結核臨床型腎結核腎積膿輸尿管結核腎自截膀胱結核前列腺結核附睪結核3.泌尿、男生殖系結核Clinicalfindings

Tuberculosisofthegenitourinarytractshouldbeconsideredinthepresenceofanyofthefollowingsituations:Chronicsystitisthatrefusestorespondtotherapy.Thefindingofwithoutbacteriaincultureoftheurinarysediment.Grossormicorscopichematuria.EnlargedepididymiswithabeadedorthickenedAchronicdrainingscrotalsinusIndurationornodulationoftheprostateandthickeningofoneorbothseminalvesicles.3.泌尿、男生殖系結核ClinicalfindingsThediagnosisrestsonthedemonstrationoftuberclebacilliintheurinebyculture.Theextentoftheinfectionisdeterminedby:1.Thepalpablefindingsintheepididymises,prostateandseminalvesiclesTherenalandureterallesionsasrevealedbyIVPinvolvementofthebladderasseenthroughthecystoscopeThedegreeofrenaldamageasmeasuredbylossoffunction.Thepresenceoftuberclebacilliinoneorbothkidneys.3.泌尿、男生殖系結核ClinicalfindingsA.Symptoms:ThereisnoclassicclinicalpictureofrenaltuberculosisMostsymptomsofthisdisease,arevesicalinorigin(cystitis)3.泌尿、男生殖系結核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、男生殖系結核ClinicalfindingsB.Signs:Laboratoryfindings:persistentpyuria(“sterile”pyuria)

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

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

3.泌尿、男生殖系結核ClinicalfindingsB.Signs:X-Rayfindings:

IVP—thetypicalchangesinclude:

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

ureteralocclusionandrenaldestruction

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

“golf-hole”

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

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

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

腎切除:無功能腎結核；腎實質破壞2/3個大盞以上，合并有難以控制的高血壓；伴輸尿管嚴重梗阻。部分腎切除：局限在一極的病變。病灶清除術:

適合于結核膿腫，一般穿刺解決。整形手術：矯正輸尿管狹窄手術膀胱攣縮可采用回腸或乙狀結腸膀胱擴大術尿路改道3.泌尿、男生殖系結核TreatmentForaseverelycontractedbladder,enterocystoplastywillincreasevesicalvolume．3.泌尿、男生殖系結核Treatment一側腎結核（功能已喪失），對側腎積水如何處理？根據積水側功能情況進行治疔！功能尚佳者可先切除結核病腎，再解除積水梗阻。若積水嚴重，腎功能不良則應先解除梗阻，然后切除無功能的結核腎臟。3.泌尿、男生殖系結核PrognosisInahighpercentageofcases,Cureisobtainedbymedicalmeans.Unilateralrenallesionshavethebestprognosis.3.泌尿、男生殖系結核Malegenitaltuberculosis主要來源于其他部位的結核病灶，經血行感染而來。50~70%合并男生殖器結核附睪和前列腺結核常同時存在3.泌尿、男生殖系結核Tuberculosisofepididymis大多為單側，起病緩慢。多從尾部開始發病。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，經久不愈。輸精管增粗，呈串珠伏。直腸指檢，前列腺有硬結。3.泌尿、男生殖系結核3.泌尿、男生殖系結核3.泌尿、男生殖系結核Tuberculosisofepididymis

附睪結核應與慢性附睪炎鑒別.

治疔原則

與腎結核相同，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，術時應盡量保留睪丸。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、男生殖系結核TreatmentInunilateralepididymalinvolvement,epididymectomypluscontralateralvasectomyisindicatedtopreventdescentoftheinfectionfromtheprostatetothatorg