Genitourinary tuberculosis includes urological tuberculosis, male genital tuberculosis and female genital tuberculosis, which are divided as follows.
[Definition
The urinary system consists of kidney, ureter, bladder and urethra. Tuberculosis that occurs in the organs of the urinary system is called urologic tuberculosis. Urological tuberculosis occurs first and mainly in the kidney. Tuberculosis of the kidney can travel down to form tuberculosis of the ureter, bladder, and urethra. Most cases can be cured with proper anti-tuberculosis medication and most do not require surgery. Some male patients with urologic TB are combined with epididymal TB. Clinical importance should be attached to urine examination in patients with pulmonary and other tuberculosis to facilitate early detection and treatment of urological tuberculosis.
Clinical manifestations
I. Systemic manifestations of tuberculosis
Most of them have no obvious symptoms of systemic toxicity of tuberculosis. Acute progressive and late severe patients may have systemic manifestations such as fever, malaise, night sweats, loss of appetite, anemia, and wasting. In case of bilateral renal tuberculosis or severe bladder tuberculosis with contralateral hydronephrosis, chronic renal insufficiency such as swelling, anemia, nausea, vomiting, oliguria or even sudden anuria may appear; some patients with renal tuberculosis may be complicated by hypertension.
Urinary system manifestations
In the early stage, there is often no clinical manifestation, but with the development of the disease, the following manifestations may appear.
1, urinary frequency, urinary urgency, painful urination and other bladder irritation signs are often the main complaints of patients at the time of consultation. Urinary frequency is the first symptom of renal tuberculosis in the early stage, urinating more than 10 times a day; as the disease progresses, the frequency of urination increases to more than 10 times to 20 times a day and night, and nocturia is more obvious. In severe bladder tuberculosis, the volume of urine does not exceed 50 ml each time in those with bladder contracture, and the number of urination can reach more than 100 times per day and night. After the occurrence of urinary urgency and painful urination, children may be afraid to urinate due to severe painful urination, resulting in urinary retention.
2. Hematuria and pus urine Mostly terminal hematuria, mostly after the symptoms of urinary frequency, urinary urgency and urinary pain. Some patients show painless hematuria throughout, and renal colic is rare. Pus urine is also common and may also appear as purulent hematuria. Sometimes the urine is cloudy like rice soup.
3. Difficulty in urination, thin urine line, short range and weakness in urination are the only symptoms of urethral stricture.
4.Usually there is no obvious back pain, pressure pain and percussion pain in the kidney area on the diseased side are rare, and local masses are rarely touched. Formation of perirenal skin sinus tract, vesicovaginal fistula, and vesicovaginal fistula, with corresponding or acute abdominal manifestations when penetrating the abdominal cavity.
6. Clinical manifestations of the male genital system may occur in those with combined male genital tuberculosis (see male genital tuberculosis).
Laboratory tests
1, routine urine examination urine examination is important for diagnosis. Routine urine examination is acidic and contains protein, red blood cells and white blood cells. Occult hematuria is the earliest laboratory indication of urological tuberculosis.
2. Bacteriological examination of urine
(1) No bacterial growth in urine general culture.
(2) Three consecutive direct smears of urine sediment may detect acid-resistant bacilli, but they need to be distinguished from acid-resistant bacilli such as Mycobacterium circumcissi and Bacillus subtilis.
(3) Culture and identification of Mycobacterium tuberculosis may yield positive results. When urinary tuberculosis is highly suspected and Mycobacterium tuberculosis is not detected, do not dismiss urinary tuberculosis easily.
(4) Rapid culture method of urine Mycobacterium tuberculosis can shorten the culture time, but false negatives and false positives are still troubling problems.
(5) urine specimen Mycobacterium tuberculosis DNA fragmentation detection, sensitivity, high specificity, fast detection.
3. Immunological tests Positive immunological tests for tuberculosis are an important basis for the presence of tuberculosis infection.
(1) Humoral immunological tests include tuberculosis antibody, antigen, and tuberculosis immune complex test.
(2) Cellular immunological tests include in vivo tests such as PPD skin test and in vitro tests such as γ-interferon secretion test by T cells stimulated by specific TB antigen [including γ-interferon release analysis test (IGRA), γ-interferon releasing specific T cell assay (T-SPOT), etc.]. IGRA and T-SPOT are more meaningful than PPD skin test in identifying Mycobacterium tuberculosis infection and non-tuberculous mycobacterial infection. PPD skin tests are more relevant. Humoral immunoassay and cellular immunoassay results can complement each other but cannot replace each other. A positive urine TB antibody test is more diagnostic than a positive blood TB antibody test. False negative immunological test results may occur in patients with low immune response or immunosuppression, and false positive PPD skin test may occur in allergic patients, especially those with skin allergy, which should also be distinguished.
Imaging examination
Including plain X-ray, imaging, ultrasound, CT, MRI, nephrogram, etc., have no diagnostic value for early renal tuberculosis. It is important to clarify the site and scope of lesion and whether the contralateral kidney is normal as soon as possible.
(1) The typical change on transvenous or retrograde pyelogram is destruction or calcification of the renal parenchyma. The destruction may be limited to one calyx or involve the whole kidney.
(2) X-rays show uneven margins of the calyces, such as worm-like or with obvious cavities, and uneven, rigid and narrowed ureteral margins.
(3) CT examination of the abdomen can detect renal lesions earlier than plain X-rays, and is better than intravenous urography for observation of advanced lesions. It can clearly show enlarged renal calyces and renal pelvis, hypodense shadows, cavities and calcifications in the renal parenchyma, and can detect fibrotic thickening of the pelvic lumen wall and ureteral wall. Enhancement scan can also observe renal function, renal parenchymal thickness, and the degree of destruction of renal structure, which can provide an objective basis for the selection of surgical plan.
(4) Ultrasound images of urological tuberculosis can be divided into renal cyst type, hydronephrosis type, renal pus type, renal heavy calcification type and mixed type. ultrasound can track and observe the effect of treatment.
(5) Radionuclide nephrogram: It is of clinical significance to understand the function of both kidneys and the degree of urinary tract patency.
The diagnosis is more complicated when tuberculosis of one side of the kidney is combined with hydronephrosis of the opposite pelvis. Because it is difficult to make retrograde contrast after bladder contracture, and it is difficult to show renal lesions by conventional methods of intravenous contrast after hydronephrosis, the film can be taken after 30 to 120 minutes of intravenous contrast injection, or by direct puncture contrast of the kidney.
Other tests]
1, cystoscopy is the most important method to confirm the diagnosis of bladder tuberculosis. In typical cases, the bladder mucosa is seen to be congested and edematous, with tuberculous nodules, and the development of lesions can be seen as tuberculous dark red ulcers or tuberculous granulation wounds. Cystoscopy, ureteral catheter insertion and retrograde pyelogram are not recommended in severe cases of bladder tuberculosis, and cannot be performed when the volume is less than 50 ml.
2, kidney puncture biopsy B ultrasound or CT-guided kidney puncture to obtain tissue specimens, pathology and antacid bacillus smear and Mycobacterium tuberculosis culture examination has a confirmatory value. However, care should be taken to prevent the occurrence of perinephric abscess.
Diagnostic points
1. Medical history A history with clinical manifestations of chronic cystitis, untreated by anti-infective drugs, hematuria or occult hematuria is an important clue to diagnose urological tuberculosis. The presence of pulmonary tuberculosis or other extra-renal tuberculosis lesions, hard nodules found in the epididymis, vas deferens or prostate, and chronic fistulae in the scrotum suggest the possibility of urological tuberculosis.
2, 24-hour urine sediment to find positive antacid bacilli, except other mycobacteria. Positive culture of urinary Mycobacterium tuberculosis has diagnostic significance. Positive urine TB antibody and positive 24-hour urine sediment DNA test for Mycobacterium tuberculosis have important reference value.
3, cystoscopy sees lesions such as bladder mucosa congestion, edema, tuberculosis nodules or ulcers.
4, imaging examination is consistent with the changes of urological tuberculosis.
The diagnosis can be confirmed based on clinical manifestations, finding Mycobacterium tuberculosis in urine, immunological examination, CT or MRI examination of kidney, pyelogram, cystoscopy and pathological examination.
[Differential diagnosis
1, chronic non-specific cystitis These patients with hematuria and urinary frequency, urinary urgency, painful urination and other symptoms of bladder irritation are more intermittent episodes, sometimes light and sometimes heavy, usually no progressive aggravation, antibiotic treatment can improve the symptoms. In women, chronic cystitis can mostly be found as a trigger or primary focus, such as hymenal umbilicus, urethral hymenal fusion, and paraurethral gland abscess. Chronic cystitis in men can have chronic anterior cleft adenopathy, urethral stricture, etc. In addition urological malformations, foreign bodies in the bladder, and variants complicating chronic cystitis also need to be identified.
2.Urological tumor often manifests as intermittent painless meatus throughout hematuria, similar to early renal tuberculosis. The tumor is mostly above 40 years old and can be differentiated by ultrasound, intravenous urography and CT. Early bladder tumor hematuria is intermittent, appears suddenly, sometimes very serious, and can disappear suddenly without any treatment, cystoscopy can confirm the diagnosis.
3.Urological stones Hematuria mostly appears after activity or after renal colic. Kidney and ureteral stones are hematuria throughout the whole process, the blood volume is not much and blood clots are rare. Bladder stones can be complicated by symptoms of urinary frequency, urinary urgency and pain, but there is often interruption of urine flow, increased lower abdominal pain after urination, and pain radiating to the head of the penis, perineum and anus. Intravenous urography and ultrasound can make the distinction.
Treatment
Basic principles The diagnosed cases should be treated actively with anti-tuberculosis. Drug therapy is the main treatment, together with the necessary surgical treatment. Early and proper use of anti-tuberculosis drugs can cure most of them, but a few need surgical treatment. Patients who need surgery should be treated with a combination of anti-tuberculosis drugs for 2 months or more before surgery, and must continue anti-tuberculosis drug treatment after surgery to keep urinary routine and urinary tuberculosis bacteriological examination negative for 6 months or more.
1.Anti-tuberculosis chemotherapy
(1) Combination of anti-tuberculosis drugs is the most basic and important treatment for urological tuberculosis. The principles and protocols of anti-tuberculosis drug application are described in the chapter of “Chemotherapy of tuberculosis”, and the modern principles of “early, combination, regular, appropriate dosage and full course” of tuberculosis treatment should be implemented. The principles of “early, combined, regular, appropriate dosage, whole course” of modern tuberculosis treatment should be implemented. In primary patients, the intensive phase is usually a combination of rifampin, isoniazid, pyrazinamide, and streptomycin (or ethambutol) for 3 months or longer, and the maintenance phase is a combination of isoniazid, rifampin, and ethambutol for 6 to 9 months, for a total duration of 9 to 12 months or longer. Aminoglycosides and quinolones have higher intrarenal concentrations and better anti-tuberculosis effects. Aminoglycosides have less toxic side effects than amikacin, quinolones have the strongest effect of moxifloxacin, and levofloxacin has better potency and can be used as appropriate. For patients with relapsed tuberculosis and combined HIV/AIDS, the course of treatment should be extended appropriately. Drug-resistant tuberculosis should be treated with a combination of sensitive anti-tuberculosis drugs according to the results of drug susceptibility testing (see the section on drug-resistant tuberculosis).
(2) Efficacy assessment and main assessment items Symptoms gradually improve to completely disappear under anti-tuberculosis chemotherapy, but the efficacy should not be judged based on symptoms alone. The negative urine cells and Mycobacterium tuberculosis, and the reduction or healing of lesions on CT (or MRI) or imaging of the urinary system are the important bases for effective treatment, and regular checkups during treatment can help judge the efficacy. During the first year of treatment, routine urine examination and Mycobacterium tuberculosis should be performed once a month, and CT (or MRI) or imaging of the urinary system should be performed once every 3-6 months; after one year, urine examination should be performed once every 2-3 months. The absence of Mycobacterium tuberculosis in urine for six consecutive months is called stable negative, and no recurrence for five years can be considered as a cure.
2.Surgical treatment
Due to the progress of modern anti-tuberculosis drug treatment, the number of cases of urological tuberculosis requiring surgery has decreased significantly, but it is still one of the important treatment means. Surgery is used when the kidney is severely damaged and functionally lost or when medical treatment is ineffective, or when there are serious complications, such as ureteral stenosis, bladder contracture with contralateral hydronephrosis. Surgery should be performed to remove as much tuberculous tissue as possible and preserve as much organ function as possible.
(1) Nephrectomy is the most commonly used operation. It is suitable for severe and extensive destruction of one side of the kidney tuberculosis, pus accumulation in the kidney; extensive caseous cavity type of kidney tuberculosis; severe destruction of renal pelvis and ureter; severe destruction or non-function of one side of the kidney and mild lesion of the other side, with the cooperation of drugs, the nephrectomy of the severe side can be performed. In cases of extensive calcification of renal tuberculosis and ureteral closure, which is called “self-excised kidney”, nephrectomy should be performed if there is no contraindication. The ureter with tuberculosis should be removed during surgery.
(2) Partial nephrectomy The lesion is limited to a part of the kidney, and there is no stenosis in the renal pelvis and ureter, and partial nephrectomy is feasible if drug treatment is not effective.
(3) Urological reconstructive and repair surgery Uretero-vesical junction stenosis, pelvic ureteral junction stenosis, and shorter middle ureteral stenosis can be treated with reconstructive surgery. In patients with small bladder capacity resulting in hydronephrosis, ileal or colonic bladder enlargement and ureteral transplantation on the ileum or colon should be performed. Patients who are not allowed to undergo larger surgery can undergo only nephrostomy or ureterostomy.
Male genital tuberculosis
Definition
The male reproductive system includes the prostate, testes, epididymis, vas deferens, ejaculatory ducts, urethra and urethral corpus cavernosum (penis). Tuberculosis that occurs in these organs is called male genital tuberculosis. Among them, epididymal tuberculosis is the most common. Clinically, urological tuberculosis is commonly associated with male genital tuberculosis.
Clinical manifestations
Most of them have no obvious symptoms of systemic toxicity of tuberculosis. The manifestations of male genital tuberculosis are mainly as follows
(1) Epididymal and testicular tuberculosis: Epididymal tuberculosis is the most common male genital tuberculosis. Its symptoms may precede those of renal tuberculosis. Some patients have a history and symptoms of tuberculosis of the urinary system or other sites. A small number of patients have hematuria. Most have slow progression and mild symptoms. There may be painless or painful hard nodes and masses in the epididymis, vas deferens or prostate, and chronic sinus tracts in the scrotum. The epididymis is gradually enlarged and the pain is not obvious; occasionally there is a feeling of downward movement or slight vague pain. Individuals with rapid onset may have high fever, rapid enlargement of scrotum and pain, similar to acute epididymitis; after the inflammation subsides, hard nodules are left behind, which may adhere to the skin and even form cold abscesses and scrotal sinus tracts. It may manifest as infertility.
(2) Tuberculosis of the prostate and seminal vesicles: early manifestations are similar to chronic prostatitis, accompanied by discomfort in the perineum and slight rectal pain. The disease may develop with hematospermia and painful oligospermia and ejaculation. A hard nodule may be palpable in the prostate and seminal vesicles on rectal examination. A few severe prostate tuberculosis may form cold abscesses that break down in the perineum and form sinus tracts, and may also form fistulas of the bladder, urethra, and rectum.
(3) Tuberculosis of the vas deferens and penis: localized bead-like nodules can be found in the vas deferens. The penile tuberculosis causes glans nodules and chronic ulcers, which are usually painless and may not heal for a long time, and may destroy the head and body of the penis. Obstruction of the vas deferens will result in loss of fertility.
Laboratory tests]
1, semen routine examination No sperm or little sperm often indicates bilateral vas deferens or epididymal tuberculosis sperm channel obstruction.
2. Bacteriological, molecular biological and immunological examinations of tuberculosis in prostatic fluid, semen, local discharge of lesion rupture and purulent secretion of sinus tract, any positive result can support the diagnosis.
Imaging examination]
1, ultrasound examination of the epididymis local or overall enlargement, its visible hypoechoic area, uneven strength, irregular shape, unclear border, may have small liquid dark areas and scattered calcification points; mostly accompanied by testicular sphincter effusion, lesions without blood flow. The prostate is seen to have uneven borders, uneven internal dots, thickened and dense, and partially calcified; when there is an abscess or cavity, a hypoechoic area or translucent area is seen.
2. Intravenous urography: Severe prostate tuberculosis can be seen as cavity-like destruction with irregular margins.
3, seminal vesicography: vas deferens seminal vesicle lesions can be seen. The vas deferens is narrowed or the vas deferens and seminal vesicles are not visualized.
4.CT and MRI examinations may show testicular enlargement, irregular morphology, inhomogeneous density, speckled calcification foci and low-density focal shadows in the parenchyma, which may have spherical enhancement, indistinct demarcation between testicular parenchyma and envelope, and fusion of scrotal septum with the diseased testicle. MRI shows that the structure of the testis is still intact in the early stage, but there may be abscess formation in the late stage; it shows mostly low signal on T1-weighted images and mixed high and low signal on T2-weighted images, with calcification and fibrosis, obvious patchy low signal areas, and a small amount of syringomyelia. MRI of prostate tuberculosis can show low signal, high signal or mixed signal.
Other examinations
1, urethroscopy can be seen
(1) dilatation of the prostatic urethra at the proximal end of the seminiferous tubercle, with congestion and thickening of the mucosa.
(2) Dilation of the prostatic duct opening in the shape of a golf hole.
(3) Longitudinal trabecular changes in the mucosa of the prostatic urethra.
2. Transrectal ultrasound guided prostate puncture biopsy Specimens can be subjected to antacid staining, Mycobacterium culture and identification, pathological examination and molecular biology examination, etc.
Diagnosis】
The diagnosis can be made based on the clinical manifestations of male genital tuberculosis, laboratory and imaging examinations, etc.
(1) Epididymal tuberculosis: typical epididymal nodules, skin adhesions, sinus tracts and bead-like vas deferens changes, along with the basis of tuberculosis infection (see urological tuberculosis), the diagnosis can be confirmed; the presence of renal tuberculosis is more supportive of the diagnosis.
(2) Prostate tuberculosis: symptoms of chronic prostatitis or hematospermia, painful ejaculation, etc., nodules on prostate finger examination, irregular pattern, pressure pain, enlarged gland or shrinking gland forming a hard mass. Antacid bacilli can be found in prostatic fluid or semen smear.
(3) Testicular tuberculosis: The diagnosis needs to be confirmed pathologically when the testicle is enlarged or nodular with mild discomfort.
(4) Vas deferens and penile tuberculosis: localized beaded nodules in the vas deferens, nodules in the glans penis and chronic painless ulcers that do not heal for a long time, or infertile, can be diagnosed by pathologic biopsy.
Differential diagnosis
1. Early epididymal tuberculosis should be distinguished from chronic epididymitis. Chronic epididymitis is more painful, often with a history of acute and recurrent episodes, and the epididymal mass is not as hard and large as tuberculosis, rarely forming limited hard nodes, not forming sinus tracts, no skin adhesions and vas deferens-like changes. Gonococcal epididymitis has a history of gonorrhea, an acute course, local redness and pain, and purulent discharge from the urethra, in which intracellular gram-negative diplococci can be detected. Epididymitis due to chlamydial infection can also cause acute epididymitis similar to gonorrhea, with a history of non-gonococcal urethritis in the patient. Infiltrates and sclerotia caused by scrotal filariasis are within the spermatic cord and can be separated from the epididymis, and the sclerotia they form tend to change more in a short period of time, whereas tuberculosis sclerotia change slowly; filariasis is regional, and patients can have both elephantiasis and chylous effusion.
2, testicular tuberculosis, vas deferens, penile tuberculosis need to be differentiated from malignant tumors.
3, simple prostate tuberculosis needs to be distinguished from non-specific chronic prostatitis, especially granulomatous prostatitis, early prostate cancer. In case of diagnostic difficulties, biopsy can be used to differentiate.
Treatment
Internal treatment of male genital tuberculosis (see genitourinary tuberculosis). Surgical treatment mainly addresses epididymal tuberculosis. Indications for surgery are.
(1) The effect of drug therapy is not obvious.
(2) Large lesions and formation of abscesses on one or both sides.
(3) severe local caseous lesions.
(4) Chronic sinus formation in the scrotum of one or both epididymis.
(5) Combined testicular lesions should be removed at the same time. Anti-tuberculosis medication should be administered for 8 weeks before surgery.
The assessment of the efficacy of reproductive tuberculosis is mainly based on bacteriological examination of genital secretions, imaging and physical examination of external genitalia.
Female genital tuberculosis
Definition
The internal genital organs of the female reproductive system consist of ovaries, fallopian tubes, uterus, vagina and vestibular glands; the external genital organs include the mons veneris, labia majora, labia minora, clitoris, vaginal vestibule and vestibular bulb. Tuberculosis that occurs in these systems and organs is called female genital tuberculosis.
Clinical manifestations]
In mild cases, there is no obvious clinical manifestation. The clinical manifestations of the female reproductive system are mainly
(1) Infertility.
(2) varying degrees of lower abdominal pain, often aggravated by sexual intercourse, exercise and menstruation. In combination with pyogenic infection, there is significant abdominal pain, fever, and painful masses similar to acute pelvic inflammatory disease.
(3) Menstrual disorders: often manifest as abnormal uterine bleeding, which may be excessive in the early stage, sometimes intermenstrual bleeding, postmenopausal bleeding, and in the late stage, scanty menstruation or amenorrhea.
(4) Increased leucorrhea may occur in endometrial tuberculosis or vaginal tuberculosis. In cervical tuberculosis, the discharge may be purulent or purulent, and sometimes there is even contact bleeding or foul-smelling purulent blood.
(5) In case of combined tuberculosis of other organs, symptoms of tuberculosis of other organs may occur at the same time. In pelvic peritoneal tuberculosis, there may be abdominal tenderness or ascites signs, and cystic masses may be palpated when encapsulated fluid is formed; the uterus is mostly fixed due to adhesions and is often smaller than normal; in tubal and ovarian tuberculosis, strip-like fallopian tubes or irregularly shaped hard masses formed by adhesions between the two may be palpated on both sides of the uterus; superficial ulcers or papillary hyperplasia may be seen locally in vulvar, vaginal and cervical tuberculosis.
Laboratory tests]
Menstrual blood or uterine cavity scrapings or peritoneal fluid for Mycobacterium tuberculosis examination.
(1) Smear staining for antacid mycobacteria can yield positive results, which need to be distinguished from other mycobacterial infections.
(2) Mycobacterium tuberculosis culture (including rapid culture, identification) takes a long time, but the results are reliable.
(3) Molecular biology methods such as polymerase chain reaction (PCR), ligase chain reaction (LCR), fluorescence quantitative real-time PCR, gene chip technology, DNA sequencing and other methods to detect Mycobacterium tuberculosis DNA may obtain positive results.
[Imaging examination
(1) X-ray: Some patients with genital tuberculosis may have pulmonary lesions on chest X-ray, and sometimes digestive or urinary tuberculosis lesions on abdominal X-ray. The presence of calcified shadows on abdominal pelvic X-ray suggests the presence of post-healing foci of genital tuberculosis and also suggests the possible presence of genital tuberculosis.
(2) Hysterosalpingography with iodine oil should be performed within 2-3 days after menstruation, or at any time in amenorrhea, and is contraindicated in cases of inflammatory adnexal masses and fever. Anti-tuberculosis drugs should be used prophylactically for several days before and after the procedure. The diagnostic value is divided into two categories. 1) The more reliable signs.
(1) Multiple scattered calcified shadows seen in the film.
(ii) Obstruction in the middle of the fallopian tube with iodine oil contrast into the interstitial wall.
(3) Multiple narrowing of the fallopian tubes with a rosacea-like appearance.
④Severe narrowing or deformation of the uterine cavity in those without a history of abortion or curettage.
The iodine contrast agent enters the interstitium of the uterine wall or the parametrial lymphatics or blood vessels (so-called “iodine contrast agent intraluminal perfusion”).
(6) The formation of annular or spherical high-density shadow at the equivalent of the ovary.
(2) Possible signs.
(1) Isolated calcified shadows in the pelvic film.
(2) Stiffness of the fallopian tubes with distal obstruction.
(3) Irregular and obstructed fallopian tubes.
④Bilateral obstruction of the isthmus of the fallopian tubes.
⑤ distal atresia of the fallopian tubes with iodine contrast perfusion defects in the lumen.
(6) Irregular and jagged margins of the uterine cavity.
(3) Ultrasonography Transvaginal ultrasonography can reveal separated peritoneal fluid, small foci of calcification scattered in bilateral adnexa, thickened omentum, thickened peritoneum, etc.
(4) CT and MRI can detect bilateral hydrosalpinx, thickened endothelium, and intestinal curvature or encapsulated tubo-ovarian tissue in the pelvic mass, but the specificity is poor and is rarely used clinically.
Other tests]
1.Histopathological examination is a reliable method to diagnose genital tuberculosis, especially endometrial tuberculosis. Diagnostic scraping should be chosen from 1 week before menstruation to within 12h of menstruation. Protective anti-tuberculosis treatment such as streptomycin and isoniazid is given 3 days before and 4 days after surgery. Endometrial tuberculosis is mostly found in the adjacent uterine horns, and care should be taken to obtain material there during scraping, and the specimen obtained can be subjected to pathological examination and tissue antacid staining and Mycobacterium tuberculosis DNA examination. Endometrial tuberculosis should also be considered in conjunction with the medical history in cases where the uterine cavity is small and the endometrial tissue cannot be scraped out. Lesions in other areas such as vulva, vagina and cervix can be directly biopsied for pathological examination.
2.Endoscopic examination
(1) Laparoscopic examination
(1) direct observation of the pelvic cavity, and preliminary judgment can be made based on the results of microscopy.
②Take the abdominal fluid for Mycobacterium tuberculosis culture, or take the lesion tissue under direct vision and send it for pathological examination. The use of this method is limited in cases of pelvic organ adhesions, and it is safer to take specimens for small incisions in cases with severe lesions.
(2) Hysteroscopy The site of nodular lesions and the extent of lesions can be seen directly. In the early stage, superficial yellow ulcers in the uterine horns can be seen; in the later stage, endometrial caseous changes, fibrosis and calcification, and structural changes such as adhesions, occlusion and disappearance of the fallopian tubes. Tissue can be taken for pathology and bacteriological examination.
3.Puncture examination Cystic packets can be found in the pelvic cavity and can be examined by posterior vaginal vault aspiration. Tuberculous fluid is mostly straw yellow, sometimes cloudy or bloody, and a large number of white blood cells, mainly lymphocytes or monocytes, can be seen microscopically. A centrifugal smear of the fluid can sometimes reveal acid-resistant bacilli.
Diagnosis
With clinical manifestations of female genital tuberculosis. If the primary infertility or pelvic inflammatory disease is ineffective after regular anti-inflammatory treatment, or if an unmarried woman has ascites along with uterine adnexal lesions, or if she has a history of contact with tuberculosis patients or a history of tuberculosis herself, the possibility of genital tuberculosis should be considered. The above-mentioned ancillary tests can assist in the diagnosis, and the diagnosis can be confirmed with an etiological or pathological basis.
Differential diagnosis
Chronic non-specific adnexitis, chronic pelvic inflammatory disease, ovarian tumor, and endometriosis should be differentiated.
(a) Chronic non-specific adnexitis and chronic pelvic inflammatory disease are often associated with infertility, lower abdominal pain, and adnexal thickening, but the onset is often acute, with a history of delivery, abortion, recent gynecologic surgery, or acute pelvic inflammatory disease; menstrual flow is usually heavy and amenorrhea is rare; when chronic adnexitis persists, hysteroscopy or hysterosalpingography, immunology, bacteriology, and pathology may be performed to differentiate.
(b) Ovarian tumor. In cases of encapsulated effusion, aspiration may be performed. If malignant lesions cannot be excluded, puncture may not be performed. The surface of tuberculous adnexal masses is not smooth and inactive, surrounded by fibrous adhesion thickening. Advanced malignant ovarian tumors often have cachexia, fever, accelerated blood sedimentation, and a mass in the adnexa on gynecological examination, and metastatic nodules may be found in the lower part of the pelvis without tenderness. The diagnosis can be clarified by caesarean section or laparoscopy.
Endometriosis Patients with endometriosis are generally well, do not have chronic disease, have progressive dysmenorrhea, and 1-2 or more small hard nodules are often palpable in the rectal fossa, uterosacral ligament, or posterior wall of the cervix. Diagnostic scraping, hysterosalpingogram, combined hysterolaparoscopy, etc. can mostly clarify the diagnosis.
Treatment
Internal medicine treatment of female genital tuberculosis (see genitourinary tuberculosis). Indications for gynecologic surgery.
(1) pelvic masses that shrink but do not completely subside after antituberculosis treatment and malignancy cannot be completely excluded.
(2) Internal antituberculosis treatment is ineffective or recurrent after treatment.
(3) endometrial tuberculosis for which anti-tuberculosis treatment is ineffective
(4) Fistulae that do not heal, etc. The assessment of efficacy is based on bacteriological and imaging examinations of germinal secretions and physical examination of the external genitalia. The assessment of the efficacy of internal genital tuberculosis is more difficult, usually with the help of imaging and, if necessary, endoscopic review.