[Etiology] Urinary tuberculosis is part of systemic tuberculosis, mostly secondary to pulmonary tuberculosis, and rarely secondary to intestinal tuberculosis or osteoarticular tuberculosis. It can involve the kidney, ureter, bladder, urethra, prostate, seminal vesicles, testes, vas deferens, and fallopian tubes.
The pathological basis for radiological diagnosis of genitourinary tuberculosis is as follows: When Mycobacterium tuberculosis spreads to the genitourinary tract via blood or lymph, it often first involves the renal cortex. Under suitable conditions for growth, foci of caseous necrosis are formed, followed by development to the renal medulla, which develops into foci of caseous necrosis in the renal papillae and subsequently spreads to the renal calyces to form tuberculous cavities, i.e., typical symptoms of renal tuberculosis appear, and the tuberculous lesions can spread to all parts of the genitourinary system with the urinary tract.
[Clinical manifestations]
I. Medical history
Frequent urination, urgent urination, painful urination, and pus urination are common symptoms in the early stage, and hematuria is not uncommon.
2, the development of the disease may have fever, night sweats, wasting, weakness and other symptoms of tuberculosis poisoning, and often accompanied by other organs of tuberculosis corresponding symptoms.
3, long-term persistent chronic cystitis, and the general urine culture negative, and the general antibacterial drug treatment after the symptoms are not reduced but aggravated, even if the urine culture for general bacteria can not exclude the possibility of renal tuberculosis and secondary bacterial infection.
Physical examination There are no positive signs in the early stage, but in the late stage, there are signs of tuberculosis systemic toxicity, such as fever, facial flushing and emaciation. Sometimes enlarged kidney is palpable in the kidney area, with local pressure pain and percussion pain.
Auxiliary examination
The urine is often cloudy and washed, with a little urine protein, acidic reaction of fresh urine, leukocytes, pus cells and red blood cells on microscopic examination of the sediment, and a positive rate of more than 70% on direct smear antacid staining for Mycobacterium tuberculosis, and a positive rate of about 90% on culture or animal inoculation for Mycobacterium tuberculosis.
2, erythrocyte sedimentation rate is often increased. In advanced renal decompensation, there may be anemia and increased plasma urea nitrogen and myophenol values.
3.Urological X-ray plain film
4.Intravenous pyelogram
[Imaging performance]
1.Flat film
(1) Calcification of the renal parenchyma is the main finding. The low density of the calcification foci is not very clear, which is due to the small amount of calcium salt deposition within the caseous necrotic material. The calcification foci can be small and single, or scattered and multiple. When whole kidney calcification appears, the kidney may atrophy and become small, and the kidney function is very poor or non-functional. This kind of whole kidney diffuse calcification is called “self-truncated kidney”, which is common in advanced renal tuberculosis.
(2) Ureteral calcification: Sporadic calcium salt deposits along the ureter with tuberculosis.
(3) Calcification of the bladder: there are mostly dense shadows on the bladder wall.
(4) The prostate, seminal vesicles, and vas deferens also have scattered or curved dense linear dot-like shadows.
2.Urographic and CT findings
(1) The urography begins to show early changes after the tip of the renal cone is involved in renal tuberculosis, showing a mildly blurred irregular shape in a certain calcium. If the lesion continues to expand, the renal calyx also expands and is accompanied by irregular destruction, indicating that the renal cone and cortex have undergone erosion and necrosis, and further development of the lesion, the appearance of the renal calyx is like feathery or worm-like necrosis, and the contrast agent can be seen outside the calyx, and even the fistula between the involved renal calyx and the cavity can be seen.
(2) Extensive caseous necrotic cavities in the kidney with large irregular foci of contrast-fillable destruction are seen in the advanced stage of renal tuberculosis, and such cavities are more clearly shown in the enhanced CT images with pus accumulation in the cavity and watery density without enhancement. Extensive renal tuberculosis destruction is accompanied by repair, and large amounts of calcium salts are deposited in the foci of renal caseous necrosis, which can become non-functional kidneys, called “self-cutting kidneys”.
(3) The early manifestation of ureteral tuberculosis is dilatation of ureter with worm-like edges, which is caused by the invasion of the ureteral muscle layer by the nodal pattern, resulting in dystonia and multiple ulcers. Subsequently, the ureteral wall thickens and thickens, loses elasticity, and peristalsis disappears. When there is a large amount of fibrotic scar deformation, the ureteral lumen is narrowed or the narrowing and dilatation alternate, manifesting as bead-like, spiral, and finally may become a short and rigid thin tube, or even completely atretic, all accompanied by hydronephrosis on the affected side.
(4) Tuberculosis of the bladder is mostly caused by the downstream spread of tuberculosis in the upper urinary tract. There is blurring and marginal irregularity at the junction of the vesicoureter, volume reduction, spasm and fibrosis, and the “small bladder sign”. Sometimes lamellar foci of calcification are seen in the bladder wall. If the bladder tuberculosis involves the ureteral orifice of the healthy bladder, the sphincter atresia is incomplete and urinary reflux occurs, which leads to the phenomenon of hydronephrosis on the healthy side.
(5) Urological tuberculosis can spread to reproductive organs, including prostate, seminal vesicles, epididymis and vas deferens in men, mainly through the tuberculosis bacilli in the urine of the kidney entering the prostate and seminal vesicles through the prostatic tubules and ejaculatory ducts of the posterior urethra, and then from the vas deferens to the epididymis and testes, and also through hematogenous dissemination to these organs.
3.B ultrasound: early stage cannot be detected. Intermediate and late stages can show.
(1) Tuberculosis cavity: single or multiple liquid dark areas with unsmooth edges and scattered light spots inside.
(2) Calcification of the renal parenchyma: in small cases, small light clusters with acoustic shadow, and in large cases, calcification of the whole kidney, showing dense arc-shaped light clusters with posterior acoustic shadow.
(3) When the lesion is extensive and becomes a septic kidney, the hydronephrosis sound image appears.
(4) The renal envelope is blurred or the kidney is shrunken and deformed.
Calcification of left renal tuberculosis: Plain film shows encapsulated calcification in the left kidney area, and there are also patches of calcification within it, which is a “self-cut kidney”. Calcification of the left ureter is also seen. The kidney and ureter were found to be tuberculous. Retrograde imaging shows enlarged hydronephrosis in the left upper and middle calyces, partial destruction of the lower calyces, partial calcification in the renal parenchyma, and irregular destruction and dilatation of the upper left ureter. The bladder volume was small with irregular margins.
[Differential diagnosis]
Differential diagnosis of urinary tract tuberculosis.
(1) Calcification due to renal and ureteral tuberculosis should be differentiated from calculi. The latter are dense, mobile, and located in the lumen.
(2) Calcification of seminal vesicles is mostly tuberculous, and calcification of prostatic tuberculosis should be distinguished from stones.
(3) Tuberculous hydronephrosis should be distinguished from non-tuberculous hydronephrosis.
Treatment of [renal tuberculosis]
Since renal tuberculosis is part of systemic tuberculosis, treatment must pay attention to both systemic treatment and local treatment to achieve satisfactory results. Specifically, on the one hand, anti-tuberculosis drugs, proper rest, sunlight and adequate nutrition are given, and on the other hand, diseased kidney or diseased tissues are surgically removed as needed to shorten the course of treatment and improve the efficacy.
(A) Anti-tuberculosis drug therapy: The basic condition for simple drug therapy is that the kidney is still functioning well and the urinary drainage is not obstructed.
The indications for drug therapy are:
(i) preclinical renal tuberculosis.
(ii) renal tuberculosis with small lesions.
(iii) Bilateral or solitary renal tuberculosis that is in advanced stage and not suitable for surgery.
(iv) patients with active tuberculosis in other parts of the body who are temporarily unfit for surgery.
⑤ patients with other serious diseases that are temporarily unfit for surgery.
There are many types of anti-tuberculosis drugs, such as isoniazid, streptomycin, para-aminosalicylic acid, rifampin, kanamycin, cycloserine, ethambutol, ethionamide, pyrazinamide, tendragynine, etc. Generally, a combination of 3 drugs is used: isoniazid 100 mg orally 3 times a day; streptomycin l g daily in two intramuscular injections, changing to 2 g weekly after l-3 months; and sodium para-aminosalicylate 2-4 g 4 times a day. To reduce the gastric irritation of sodium para-aminosalicylate, sodium bicarbonate can be added at l gram 3 times a day. Of course, it can be combined with other drugs listed above. The medication course is 2 years, with a minimum of l-1.5 years. It is also possible to combine rifampin 600 mg, isoniazid 300 mg and pyrazinamide 1.0 g with the application of vitamin C 1.0 g orally once a day. After two months, the treatment was changed to rifampicin and pyrazinamide and continued for 4 months.
(ii) Surgical treatment: Surgical treatment of renal tuberculosis includes nephrectomy, partial nephrectomy and nephrectomy. The choice of surgical method depends on the extent of the lesion, its degree and its response to drug therapy.
1, nephrectomy: unilateral nephrectomy is suitable for unilateral nephrotuberculosis with large destruction, unilateral tuberculous septic kidney, calcified kidney, and good kidney function on the opposite side. In case of bilateral renal tuberculosis, if one side is severely damaged and the renal function is lost while the other side is light enough to compensate, the kidney on the heavy side should be removed with the cooperation of anti-tuberculosis drugs.
2.Partial nephrectomy: If the lesion is confined to one pole of the kidney and does not improve after long-term drug treatment, or if it is complicated by poor drainage of urine due to narrowing of the funnel of the kidney, partial nephrectomy is indicated.
If the tuberculosis cavity formed near the surface of the renal parenchyma is not accessible to the renal calyx and drug treatment is ineffective, nephrectomy is feasible.
(C) principles of management of late complications of renal tuberculosis: late complications of renal tuberculosis mainly include contralateral hydronephrosis and bladder contracture.
1, the principle of management of contralateral hydronephrosis is that the hydronephrosis side of the kidney function is sufficient to compensate, and the blood urea nitrogen and muscle liver is normal, first remove the tuberculous kidney, and then deal with hydronephrosis; if the hydronephrosis side of the kidney function has been unable to compensate and lead to elevated blood urea nitrogen and creatinine, first hydronephrosis side nephrostomy, and then remove the tuberculous kidney and deal with hydronephrosis after the kidney function has improved. When dealing with hydronephrosis on the opposite side, if there is no bladder contracture, ureteral bladder reimplantation is feasible.
2, bladder contracture, then bladder enlargement should be performed along with ureteral intestinal transplantation. The principle of management of bladder contracture is that if there is no urethral stricture or vesicovaginal fistula, sigmoid cyst enlargement is often used. In case of urethral stricture or vesicovaginal fistula, ileal cystectomy or rectal cystectomy is used.