OVERVIEW
Tuberculosis of the bladder is secondary to renal tuberculosis and in a few cases spreads from prostate tuberculosis. Bladder tuberculosis most often coexists with genitourinary tuberculosis. Early lesions consist of inflammation, edema, congestion, and ulceration, with bladder contracture occurring in advanced stages. Involvement of lesions in the ureteral orifice occurs stenosis or atresia incomplete, resulting in hydronephrosis, ureteral effusion, renal hypoplasia. Tuberculosis of the bladder often evolves from renal tuberculosis. The initial symptom of most patients with tuberculous cystitis is frequent urination, which gradually worsens and is accompanied by urinary urgency, urinary pain and hematuria. Urination gradually increases from 3-5 times/day to 10-20 times/day. If the bladder symptoms worsen, the mucous membrane has extensive ulceration or bladder contracture, and the capacity shrinks, then the urination reaches dozens of times a day, or even incontinence, which is very painful for the patients.
Etiology
Secondary to renal tuberculosis, a few spread from prostate tuberculosis.
Symptoms
Bladder tuberculosis is part of urinary tuberculosis and has similar symptoms. Since most bladder tuberculosis originates from renal tuberculosis, early lesions may lie in the kidneys and often have no clinical symptoms. As the disease progresses, bladder irritation signs become more pronounced, manifesting as urinary frequency, urgency, and urinary pain, which are often the main complaints of patients when they visit the doctor. In patients with bladder tuberculosis, the frequency of urination is more severe, as the lesion spreads to form tuberculous cystitis.
Hematuria and pyuria are also more common. Most often the hematuria is terminal.
In severe cases of bladder tuberculosis, hydronephrosis can result, and symptoms of chronic renal insufficiency, such as edema, anemia, nausea, vomiting, oliguria, or even sudden anuria, can occur.
Tuberculous ulcers in the bladder wall penetrating into neighboring organs may form tuberculous vesicourethral node, intestinal fistula or vesicovaginal fistula, and urine flows into the abdominal cavity when it penetrates the abdominal cavity to present with the clinical manifestations of acute abdomen.
Examination
1. Urine examination
There are a lot of red blood cells and pus cells in the urine. If there is no mixed infection, mid-stream urine bacterial culture is negative, and 60% of tuberculosis culture is positive.
2. X-ray examination
Excretory urography, in some cases, shows tuberculosis lesions on one side of the kidney. In advanced cases, there is contralateral hydronephrosis and renal hypoplasia. Cystography shows that the edge of the bladder is rough and not smooth. Cystography showed a reduced bladder capacity of less than 50 mL, and some patients had vesicoureteral reflux on the contralateral side.
3. Cystoscopy
In the early stage, there are edema and congestion and tuberculous nodules around the ureteral orifice, which gradually spread to the deltoid region and the contralateral ureteral orifice, and even to the whole bladder. The tuberculous nodule breaks down and forms a granulation wound with necrotic hemorrhage. There is a clear boundary between the lesion mucosa and normal bladder mucosa.
Diagnosis
1. History of renal tuberculosis.
2. Significant frequency of urination with very small amount of urine each time, and incontinence in severe cases.
3. palpable enlarged kidney in the upper abdomen.
4. Symptoms of advanced chronic renal insufficiency.
5. Cystography shows reduced bladder capacity, rounded shape with irregular margins, and contrast medium may reflux into the ureter and renal pelvis through the ureteral orifice.
Questions you may be concerned about
How is bladder tuberculosis usually detected?
Bladder tuberculosis can be detected by routine urinalysis, DNA testing for Mycobacterium tuberculosis in urine and cystoscopy and cystography.
Urine routine in patients with bladder tuberculosis can see more pus cells and red blood cells, and urine examination to find antacid bacilli is often positive. Cystoscopy can see bladder mucosal congestion, edema, tuberculosis nodule or ulcer formation and can see the bladder capacity becomes smaller, microscopic biopsy can confirm the bladder tuberculosis.
Mycobacterium tuberculosis DNA assay is a fluorescence quantitative PCR test technique to detect whether the specimen contains Mycobacterium tuberculosis DNA, if found positive, it can be sure that the patient is infected with Mycobacterium tuberculosis.
On cystography, patients with existing bladder contracture have a very small rounded bladder with non-smooth edges, and in severe cases, the bladder neck is open. If spontaneous rupture of the tuberculous bladder occurs, there is sudden abdominal pain, and yellow urine can be seen on abdominal puncture. In late stage, intravenous urography can show renal ureteral tuberculosis and small bladder capacity.CT examination is now also widely used in the diagnosis of genitourinary tuberculosis.
Tuberculosis of the bladder is mostly secondary to renal tuberculosis, and the early lesions are inflammation, edema, congestion and ulceration, and in the late stage, contracture of the bladder will occur, and when the lesion involves the ureteral orifice, stenosis or atresia will occur, resulting in renal ureteral fluid and renal hypoperfusion. Most patients with tuberculous cystitis have frequent urination as the first symptom, and then the frequency of urination gradually worsens and is accompanied by urinary urgency, urinary pain and hematuria.
If the patient is suspected of tuberculosis of the bladder, it is recommended to go to a regular hospital to receive examination, patients should not diagnose on their own, so as not to delay the condition.
Differential diagnosis
1. Non-specific cystitis
Commonly found in women, especially newly married women. Both have frequent urination, urinary urgency, urinary pain, hematuria and pyuria. However, if cystitis is accompanied by pyelonephritis, the patient has fever and low back pain, pressure pain in the suprapubic region, and positive bacterial culture of mid-stream urine. Excretory urography, no destructive lesions in the kidneys. Treatment with antibiotics was effective.
2. Urethral syndrome
Seen in women, in addition to frequent urination, urinary urgency, urinary pain, mostly accompanied by pain in the lower abdomen or suprapubic area, vulvar itching. Often due to exertion, low water intake or after sexual intercourse, resulting in an acute attack. On cystoscopy, the bladder mucosa is smooth, darker in color, and the blood vessels are clear. Some are blurred but still recognizable. The vasculature of the triangular area is blurred, structurally disturbed, and pale due to repeated inflammatory damage. Excretory urography, no abnormal findings in the kidneys.
3. Urethritis
There is urinary frequency, urgency, painful urination. The pain radiates to the head of the penis. However, urethritis is hematuria at the beginning of urine. In severe cases, there is purulent discharge from the urethra, which is obvious in the morning. Cystoscopy: no inflammatory changes in the bladder, no tuberculous nodules. Treatment with antibiotics is effective.
4. Bladder stones
Mostly seen in children, due to the irritation and damage of stones, there are frequent urination, urgency and painful urination. However, bladder stones have difficulty in urination, which is characterized by sudden interruption of urination, and the difficulty and pain can be relieved after changing the position. Plain radiograph of the bladder area, showing opaque shadows. Cystoscopy, which allows direct visualization of the stones.
Treatment
1. Drug treatment
At present, there are more drugs with clinical application value, but isoniazid, streptomycin, p-aminosalicylic acid has better efficacy and less toxicity, which is called the first line of drugs, and others such as aminothiourea, pyrazinamide, kanamycin, cycloserine zymosan and so on, the effect of these drugs is not as good as that of the first line of drugs, and the toxicity is also greater, and it is only used in the case of tuberculosis bacteria resistance to the first line of drugs, so it is called the second line of drugs. Rifampicin and ethambutol are newer drugs, because of their higher efficacy and lower toxicity, in recent years, they have tended to replace p-aminosalicylic acid as the first-line drugs.
2. Surgery
Surgery is aimed at removing irreparable destructive lesions, relieving obstruction and rescuing renal function. The basic principles are: no active tuberculosis foci outside the urinary tract and male genitalia; at least 2 weeks of anti-tuberculosis must be done before surgery, and the treatment program still needs to be completed after surgery. Surgical treatment of contracted bladder: differentiate from bladder spasm caused by tuberculous inflammatory irritation before surgery. After 3 to 6 months of anti-tuberculosis treatment inflammation subsides capacity recovery, most of the bladder spasm, no need for surgery; if there is no improvement, then the bladder contracture. Surgical modalities include: bowel bladder enlargement, urinary diversion, and so on.