Urological tuberculosis

　　Urological tuberculosis is more common in males. It is common from 20 to 40 years old (accounting for 66.3%). About 50 to 70% of male renal tuberculosis patients have combined male reproductive system tuberculosis. The more severe the urological tuberculosis lesion, the more opportunities there are for combined male reproductive system tuberculosis.

　　The blood-borne dissemination of Mycobacterium tuberculosis to the kidneys first causes millet-like tuberculosis nodules in multiple glomeruli in both kidneys. The center of the nodules may undergo caseous necrosis. At this time, Mycobacterium tuberculosis can be found in the urine, but there may be no other urological clinical symptoms, which is the 'pathological renal tuberculosis' stage. If the lesion does not heal and spreads, it will develop into the 'clinical renal tuberculosis' stage. About 90% of clinical renal tuberculosis occurs unilaterally. The Mycobacterium tuberculosis in the renal tuberculosis focus can spread through urine, often involving the ureter, causing tuberculosis nodules and ulcer formation. The lesion can invade the submucosal layer even the muscular layer, followed by fibrous tissue proliferation, ureteral thickening, stiffness into string-like, and luminal segmentation stenosis. It can cause hydronephrosis of the upper ureter and renal pelvis, further promoting kidney destruction and gradual loss of renal function. The focus can also involve the bladder. Bladder tuberculosis is of great significance for the diagnosis, treatment, and prognosis of urological tuberculosis; the bladder mucosa is congested and edematous, and tuberculosis nodules form, especially around the orifice of the affected ureter. Later, it spreads to the trigone and the opposite ureteral orifice, causing hydronephrosis due to stenosis or incomplete obstruction of the opposite ureteral orifice. If the entire bladder is involved, it can cause bladder contraction, exacerbating kidney function damage. The lesions of urethral tuberculosis are mainly ulcers and fibrosis, forming urethral stricture. A few patients have complete occlusion of the ureter, widespread calcification of the whole kidney, mixed with caseous material, and Mycobacterium tuberculosis cannot enter the bladder with urine. The changes of the bladder are improved or healed, and the symptoms disappear. This condition is called 'renal autolysis', but in fact, the focus in the kidney still exists at this time.

　　Urological tuberculosis mainly refers to renal tuberculosis, which usually occurs secondary to other parts of tuberculosis foci, such as hematic dissemination of pulmonary tuberculosis, or from bone and joint tuberculosis, or intestinal tuberculosis dissemination. Severe complications include bladder spasm and renal积水. The more severe the urological tuberculosis lesion, the more opportunities there are for combined male reproductive system tuberculosis.

　　Urinary system tuberculosis is common in young and middle-aged adults aged 20-40. Ask whether the patient has a history of pulmonary tuberculosis and osteal tuberculosis, and evaluate whether the patient has physical weakness, malnutrition, and low systemic resistance.

　　1. Frequent urination, urgency, dysuria

　　Frequent urination is the initial symptom, caused by the stimulation of the bladder by the pus containing tuberculosis bacilli. After the formation of tuberculous cystitis, frequent urination worsens, and there is a gradual increase in urgency and dysuria. In the late stage, due to the constriction of the bladder, daily urination can reach several times, and even incontinence may occur.

　　2. Hematuria, pyuria

　　Renal vascular destruction causes gross hematuria, bladder tuberculosis ulcer causes terminal hematuria, and the kidney excretes caseous material, resulting in cloudy pus urine.

　　3. Renal area pain and mass

　　When pyonephrosis, hydronephrosis, or renal lesions involve the capsule, it can cause dull pain in the renal area, or the appearance of renal mass.

　　4. Tuberculosis intoxication symptoms

　　In cases of severe renal tuberculosis or combined tuberculosis of other organs, tuberculosis intoxication symptoms may occur, manifested as fatigue, fever, night sweats, and other symptoms. When both renal functions are severely affected, uremia may occur.

　　5. Male reproductive system tuberculosis

　　It is manifested as painless hard nodules in the epididymis, with slow development, swelling, and adhesion to the scrotal skin, forming cold abscesses that溃溃流出稀黄色脓液, forming sinus tracts that do not heal for a long time. The affected side of the vas deferens becomes thickened, with bead-like small nodules. Prostatic tuberculosis has no obvious symptoms and is not easy to find. Rectal examination can touch the hard nodules of the prostate, but there is no tenderness.

　　Urinary system tuberculosis seriously affects patients' daily life, so it should be actively prevented. The fundamental measure for urinary system tuberculosis is to prevent pulmonary tuberculosis. Paying attention to urine examination of patients with pulmonary tuberculosis and other tuberculosis can help to discover urinary system tuberculosis early.

　　Most urinary system tuberculosis is secondary to pulmonary tuberculosis, and the tuberculosis lesions mainly invade the kidneys, causing renal tuberculosis. The specific examination is as follows:

　　1. Plain film

　　(1) Renal parenchymal calcification is the main finding, with low density and not very clear calcification foci, which are caused by the deposition of a small amount of calcium salts in the caseous necrotic material. The calcification foci can be very small and solitary, or scattered and multiple. When there is complete renal calcification, the kidney can atrophy and become smaller, with very poor or no renal function. This type of diffuse renal calcification is called 'autopsy kidney' and is common in advanced renal tuberculosis.

　　(2) Ureteral calcification, scattered calcium salts depositing along the ureter affected by tuberculosis.

　　(3) Bladder calcification, often with dense shadows on the bladder wall.

　　(4) The prostate, seminal vesicle, and vas deferens also have scattered or curved dense linear punctate shadows.

　　2. Urography and CT

　　(1) After renal tuberculosis involves the tip of the renal pyramid, urography begins to show early changes, manifested as slightly blurred and irregular shapes. As the lesion continues to expand, the renal calyces also expand and are accompanied by irregular destruction, indicating that the renal pyramids and cortex have undergone erosion and necrosis. As the lesion further progresses, the shape of the renal calyces becomes feather-like or eroded-like necrosis, and it can be seen that there is already contrast agent entering outside the calyces. Even the fistula between the affected renal calyces and the cavity can be seen.

　　(2) In the late stage of renal tuberculosis, extensive caseous necrotic cavities can be seen in the kidney, showing large and irregular areas that can be filled with contrast agent, and these cavities are more clearly shown in the enhanced CT images. There is pus in the cavity, with a water-like density and no enhancement. Widespread renal tuberculosis destruction, with repair, large amounts of calcium salts deposited in the renal caseous necrotic foci, can form a non-functional kidney known as 'self-amputation kidney'.

　　(3) Early manifestations of ureteral tuberculosis are ureteral dilation with a worm-eaten edge, which is caused by the invasion of the muscular layer of the ureter by tuberculosis, leading to tension disorder and multiple ulcers. Subsequently, the wall of the ureter thickens and becomes thick, loses elasticity, and peristalsis disappears. When there is a large amount of fibrosis scar deformation, the lumen of the ureter narrows or alternates between narrowing and dilation, showing a bead-like or spiral shape, and finally can become a short and rigid thin tube, even completely occluded, all accompanied by hydronephrosis on the affected side of the kidney.

　　(4) Bladder tuberculosis is often caused by downward spread of upper urinary tract tuberculosis. Blurred and irregular edges appear at the junction of the bladder and ureter, and the volume also decreases, with spasm and fibrosis, leading to the 'small bladder sign'. Sometimes, there may be patchy calcification on the bladder wall. If the bladder tuberculosis involves the healthy side of the bladder and ureteral orifice, it can cause incomplete sphincter closure, leading to urinary reflux, forming hydronephrosis on the healthy side of the kidney.

　　(5) Urogenital tuberculosis can spread to reproductive organs, in males, it is the prostate, seminal vesicle, epididymis, and vas deferens. This is mainly through the tuberculosis bacilli in the urine of renal tuberculosis entering the prostate and seminal vesicle through the posterior urethral prostate tubules and the ejaculatory duct, and then through the vas deferens to the epididymis and testis. It can also spread to these organs through hematogenous dissemination.

　　3. Ultrasound examination

　　① Tuberculosis cavities, single or multiple liquid dark areas with irregular edges and scattered light points inside.

　　② Renal parenchymal calcification, small ones appear as small light spots with acoustic shadows, and large ones show dense arc-shaped light spots with posterior acoustic shadows.

　　③ When the lesions become extensive and form abscessed kidneys, renal hydrops is shown in the ultrasound images.

　　④ The renal capsule is blurred or the kidney is shrunken and deformed.

　　In addition to receiving standardized and scientific treatment, renal tuberculosis patients should also pay more attention to their diet. They should pay attention to diet adjustment in daily life, coordinate diet and treatment, and achieve a synergistic therapeutic effect.

　　1. Supplement foods rich in calcium and iron. Calcium can promote the calcification and healing of tuberculosis lesions, so it is recommended to consume milk, curd, shrimp shells, tofu, green vegetables, and other calcium-rich foods regularly. If tuberculosis patients have hemoptysis, they should increase the intake of iron-rich foods such as animal blood, liver, and green vegetables.

　　2. The supply of carbohydrates. According to the normal physiological needs. However, when the condition of tuberculosis patients worsens, about 20 to 35 grams of carbohydrates can be given per day to meet the body's needs as much as possible.

　　3. High-protein diet (protein foods). Eggs, animal viscera, fish, shrimp, lean meat, and tofu are the main sources of protein. Milk and dairy products are also preferred due to the rich content of casein and calcium in milk, which can promote calcification of the tuberculosis lesions and is beneficial for the recovery of the body.

　　4. Moderate fat intake. Tuberculosis patients often have anorexia and poor appetite, so it is advisable to prepare food with less oil (oil food) when cooking, such as rice noodles, oatmeal, red beans, mung beans, fish, honey (honey food) and so on.

　　Urinary system tuberculosis is a systemic disease. Therefore, it is necessary to pay attention to systemic treatment, including nutrition, environment, rest, medical sports, and so on.

　　The progress of modern chemotherapy has changed the treatment principles for urinary system tuberculosis, with drug treatment as the mainstay, supplemented by necessary surgical treatment. Early urinary system tuberculosis lesions are usually mild and limited in scope. With the correct use of antituberculosis drugs, most cases can be cured. Surgical treatment is only needed when there is severe kidney destruction or serious complications of the urinary system, such as ureteral stenosis, tuberculous bladder cicatricial contraction with contralateral renal hydronephrosis. The purpose of surgery is to remove irreparable destroyed foci, relieve obstruction, and rescue renal function.

　　Nephrectomy is suitable for extensive destruction of one side of the kidney due to tuberculosis, or for tuberculosis kidneys with severe secondary infection and loss of function, where the diseased kidney can be removed. Bilateral tuberculosis is not an absolute contraindication to surgery. If one side of the kidney has been destroyed and is non-functional, and the other side has a milder lesion, the severely damaged side can still be removed.

　　Partial nephrectomy is suitable for tuberculosis foci localized to one pole of the kidney where drug treatment cannot cure, and there are no changes in the renal pelvis and ureter. If a partial nephrectomy is necessary for the only functioning kidney, 2/3 of the renal tissue should be preserved to avoid renal insufficiency, and the indications must be strictly controlled. Due to the progress of drug treatment, partial nephrectomy is rarely used in the treatment of kidney tuberculosis.

　　Surgical excision of kidney foci is suitable for tuberculous cavities that are completely closed or difficult to heal due to poor drainage within the renal parenchyma. In cases where the cavity is filled with caseous material, drug treatment often fails and is a source of latent infection. By incising and removing the material, it can prevent the abscess from expanding or rupturing and can preserve the unharmed renal tissue.

　　Common antituberculosis drugs include rifampin, isoniazid, pyrazinamide, ethambutol, and streptomycin, among others. Generally, the combination of two or three drugs is effective, which can delay the appearance of drug resistance and reduce toxic reactions. The application of a three-drug combination can shorten the course of treatment to 6 months to 1 year.