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TuberculosisTB of the Genitourinary Tract

Urinary TB. A disease of young adults. 60% between 20~40y.Infecting organism ? Mycobacterium tuberculosis (??????,????), Tubercle bacilli . Infecting Route(????). Hematogenous route(????) from the lungs.Primary sites(????): Kidney, Prostate (???)Other organs involved: direct extension

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TuberculosisTB of the Genitourinary Tract

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    1. Tuberculosis(TB) of the Genitourinary Tract ??????? ???????? ? ?

    2. Urinary TB A disease of young adults. 60% between 20~40y. Infecting organism Mycobacterium tuberculosis (??????,????), Tubercle bacilli

    3. Infecting Route(????) Hematogenous route(????) from the lungs. Primary sites(????): Kidney, Prostate (???) Other organs involved: direct extension

    4. Pathogenesis(????) Tubercle bacilli hit the renal cortex(???): ?Normal resistance(???): organism destroyed ?Sufficient virulence(???): clinical infection established.

    5. Pathogenesis TB of kidney: progresses slowly, 15~20y to destroy a kidney with good resistance. No clinical disturbance until the calyces / pelvis(??/??) involved.

    6. Pathology(??)

    7. Kidney & Ureter (???) Grossly: a soft, yellowish localized bulge (??). On section: involved area filled with cheesy material (caseation, ?????).

    8. Kidney & Ureter Walls of pelvis, calyces and ureter thickened. Ulceration(????) in calyces. Complete ureteral stenosis(?????) ?Autonephrectomy(???). ?Bladder urine normal and symptom absent.

    9. Kidney & Ureter Basic lesionTubercle foci(????) Epithelioid reticulum(????) Peripheral giant cells Heal by fibrosis(???).

    10. Kidney & Ureter TB is a combination of caseation(????), cavitation(????) and healing by fibrosis &scarring(????????). Depending on virulence vs resistance. Calcification(??): strongly suggestive of TB. Secondary renal stones in 10%.

    11. Left kidney: autonephrectomy Right Kidney: hydronephrosis & ureteral reflux (???&?????) Contraction of the bladder (????)

    12. ????

    13. ?????

    14. Caseation & Fibrosis

    15. L Renal Dysfunction on Isotope Scan (?????)

    16. Calcification (??)

    17. Bladder Tubercle form: white/yellow raised nodules(??) surrounded by a halo of hyperremia(??). Tubercles break down?deep ragged ulcers ?bladder irritable.

    20. Diagnosis(??)

    21. Just saying you had turned a corner doesnt make it so. Just saying there is massive destruction doesnt make it so. __John Kerry Just saying there is TB also doesnt make it so. We must provide Demonstration of tubercle bacilli in urine by culture.

    22. Diagnosis: Symptoms(??) No classic clinical picture of renal TB. Most are vesical in-origin(????): burning, frequency(??) & nocturia(??), hematuria(??)

    23. Diagnosis: Signs(??) Kidneyno enlargement / tenderness(??) External genitalia(????): thickened, nontender epididymis(??) chronic scrotal draining sinus(????) Induration/nodulationof prostate & seminal vesicles(???/????)

    24. Diagnosis: Lab Findings ?Persistent pyuria(??) without organism on culture. But acid-fast stains: ?60%(+). ? Culture for TB (1st morning urine): (+) percentage very high. ?Tuberculin test(??????): (-) against TB.

    25. Diagnosis: X-ray Findings Chest film Plain film(??): Enlargement of 1 kidney Obliteration(??) of the renal & psoas (???) shadow Renal stones(???) 10%

    26. Diagnosis: X-ray Findings Excretory urograms(???????): Moth-eaten(??) appearance of ulcerated calyces. Obliteration of 1/more calyces. Dilation of calyces. Abscess cavities connecting with calyces.

    27. Excretory urograms: Ureteral stricture with secondary dilatation. Absence of function of the kidney. Retrograde Urography

    30. MRU or CT

    31. Diagnosis: Instrumental Exams Cystoscope(???): Tubercles & ulcers, contraction(??) Cystogram(????): Ureteral reflux(?????)

    32. Differential Diagnosis ???? Chronic nonspecific cystitis ????? Epididymitis ??? Multiple small renal stones and medullary sponge kidneys(???) Urinary bilharziasis(????) Bladder stones or cancer.

    33. Treatment (??) TB must be treated as a generalized disease!

    34. Basic treatmentMedical ?? Surgical excision(????) merely adjunct

    35. Treatment: Renal TB Combination of drugs(1st line): 1. Isoniazid (INH, ???) 200~300mg/d 2. Rifapin (RFP, ???) 450~600mg/d 3. Ethambutol (EMB, ????) 15mg/kg/d 4. Streptomycin (STM, ???) 1g/d im 5. Pyrazinamide (PZA, ????) 1.5~2g/d

    36. Treatment: Renal TB Prefer INH + RFP + EMB Resistance to 1st line drugs: Aminosalicylic acid (?????) Capreomycin (????) Cycloserine (????) Ethionamide (?????) Viomycin (???)

    37. Treatment: Renal TB Nephrectomy(???) : 1. After 3 m, urine culture still (+) and gross involvement radiologically evident. 2. Severe sepsis(???), pain or bleeding from 1 kidney. 3. Marked advanced on 1 side and minimal damage on the other.

    38. Treatment: Vesical TB Tends to heal when treatment for the primary infection is given. Ulcers : trans-urethral electrocoagulation (?????) Extreme bladder contraction: urinary diversion(????); augmentation cystoplasty(????????)

    39. Treatment: General Measures Optimal nutrition: important Irritable bladder: bladder sedatives(???)

    40. Prognosis(??) Relapse(??): Ureteral stenosis; Vesical contraction

    41. Prognosis Overall control rate: 98% at 5 years Urine study: every 6 m during treatment; every year for 10 years.

    42. Case Report A 56y male with left abdominal mass & anemia(??). X-ray showed a large stone in L kidney with severe hydronephrosis.

    48. ? ?

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