泌尿及男性生殖系結核TuberculosisoftheUrinaryandMaleGenitalSystemGENITOURINARYTUBERCULOSIS

Tuberculosishasbeenoneofthegreatimitatorsofalltime,andonlyafewyearsagowasthoughttobeadiseaseofthepast.Tuberculosis(TB)isadeadlyinfectiousdiseasewitharisingincidenceworldwide.Theurologist’sawarenessoftheclinicalfeaturesofgenitourinary(GU)TBisnecessarytoeffectivelytreatpatientswiththisdisease.Areviewoftheliteraturewillrevealthattheclinicalfeaturesandpathologyofgenitourinarytuberculosisdescribedintheearlierpartofthe20thcenturyhasremainedessentiallyvalidtodate.Currentresearchfocusesonepidemiologyofthenewresurgenceofthedisease,aswellasrapiddiagnosticmodalitiesandnewtreatmentregimenstocombatmultidrugresistantTB.TheGreatImitator是癥狀不特異，容易誤診的疾病。多為系統性疾病。

結核病有記載的歷史，可以追溯到6000年前的意大利和埃及。法老王阿肯那頓,王后奈費爾提蒂

Akhenaton,aPharaohoftheeighteenthdynastyofEgypt,andhiswifeNefertitibotharebelievedtohavediedfromtuberculosis

SignsofthediseasehavealsobeenfoundinthespinesofEgyptianmummiesdatingbetween3000and2400

BCE

(Zinketal,2003).

我國1973年湖南長沙馬王堆一號墓出土的2100年前的女尸肺上部及左肺門，發現有結核鈣化灶，說明其生前可能是一個結核病患者。這是我國最早的可查證的結核病患者。《上海大眾衛生報》2015-5-22Thebacilluscausingtuberculosis,Mycobacteriumtuberculosis,wasidentifiedanddescribedonMarch24,1882byRobertKoch.世界防治結核病日(WorldTuberculosisDay)在1982年紀念科赫氏發現結核菌100周年時，世界衛生組織(WHO)和國際防癆和肺病聯合會(IUATLD)共同倡議將3月24日作為“世界防治結核病日”，以提醒公眾加深對結核病的認識。流行病學資料GenitourinaryTB

Extrapulmonarysitesaccountfor10%oftuberculosiscases.GenitourinaryTBaccountsfor30%to40%ofallextrapulmonaryTB,secondonlytolymphonodalaffection(Eastwoodetal,2001).Indevelopedcountries,urogenitaltuberculosisoccursin2%to10%ofcasesofpulmonarytuberculosis,whileindevelopingcountriesitoccursinasmanyas15%to20%ofcases.2023/10/2812腎結核

TuberculosisofKidney2023/10/2813概述感染途徑：血行感染、順行播散、是全身結核的一部份病理性結核臨床性結核腎自截膀胱攣縮Mostpersonscontroltheinitialinfectionanddevelopnoclinicalillness.Theyhavedormantbacilli,whichmaybegintoproducediseaseyearslaterafterdebilitatingdisease,trauma,corticosteroids,immunosuppressivetherapy,diabetes,orAIDS.2023/10/2815腎結核

診斷一、臨床表現：

1.膀胱刺激癥狀

2.血尿

3.膿尿

4.腎區脹痛不適

5.全身癥狀

ClinicalManifestations

InthewordsofChang:“thekidneyisaninarticulateorgan;itsvocalcordsarethebladder”(Chang,1976).中醫：腎與膀胱相表里2023/10/2817腎結核

診斷二、實驗室檢查：

1.尿常規：RBC、WBC2.尿濃縮查結核桿菌

3.結核菌培養或動物接種

Diagnosis1UrinalysisandCultureoldtuberculin，OTPurifiedProteinDerivative–TuberculinTest—MantouxTestNucleicAcidAmplification(NAA)Testing—PCRDiagnosis2RadiographyandEndoscopyPlainRadiographIntravenousUrography(IVU)ComputedTomographyandMRIUltrasonographyRetrogradePyelogramandAntegradePyelogramCystoscopyandUreteroscopy

結核的影像學表現在有效的抗結核藥物被發明之前，結核病的主要治療手段是營養、陽光加大氣。

ThegreatestmilestoneinthetreatmentofTBwasthediscoveryoftheantituberculousdrugs,startingwithstreptomycinin1944,followedbypara-aminosalicylicacidin1946,isoniazid(INH)in1952,andrifampicinin1966.Thesediscoverieswerefollowedbytheintroductionofshortercoursesofchemotherapyforallformsoftuberculosis.2023/10/2824腎結核治療一、一般處理：休息、營養、增強體質二、藥物治療：

1.應用抗結核藥物適應癥

2.用藥原則：早期、聯合、足量、足期、規律

3.常用抗結核藥物：異煙肼、利福平、乙胺丁醇、鏈霉素、吡嗪酰胺等

2023/10/2825腎結核治療

4.長程療法：（18-24個月）異煙肼o.1一日三次利福平0.45一日一次乙胺丁醇0.25一日三次

短程療法：

（6個月）2023/10/2828腎結核治療三、手術治療

1.全腎切除術

(1)適應癥

(2)術前抗結核兩周以上

(3)術后常規抗結核

2023/10/2829腎結核治療三、手術治療

2.部分腎切除術

(1)適應癥

(2)術前抗結核3-6個月

(3)術后常規抗結核

2023/10/2830腎結核治療三、手術治療

3.腎結核晚期并發癥的處理

(1)一側腎結核對側積水（吳氏理論）

(2)膀胱攣縮及UVJ狹窄

TreatmentMedicalTherapyAntituberculousDrugsSurgicalTherapyProcedurestoRelieveObstructionNephrectomyPartialNephrectomyUreteropelvicandUreteralSurgeryBladderSurgeryProstateandUrethra20世紀90年代后，WHO在全球推廣直接面視下的督導化療，使得結核病患者在6～8個月的治療期間接受規范的治療管理，進一步提高了結核病的治愈率。2023/10/2833附睪結核

TuberculosisofEpididymis

No.Cases%TuberculosisCasesbyPrimarySiteofDisease

Pulmonary107373.5Lymphatic15210.4Pleural694.7Miliary382.6Boneorjoint362.5Meningeal221.5Genitourinary171.2Peritoneal120.8Other412.8

Total1460100.0TuberculosisCasesbyAllSitesofDiseaseOnlypulmonarydisease99868.4Onlyextrapulmonary