Bladder tuberculosis

　　1. Etiology

　　Bladder tuberculosis is a part of urinary system tuberculosis, mostly originating from renal tuberculosis, due to the contamination of tuberculous urine and the spread along the submucosal layer of the ureter.

　　2. Pathogenesis

　　The contamination of urinary tuberculosis and the spread of tuberculous tuberculosis along the submucosal layer of the ureter quickly lead to congestion and edema in the trigone area of the bladder, and gradually form tuberculous nodules. The trigone is initially affected and quickly spreads to the entire bladder wall, causing the tuberculous nodules to fuse, coagulate, and form ulcers. If the ulcers extensively invade the muscular layer of the bladder, even after the affected kidney is removed, severe fibrosis may still occur in the bladder muscular layer. This causes the bladder muscle to lose its stretching ability, resulting in a decrease in capacity and the formation of a tuberculous small bladder - bladder cicatricial contraction. In severe cases of tuberculous ulcers in the bladder, a few cases may penetrate the entire bladder layer and invade or penetrate other organ tissues, forming tuberculous bladder fistulas, such as vesicovaginal fistulas, vesicorectal fistulas, and so on. There are also cases where perforation occurs at the top of the bladder, with urine flowing into the abdominal cavity, causing acute abdomen. After bladder cicatricial contraction, due to the reduced capacity of the bladder, the ability to regulate the intravesical pressure is lost, and the intravesical pressure is often in a relatively high state. With the decrease in capacity, the intravesical pressure is repeatedly strengthened, causing hydronephrosis of the upper urinary tract. In addition, the scar tissue formed by bladder tuberculosis can lead to stenosis of the ureteral orifice; and, fibrosis of the bladder tissue, which loses the sphincteric action, can cause incomplete closure of the ureteral orifice, which is also a factor causing changes in hydronephrosis of the upper urinary tract. These conditions may occur during the active phase of bladder lesions, or after the application of anti-tuberculosis drugs, when the tuberculous lesions tend to heal and tissue fibrosis occurs.

　　Urinary bladder tuberculosis involves the urethra, causing urethral mucosal ulcers and erosions. Patients experience severe burning pain in the urethra at the end of urination, and in severe cases, it can form tuberculous urethral stricture or urethral fistula.

　　Complications of severe urinary bladder tuberculosis include bladder contraction, contralateral renal积水, spontaneous rupture of tuberculous bladder, tuberculous bladder fistula (bladder rectal fistula, bladder vaginal fistula), and urethral stricture or urethral fistula.

　　In addition to frequent urination, there are often accompanied by dysuria, pyuria, hematuria, etc., which can improve after anti-tuberculosis treatment. The symptoms of bladder contraction, except for frequent urination and incontinence, are often without dysuria, pyuria, or hematuria, and the symptoms cannot improve after anti-tuberculosis treatment. Sometimes, due to further fibrosis of the bladder lesions, the symptoms may even worsen.

　　Analysis of medical history and clinical manifestations:

　　1. Presence of chronic cystitis with irritative symptoms, with no significant effect after antibiotic treatment.

　　2. Urine is acidic, with pus cells, and no bacteria grow in the normal culture.

　　3. Presence of pulmonary tuberculosis or other extrapelvic tuberculosis foci, with small amounts of protein in urine and red blood cells detected in urine microscopy.

　　4. Hard nodules found in epididymis, seminal vesicle, spermatic cord, or prostate, and chronic sinus tracts in the scrotum.

　　The fundamental measure to prevent urinary生殖系 tuberculosis is to prevent pulmonary tuberculosis. Due to the progress of molecular biology in recent years, the Centers for Disease Control and Prevention in the United States (1989) proposed a strategic plan to eliminate tuberculosis within 20 years. Humans may use new preventive, diagnostic, and treatment methods to eliminate tuberculosis. The main measures are as follows.

　　1. To prevent the development of infection into clinical disease, in the past, isoniazid 300mg per day was used for the prevention and treatment of people who had close contact with recent tuberculosis patients and other possible tuberculosis patients. After treatment, the incidence of tuberculosis decreased, reducing the spread of the disease. The application of short-course chemotherapy has found that intermittent medication can also achieve similar effects to daily medication. Experimental research uses rifampicin and pyrazinamide twice a week, and after 2 months of medication, it can effectively prevent the development of infection into tuberculosis. If this method is used for prevention and treatment, it can greatly reduce the spread of tuberculosis with only 10 or more doses of medication.

　　2. Research on the genus-species specificity, surface antigens of Mycobacterium tuberculosis, the production of monoclonal antibodies, and the production of Mycobacterium tuberculosis-specific DNA probes for early diagnosis of tuberculosis.

　　3. In 1998, Cole and others determined the sequence of Mycobacterium tuberculosis DNA. Vaccines made from Mycobacterium tuberculosis DNA not only have the effect of preventing tuberculosis but can also be used for treatment, eliminating the remaining Mycobacterium tuberculosis after drug treatment. This breakthrough will accelerate the control and elimination of human tuberculosis infection.

　　1. Urine examination:Urine routine examination shows a large number of pus cells and red blood cells. During inflammatory spasm, the degree of pyuria and hematuria is basically consistent with urinary frequency, while in bladder contracture, although urinary frequency is significant, there are not many inflammatory cells in the urine. Urine examination for acid-fast bacilli is often positive, and polymerase chain reaction (PCR) technology can improve the positive rate of examination and is rapid.

　　2. Cystoscopy:Visible bladder mucosal congestion and edema; formation of tuberculous nodules or ulcers; and there is also a decrease in bladder capacity, which can be confirmed as tuberculosis by biopsy.

　　3. Bladder造影:Inflammatory spasm may cause pain during the injection of contrast medium, the bladder shape may be normal, or it may be folded with bladder neck spasm; while in patients with bladder contracture, there is no pain during the injection of contrast medium, only a sense of fullness, the bladder is very small and round, the edges are not smooth, and it does not fold. In severe cases, the bladder neck is dilated, the posterior urethra is dilated, and saddle anesthesia may be used for differentiation: inflammatory spasm can expand the bladder capacity after saddle anesthesia, while bladder contracture cannot expand. Spontaneous rupture of tuberculous bladder can cause sudden abdominal pain, percutaneous bladder puncture can show yellow urine, and bladder造影 can help in diagnosis.

　　4. IVU examination:Late-stage symptoms include anemia, edema, renal insufficiency, etc., and IVU examination can show signs of renal and ureteral tuberculosis and a decrease in bladder capacity.

　　5. CT examination:In recent years, CT examination has been widely used in the diagnosis of urogenital tuberculosis. Its advantages are that it is sensitive to calcification, functional abnormalities of the kidneys, and perirenal expansion. It can also show parenchymal scars and necrotic foci with low density, and late renal lesions can all show hydronephrosis, renal atrophy, and renal calcification.

　　1. What foods should bladder tuberculosis patients eat to be good for their bodies:

　　Eat more diuretic foods, such as watermelons, grapes, pineapples, celery, pears, etc.

　　2. What foods should bladder tuberculosis patients avoid eating:

　　Avoid eating sour and spicy foods with刺激性, such as strong alcohol, chili, original vinegar, sour fruits, etc.

　　(The above information is for reference only, for detailed information, please consult a doctor.)

　　1. Treatment

　　The treatment of bladder tuberculosis is similar to that of renal tuberculosis. After the 1940s, streptomycin and para-aminosalicylic acid were successively introduced, and it was gradually discovered that drug treatment could achieve clinical cure of the tuberculosis focus. Surgical treatment is becoming less frequent, and the surgical treatment of bladder tuberculosis is even more rare. After the 1950s, isoniazid, which has high efficacy, low toxicity, and low price, appeared. Through experimental research, the efficacy has been greatly improved by the method of combined medication, almost curing all early lesions, and the treatment of bladder tuberculosis has undergone tremendous changes. Since rifampin was introduced in 1966, due to its high efficacy and few side effects, its efficacy in the treatment of bladder tuberculosis has been further improved when used in combination with other drugs. Bladder tuberculosis is a part of renal tuberculosis and a local manifestation of systemic disease. In the treatment, attention must also be paid to improving the patient's resistance, such as increasing nutrition and proper rest. Regardless of the severity of the bladder tuberculosis lesions, anti-tuberculosis drug treatment should be given first, and then consider whether there are indications for surgical treatment.

　　1. Drug treatment:Currently, there are many drugs with clinical application value, but isoniazid, streptomycin, and p-aminosalicylic acid have better efficacy and lower toxicity, and are known as first-line drugs. Other drugs such as thiosemicarbazide, pyrazinamide, kanamycin, cycloserine, viomycin, etc., have less efficacy than first-line drugs and greater toxicity. They are only used when the tuberculosis bacteria have developed resistance to first-line drugs, and are therefore known as second-line drugs. Rifampicin and ethambutol are relatively new drugs. Due to their high efficacy and low toxicity, they have been gradually replacing p-aminosalicylic acid and are now considered first-line drugs.

　　(1) Brief introduction to commonly used anti-tuberculosis drugs:

　　① Isoniazid (isoniazid, INH): The serum concentration reaches the highest peak within 1 to 2 hours after oral administration, with a half-life of 6 hours. The effective inhibitory concentration can still be detected in the blood 24 hours later. Since the growth and reproduction cycle of the tuberculosis bacteria is relatively long, and it has been proven that the efficacy of the drug is related to the peak serum concentration and has little to do with the sustained concentration, the general dose is 300mg per day, taken all at once. This dose rarely causes adverse reactions, so it can be taken for a long time, even for several years continuously. Isoniazid quickly penetrates into the tissues after absorption, and is also easy to penetrate through fibrosis and caseous lesions. Its main side effect is polyneuritis multiplex. It is believed to be related to the increased excretion or interference with the metabolism of vitamin B6 (pyridoxine). Therefore, 5 to 10mg of vitamin B6 should be taken with isoniazid to prevent side effects.

　　② Streptomycin (streptomycin): The serum concentration is highest 1 hour after intramuscular injection, and it decreases by 50% after 3 hours. About 60% to 90% is excreted from the urine through the kidneys. It has the strongest effect at pH 7.7 to 7.8, and its effect is significantly weakened when the pH is below 5.5 to 6.0. Taking sodium bicarbonate to alkalinize the urine can enhance its efficacy. The lesions treated with streptomycin tend to fibrosis. Its main side effect is the influence on the VIIIth cranial nerve, especially the vestibular branch. Some patients may experience anaphylactic shock after taking the medicine, which is difficult to rescue and difficult to predict by skin tests.

　　③ P-aminosalicylic acid (p-aminosalicylic acid): The plasma concentration can reach a peak within 1 to 2 hours after taking the medicine, and only a trace amount remains in the blood 4 to 6 hours later. The daily dose is 8 to 12g, taken in 3 to 4 doses. The efficacy of this medicine alone is poor, but it can enhance the effects of streptomycin and isoniazid against tuberculosis bacteria, and can delay the occurrence of drug resistance. The combined use of the three is beneficial for the therapeutic effect. This medicine has little effect on kidney function, and its main side effects are gastrointestinal symptoms, such as nausea, vomiting, and diarrhea. Due to its poor efficacy when used alone and gastrointestinal reactions, it is gradually being replaced by rifampicin and ethambutol. PAS should not be used with rifampicin.

　　④ Rifampicin (Rifampicin, RFP): This drug has effects on actively growing tuberculosis bacilli both inside and outside the cells, with strong bactericidal activity. Its effect on tuberculosis bacilli is stronger than that of streptomycin, aminosalicylic acid, and ethambutol, and is similar to that of isoniazid. It is absorbed from the gastrointestinal tract, and a peak concentration is reached 2-4 hours after a single oral dose of 600mg. The serum concentration remains high for 12 hours. Its main excretion route is the bile duct, and it can also be reabsorbed in the intestines, resulting in a long serum half-life. 30% is excreted by the kidneys. It has no cross-resistance with other anti-tuberculosis drugs, and its side effects include liver function damage, increased transaminases, jaundice, etc. It is generally used on an empty stomach and should not be taken with other beverages or foods; food can be consumed 1 hour after taking the medication.

　　⑤ Ethambutol (Ethambutol, EMB): It has bacteriostatic effects on all types of tuberculosis bacilli. It is absorbed quickly from the gastrointestinal tract, and the plasma concentration reaches a peak 2-4 hours after oral administration. It remains in the blood for a relatively long time, with 50% excreted by the kidneys 24 hours later. However, it rarely accumulates in tissues, making it relatively safe. The drug has good absorption and tissue penetration, even penetrating into caseous fibrous foci. The development of drug-resistant strains is slow, taking several months. When used with isoniazid or rifampicin, it can extend the duration of use. Its main side effect is delayed posterior uveitis, which is reversible and dose-related. The usual dose is 25mg/kg per day, taken orally once or in divided doses. After 2 months, the dose is reduced to 15mg/kg, and this dose rarely produces toxic effects. The drug has no cross-resistance with other anti-tuberculosis drugs, and it is currently trending to replace aminosalicylic acid as a companion drug to rifampicin.

　　(2) Selection of anti-tuberculosis drug regimens: According to the recommendations of the International Union Against Tuberculosis and Lung Disease (IUATLD) and the China National Conference on Tuberculosis Prevention and Treatment, medication should be taken according to the following principles for a more satisfactory effect.

　　① Adhere to regular medication (daily or intermittent, taking the prescribed dose once or in divided doses, before or after meals).

　　② Combined use of drugs.

　　③ Sustained for a sufficient period of time.

　　The disadvantages of conventional therapy are that the course is long, and a small number of patients cannot persist in taking medication and taking medication regularly, leading to recurrence of the lesion or persistent positive urine examination for tuberculosis bacilli and purulent urine. Since rifampicin and isoniazid are complete sterilizing agents, the two-phase therapy of rifampicin and isoniazid, that is, the initial intensive phase followed by the consolidation phase, is highly effective, and the duration of medication is less than 12 months as well, showing a new outlook for short-term therapy. The American Thoracic Society proposed a two-drug regimen with 9 months as one course in 1979, where the first month involved taking 300mg of isoniazid and 600mg of rifampicin daily, and for the following 8 months, the medication was taken twice a week, with each dose consisting of 900mg of isoniazid and 600mg of rifampicin. They used this regimen to treat 500 cases of tuberculosis, with a 96% cure rate. This regimen is also suitable for genitourinary tuberculosis, and it is believed that the efficacy will be even better. The general duration of medication is within 12 months, and the decision to discontinue medication or undergo surgical treatment is based on clinical results.

　　The current criteria for drug discontinuation are as follows: ① Significant improvement in general condition, normal erythrocyte sedimentation rate, and normal body temperature; ② Complete disappearance of urinary symptoms; ③ Normal urine routine examination after repeated multiple checks; ④ Long-term multiple negative acid-fast bacillus tests by urine concentration method; ⑤ X-ray urography or cystoscopy shows stable or healed lesions; ⑥ Urine culture and animal inoculation show negative for Mycobacterium tuberculosis; ⑦ No other tuberculous foci found in the general examination. It takes at least 1 year of medication to meet this standard, and 2 years of medication is relatively safe and reliable. Long-term observation should be carried out after drug discontinuation, with regular urine and urography checks, at least a follow-up of 5 years.

　　2. Surgical Treatment:Effective drug treatment has changed the status of surgical treatment. In the past, many cases that had to undergo surgical treatment can now be treated by non-surgical methods. However, a retrospective study by Fischer found that even after an average of 9 months of anti-tuberculosis treatment, 52% of surgical specimens still showed fresh tuberculous changes. Therefore, surgical treatment still plays an important role. As for the timing of surgery, it is generally recognized that it should be performed 4-6 weeks after regular anti-tuberculosis treatment. There are also many different surgical methods. According to the statistics of Gow in 1981, the number of resection operations has gradually decreased, and the number of reconstruction operations has correspondingly increased. The surgical method can be considered according to the extent of kidney damage: surgical excision, partial nephrectomy, nephrectomy, etc. Regardless of the type of surgery adopted, medication should still be continued after surgery, and refer to the aforementioned standards for drug discontinuation.

　　II. Prognosis

　　Early treatment of kidney tuberculosis, preventing severe tuberculous changes in the bladder, and paying attention to the occurrence of this complication during the treatment process can achieve better results.