Tuberculosis of the genitourinary system is a multifaceted and still topical issue. To a large extent, because of the complexity of diagnosis, due primarily to the absence of pathognomonic symptoms.
Classification
Apply the following classification of tuberculosis of the urogenital system:
Localization of the process:
- Tuberculosis of the kidneys
- Tuberculosis of the renal parenchyma
- Tuberculosis of the renal papilla (papillitis)
- Cavernous tuberculosis
- Fibrous-cavernous tuberculosis
- Tuberculous pionerophosis
– Tuberculosis of ureter: infiltrative (periurethritis), ulcerative
– Tuberculosis of the bladder: focal; ulcerative
– Tuberculosis of the urethra (rarely found): ulcerative
– Tuberculosis of male genital organs:
- Tuberculosis of the prostate glandular, cavernous
- Tuberculosis of seminal vesicles (vesiculitis)
- Tuberculosis nadiaichka (epididymitis): caseous-cavernous
- Tuberculosis of the vas deferens (deferent)
- Tuberculosis of the penis (is rare)
Phases of the process: infiltration, decay, ulcers, resorption, scarring, calcification.
Characteristics of clinical forms of tuberculosis of the genitourinary system.
The initial stage of the disease is associated with hematogenous spread of infection and active foci of primary or secondary tuberculosis to other organs. The development of a specific process goes through all the stages of morphological evolution – from hematogenous foci, surrounded by elements of tuberculous granuloma and caseous necrosis in the center, merging into limited infiltrates (caseiomas) with predominant localization in the cortex, to the complete destruction of the kidney and ureter.
Tuberculosis of the renal parenchyma
With this form of tuberculosis, slight contrasting of the cup-and-pelvic system of the affected kidney is noted, chaotic placement of the calyxes, their deformation (bulbous enlargement, amputation, etc.), a symptom of destruction is absent (nondestructive tuberculosis of the kidney).
Tuberculous papillitis
Characterized by the presence of signs of destruction (the initial form of destructive tuberculosis), which is manifested by inequality, smoothness, inexpressiveness of the contours of the calyx (symptoms of “saw”, “mouse bite”, “background”). Localization distinguishes between fornic, tubular and mixed papillitis.
Cavernous tuberculosis of the kidney
It is characterized by a breakthrough and emptying of the decay cavity, the walls of which have a typical structure of the tuberculous cavern. The decay cavities have uneven, scalloped edges, can be in the cortical or marrow substance in place of the affected calyx (papillitis). Passing in parallel, destructive and fibrotic sclerotic processes promote the spread of the process with the progressive destruction of the parenchyma and the renal cavity system (polycavernosis, cicatricial stenoses, etc.) with degeneration into fibro-cavernous tuberculosis.
The final stage of progressive kidney tuberculosis is its total defeat with the formation of pionephrosis and a number of local and system-wide complications. Depending on the number of caverns, monocavernous and polycavernous tuberculosis of the kidney is distinguished.
Tuberculous pionerophosis
On the roentgenogram is characterized by the image of an enlarged kidney with projected uneven contours and the presence of significant cavity decay cavities with scalloped edges that often merge. The process is accompanied by a decrease in kidney function (before autogonephrectomy).
Nephrosclerosis
The tuberculosis process in the kidney acquires a productive type of inflammation, the wrinkling ends (a small kidney).
Tuberculosis of the urinary system is characterized not only by kidney damage, but also by the involvement of the urinary tract in the process. In the beginning, a specific lesion is accompanied by their atony, this is manifested by the phenomenon of hydronephrosis, hydrocalicosis, pyelonectasia due to a violation of the contractility of the bowl-loch system through toxic action. Due to the further progression of the process, various deformations of the calyx-pelvis system are observed until the bowl capacity decreases with the development of hydrocalicosis) (the symptom of a “daisy”).
Tuberculosis of the ureter is always secondary, accompanied by thickening of its walls, which leads to functional stenosis. The defeat of the ureter is possible with a slight destruction of the renal parenchyma and in the case of a common process.
Lymphoid infiltration of the submucosal layer significantly complicates the function of the non-unsalted muscles of the bowl and ureter, which leads to disturbance of urodynamics and the development of hydronephrosis or pionefrosis. With the help of the X-ray method, its narrowing (stricture), expressiveness, tension (a symptom of the “string”, pulling the bladder) is determined.
Tuberculosis of the bladder
It is secondary to the lesion of the kidney and ureter. The relative later involvement in the pathological process of the bladder is associated with high resistance of its mucosa to mycobacterial infection. In a cystoscopic study, patients with tuberculous bacteriuria often have a normal bladder condition. The spread of tuberculosis infection in the submucous layer of the wall of the bladder occurs lymphogenically.
At the initial stages of the disease, tubercular rashes are localized near the urethra of the urethra on the side of the affected kidney. Subsequently tubercular tubercles are known. The erosive mucosa of the bladder is exposed to the infected urine. With the spread of the inflammatory process appears ulcerative lesions of the upper and lateral walls of the bladder, and later – his sclerotic degeneration. A consequence of such changes is the development of bilateral vesicoureteral reflux, the progression of pyelonephritis and chronic renal failure.
With the X-ray method, a decrease in the capacity of the bladder (microbubble), deformation of the contours before the appearance of a double contour (symptom of “hourglass”) is revealed. With an ascending cystogram, vesicoureteral reflux can be detected.
Tuberculosis of male genital organs
Tuberculosis of the kidney in men can be accompanied by damage to the organs of the scrotum. At palpation, the nadiachka feel for density, tuberosity, the absence of a clear boundary between the nadyaevochkom and the testicle, the thickening of the vas deferens in the form of the rosary – the tuberculous deferent.
Tuberculosis of the prostate is rarely isolated. For the most part, it is combined with tuberculosis of seminal vesicles or nadyaichka. The disease begins with the formation of tuberculous tubercles in the intermediate tissue of the gland, then they merge into a source of infiltration. Later on, caseous necrosis and purulent tissue melting are observed, caverns are formed, sometimes the curd foci undergo calcification, after removal of abscesses the prostate gland may undergo cicatricial atrophy.
Complications:
- urolithiasis disease;
- pyelonephritis;
- nephrogenic hypertension;
- chronic renal failure (latent, compensated, intermittent, terminal stage).
Residual changes. Minor residual changes – stay under supervision for 2 years: hydrocalicosis, infertility, encapsulated with calcification of tuberculoma of the small renal calyx. Significant residual changes – stay under supervision for 4 years: stricture of the tuberculosis segment, complicated by hydronephrosis (stay under observation for 5 years); nephrosclerosis; stricture of the proximal ureter, complications of ureterohydronephrosis; cicatricial deformation of the sphincter (muscle-closure) of the bladder, complicated by vesicoureteral reflux; microbubble.
Note: persons with a single kidney without disrupting the function are under observation for 2 years, with a violation of the function – 5 years.
Classification of tuberculosis of female genital organs
Apply the following classification of tuberculosis of female genital organs.
Localization of the process:
- Tuberculous salpingitis: a productive form, exudative-proliferative form, a caseous form (with or without fistula), one- and two-sided lesions
- Tuberculosis of the uterus (metritis)
- Combined defeat of the uterus and its appendages
- Tuberculosis of the cervix
- Tuberculosis of external genital organs
- Tuberculomas
- Phases of the process: infiltration, resorption, compaction, scarring.
- The nature of the current: acute, subacute, chronic.
- Bacteriovirus: MBT + and MBT-in the sowings of menstrual blood, secretions from the genital organs.
Characteristics of clinical forms of tuberculosis of female genital organs
Tuberculosis salpingitis. The productive form proceeds secretly, asymptomatically or malosymptomatically. Uterine tubes slightly thickened, edematous, loosened. Vessels of the serous membrane are injected, rigid, resemble beads, sometimes with humpback rashes. In the small pelvis a moderately pronounced adhesion process. Characteristic of the development of perivasculitis, phlebolitis. In bimanual examination, the appendages are not enlarged or slightly enlarged, painful on palpation.
Exudative-proliferative form is accompanied by symptoms that characterize the subacute course of the process. The patient is concerned about pain, excessive leucorrhoea, violation of the menstrual cycle, often there is infertility. Uterine tubes moderately dilated, swollen, hyperemic. Vessels of the serous membrane are injected. The fimbriae of the pipes acquire a bright red color, which resembles a cock’s comb. In the process of closing the fallopian tubes, the pili are wrapped inside the tube, the lumen is filled with exudate, the tubes acquire a retort-like shape with thinned walls.
The most extended exudate are the ampullar parts of the fallopian tubes. This is one of the characteristic signs of tuberculosis defeat of the fallopian tubes. Fallopian tubes in fusion with neighboring organs. Sometimes on the fallopian tubes, tube corners of the uterus along the fusion line are tuberculous tubercles. As the process decreases, there is a thickening of the walls of the fallopian tubes, a narrowing of their lumen. Fallopian tubes acquire sausage-like form.
When the interval between the fusions is filled with liquid of amber (light yellow) color, this indicates the presence of pelvic peritonitis, which is characterized by signs of tuberculous intoxication.
The caseous form is characterized by a severe course of the process with the phenomena of tuberculous intoxication, pain syndrome. In a small basin, a conglomerate is defined, which includes the appendages of the uterus, intestinal loops. The phenomena of severe pelvioperitonitis often develop.
Fallopian tubes have a sausage-like shape, a dense consistency, a rump of a rash and a fibrous plaque on a serous cover, located in the backbone space and in strong fusion with pelvic organs. The lumen of the tubes is filled with a serous, often caseous, content. Sometimes there are vaginal fistulas. In case of breakout of caseous masses in the vaginal part, a fistula with purulent discharge is visible.
Tuberculosis of the uterus (metritis) is most often a consequence of the descending spread of the process from the mucous membrane of the tube. In patients, there are abundant prolonged uterine bleeding. Sometimes after a one-, two-time bleeding there comes a persistent amenorrhea as a result of dystrophic changes in the endometrium. Often observed dysmenorrhea, acyclic bleeding.
There are focal and diffuse forms of tuberculosis of the uterus. In the latter, the entire endometrium is destroyed, which turns into a granulation shaft from caseous masses. Tuberculosis of the uterus, which developed in childhood or puberty, leads to atrophy of the uterine lining of the uterus, as a result of which primary amenorrhea may occur. In menopause, with a caseous endometrium, a pyrometer often appears. The diagnosis of tuberculosis of the uterus is based on a histological examination of the contents of the uterus.
Tuberculosis of the cervix and external genital organs. Tuberculosis of the cervix can affect not only the mucosa of the cervical canal, but also its vaginal part. Simultaneous damage to the mucous membrane of the cervical canal and endometrium is> 60% of patients and morphologically manifested by polyposis proliferation. In case of damage to the integument epithelium, an ulcer appears. In the tuberculous ulcer, the edges seem to be undermined, in the thickness of the edges of the ulcer there are tubercular elements that bleed easily in case of touch, and the bottom is covered with a film of whitish or gray-yellow color.
From the vaginal part of the cervix, the process can spread to the mucosa of the vault and walls of the vagina. The location of the ulcer and its size are different. It is painful on palpation and movement of the patient. Diagnosis is facilitated by biopsy for histological examination.
Tuberculomas are clinically manifested by pain in the lower abdomen and are diagnosed with an overview radiograph of pelvic organs. Healing can occur according to the type of resorption, fibrous degeneration. In the fallopian tubes, ovaries, myometrium, with insufficient drainage, healing often ends with an encapsulated focus.
In such outbreaks, the mycobacterium tuberculosis may persist for a long time, it also leads to aggravation or recurrence of the process.
Criteria for recovery from genital tuberculosis in women:
- a steady cessation of intoxication,
- absence of signs of inflammation in the genitals,
- normalization of body temperature,
- normalization of menstrual function,
- normalization of clinical, biochemical and immunological parameters.
Residual changes: minor residual changes – stay under supervision for 2 years: not significant adhesion in the affected organ, not spread beyond its limits; lymph nodes of the small pelvis in the phase of calcification. Significant residual changes – stay under supervision for 3 years: a significant adhesion process involving the peritoneum and subcutaneous fat, often soldered from the uterus (stay under supervision for 4 years), infertility (stay under supervision for 5 years).