Tuberculosis of the genitourinary system

The problem of extrapulmonary tuberculosis has always remained on the "secondary roles". Periodically (very infrequently) published monographs devoted to one or another particular issue. However, tuberculosis of the genitourinary system is multifaceted and is still relevant, to a large extent due to the complexity of diagnosis, due primarily to the absence of pathognomonic symptoms.

Tuberculosis is a deadly enemy, and it is necessary to "know it in person", to be able to recognize this insidious disease well and on time.

Epidemiology

In 1960, WHO experts assumed the complete eradication of tuberculosis in the near future, but already in 1993 they were forced to proclaim the slogan "Tuberculosis is a global hazard". At the same time, recognizing tuberculosis as a global problem and leading to appalling facts of morbidity and mortality (every 4 from one person gets tuberculosis and every 10 seconds dies from it, among women aged 15 to 44 years, tuberculosis causes 9% of death, while military actions take women's lives only in 4%, acquired immune deficiency syndrome - in 3% and diseases of the cardiovascular system - in 3% of cases), WHO considers dangerous only pulmonary tuberculosis, without paying extrapulmonary localizations any attention. Certainly, tuberculosis of the respiratory system is more manifest and dangerous for the life of the patient and the health of others. However, tuberculosis of the genitourinary system, firstly, significantly reduces the quality of life of the patient. Secondly, albeit to a lesser extent, but contagious. In recent years, multi-organ, generalized tuberculosis, which requires a special approach, different from the standard one (unified), is increasingly being diagnosed.

78% of all tuberculosis patients live in Romania, the Baltic States, the CIS and Russia.

A sharp decline in the incidence was due to the introduction of mandatory vaccination against tuberculosis of children on the 5th-7th day of life, as well as the creation of major anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide, protionamide, aminosalicylic acid, ethambutol, streptomycin).

The incidence of tuberculosis of respiratory organs and extrapulmonary localizations varies considerably.

Tuberculosis of the genitourinary system ranks second in the overall morbidity structure after respiratory failure and is the most common form of extrapulmonary tuberculosis. In different countries, the ratio is approximately the same: in the USA in 1999, 1460 people became ill with tuberculosis, of which 17 (1.2%) had urothuric tuberculosis (Geng E. Et al., 2002). In 2006, in Siberia and the Far East, among 34,637 tuberculosis cases, isolated genital tract damage was detected in 313 (0.9%), although generalized forms were many times more common.

[1], [2],

Symptoms of the tuberculosis of the genitourinary system

Tuberculosis of the genitourinary system has no characteristic clinical symptoms. When parenchyma is affected, patients, as a rule, do not complain. An active diagnosis of the disease is needed: examination of persons at risk, having tuberculosis of other localizations or in contact with patients! Other forms of tuberculosis of the kidneys can be asymptomatic, with faint clinical signs, or violently (regardless of the degree of urinary tract damage). Sometimes the papillitis of a single calyx with intensity of pain and dysuria, recurrent colic and macromembria causes the patient to consult a doctor early, and sometimes bilateral cavernous tuberculosis of the kidney manifests only a minor pain that the patient tolerates for years. In this case, the disease is discovered by chance, during a survey for some other reason.

Both for tuberculous papillitis and for cavernous nephrotuberculosis, one subjective complaint is usually characterized: a moderate constant dull aching pain in the lumbar region. This symptom is noted up to 70% of patients. The remaining clinical symptoms (dysuria, renal colic ) are due to the development of complications. Severe intoxication and fever is typical for the acute course of tuberculosis of the genitourinary system (recorded with a certain cyclicity).

Diagnosis of cavernous and polycavernous tuberculosis of the kidneys does not present any major difficulties. The doctor's task is to recognize nephrotuberculosis in the stage of tuberculosis of the parenchyma or papillitis, when it is possible to cure the patient without large residual changes.

The symptoms of tuberculosis of the genitourinary system have undergone some changes in recent years. Seven times less often the acute onset of the disease is recorded, significantly more often the patients notice dull constant pain in the lumbar region and the appearance of blood in the urine. As before, with tuberculosis of the genitourinary system, there may be no subjective symptoms.

Forms

Classification of tuberculosis of the genitourinary system includes the following clinical forms:

• tuberculosis of the renal parenchyma (stage I, non-destructive form);
• tubercular papillitis (II stage, limited-destructive form;
• cavernous nephrotuberculosis (stage III, destructive form);
• polycavernous nephrotuberculosis (stage IV, widespread destructive form).

Complications of tuberculosis of the genitourinary system:

• tuberculosis of the ureter;
• tuberculosis of the bladder;
• tuberculosis of the urethra;
• chronic renal failure;
• fistula of the lumbar region.

Mycobacteriuria always occurs with tuberculosis of the kidney parenchyma and is possible with other forms of nephrotuberculosis. When isolating mycobacteria tuberculosis in diagnosis, in addition to its form, indicate "MBT +".

Tuberculosis of the renal parenchyma is the minimal initial non-destructive form of nephrotuberculosis (stage I), in which not only clinical, but also anatomical cure is possible. In this case the structure of the cup-and-pelvis system is usual on urograms; destruction and retention are absent. In urinalysis in children, pathological changes may not occur, although adults usually have a moderate leukocyturia.

Mycobacteriuria in healthy kidneys is impossible - the causative agent of tuberculosis is not filtered through healthy glomeruli, so the detection of mycobacteria of tuberculosis in urine is always considered a sign of the disease. Bacteriological verification of tuberculosis of renal parenchyma is mandatory, and one positive result of urine culture is sufficient, but at least two facts of detecting mycobacteria of tuberculosis by the method of luminescence microscopy are necessary. It is impossible to distinguish the sides of the lesion with tuberculosis of the parenchyma, therefore this disease is always considered bilateral. Complications are extremely rare. The forecast is favorable.

Tuberculous papillitis (stage II, limited destructive form) can be one- and two-sided, single and multiple is complicated, as a rule, by tuberculosis of the genitourinary system. Mycobacterium can not always be fixed. It is recommended conservative treatment with inferior etiopathogenetic therapy, the formation of ureteric stricture is possible. Requiring prompt correction. The forecast is favorable.

Cavernous nephrotuberculosis can be one- and two-sided: a situation is possible when tubercular papillitis is diagnosed in one kidney, and in the other - a cavern. Complications develop in more than half of patients. As a rule, with cavernous nephrotuberculosis appoint operative treatment. Complete cure is impossible to achieve, but the application of methods of complex etiopathogenetic treatment allows in some observations to transform the cavern of the kidney into a sanified cyst. The usual outcome is the formation of tuberculosis pyelonephritis.

Polycavernous tuberculosis of the kidney (stage IV, a widespread destructive form) suggests the presence of several caverns, which leads to a sharp deterioration in the function of the organ. As an extreme variant of the course of the disease, pionephrosis with fistula formation is possible. However, self-healing is also possible, the so-called autoamputation of the kidney - the imbibation of cavities with calcium salts and complete obliteration of the ureter. Complications develop almost always, probably the formation of a tuberculous focus in the contralateral kidney. Cures are achieved, as a rule, by performing an organ-carrying operation.

Tuberculosis of the ureter usually develops in the lower third (with involvement of vesicoureteral anastomosis). Multiple ureteral lesion with "clear-cut" deformation is possible, stricture formation, which leads to rapid death of the kidney (even with limited nephrotuberculosis).

Tuberculosis of the bladder is one of the most serious complications of nephrotuberculosis, causing the patient the greatest suffering, drastically reducing the quality of his life and poorly treatable. A specific process extends to the lower urinary tract in 10-45.6% of patients with urinary tract tuberculosis, and targeted diagnostic measures, including a bladder wall biopsy, increase the detection rate of complications to 80%.

Forms of tuberculous cystitis:

• tubercular-infiltrative:
• erosive and ulcerative;
• spastic cystitis (false microcystis, and in fact - GMF);
• true wrinkling of the bladder (up to complete obliteration).

The above forms can be transferred to a heavier one sequentially or bypassing an intermediate step. If tubercular-infiltrative and erosive-ulcerative forms can be cured conservatively, then with true bladder wrinkling, surgical intervention is performed to create an official bladder. Spastic microcystis is a borderline state, highly prone to transformation into a true microcystis, meaning a patient's disability.

In the initial stage, tuberculosis of the bladder manifests itself in paraspecific changes in the mucous membrane in the region of the mouth of the most affected kidney. With tuberculous cystitis, the capacity of the bladder is already decreasing at the initial stage of the disease. The cystoscopic picture is distinguished by a large polymorphism.

Perhaps several options for the development of tuberculosis of the bladder.

• Variant A - productive inflammation with a latent clinical picture. In the initial stage on the surface of the mucous membrane visualized prosovous rashes (tubercles). Their localization may be different, but more often the rash is detected on the posterior or lateral, opposite the mouth of the most affected kidney, the wall. Rashes are not very resistant, so a biopsy of the wall of the bladder should be performed immediately when they are detected. Transition of inflammation to the interstitial layer in the absence of early full-fledged treatment usually ends with the wrinkling of the bladder of varying degrees.
• Variant B - prosovous rashes are surrounded by a zone of hyperemia, ulceration is possible. In the absence of treatment, pathological foci merge up to complete damage to the mucous membrane.
• Option B - the formation of a solitary ulcer with uneven, undercut edges, surrounded by a zone of hyperemia with fuzzy contours.
• Variant D - with exudative inflammation there is a total lesion of the mucous membrane of the bladder ("blazing bladder"), characterized by bullous edema, the emergence of contact hemorrhages and pronounced hyperemia that prevents the identification of the mouth.

In the initial stage of tubercular urethritis, the outwardly external mouths remain normal, but the catheter encounters an obstruction when it moves forward (usually 2-4 cm). Bullous edema of the mouth subsequently develops. Its severity can be so great that, if it is necessary to catheterize the mouth, the transurethral electroresection of the bull is pre-performed. When forming a fibrous process, the mouth is deformed, acquires a funnel-like shape and ceases to contract.

The presence of pathological elements on the mucous membrane and (or) dysuria is considered an indication for performing gipoplastic biopsies of the bladder wall with the capture of the submucosa. Perform a pathomorphological and bacteriological study of the biopsy. When there is a total lesion of the mucous membrane of the bladder, expressed contact hemorrhages and the location of pathological elements in the immediate vicinity of the ureteral mouth, biopsy is contraindicated.

[3], [4], [5], [6], [7], [8]

Diagnostics of the tuberculosis of the genitourinary system

Diagnosis of tuberculosis of the genitourinary system, as well as of any other disease. Begin with examination and questioning the patient. Since Hippocrates is known that the disease leaves a mark on the appearance of the patient. Already the first look at it can lead to certain thoughts. So, the shortening of the limb and the hump can testify to the tuberculosis of bones and joints born in childhood , although it can also be the result of trauma. Rough starry scars on the neck remain only after poorly treated tuberculous lymphadenitis. Along with the classical habitus phtisicus (pallor, emaciated face with a feverish blush and shining eyes), there is another option - a young, exhausted man, often with multiple tattoos (it is known that the most malignant tuberculosis occurs in prisoners). On the contrary, patients with tuberculosis of the genitourinary system make an impression absolutely healthy; women tend to have a little increased food, ruddy. Often, patients take a forced posture - they keep their hands on the waist (exception - acute tuberculosis of the genitourinary system).

Interview

When collecting an anamnesis, special attention should be paid to contact of the patient with tuberculosis patients by humans or animals. It is necessary to establish its duration and intensity; to clarify whether the patient himself was sick with tuberculosis. Especially alarming about specific damage to the organs of the genitourinary system is the fact of advanced tuberculosis in childhood and (or) disseminated tuberculosis of the lungs.

Children are annually subjected to tuberculosis diagnostics to detect tuberculosis infection and to determine indications for vaccine revaccination. To prevent tuberculosis of the genitourinary system containing live attenuated mycobacterium tuberculosis. For this, 0.1 ml of purified tuberculin containing 2 tuberculin units is injected intradermally (on the forearm). The results are evaluated after 24, 48 and 72 hours. A negative result is the absence of any skin reaction; doubtful - the formation of the foci of hyperemia with a diameter of up to 5 mm; positive test - the occurrence of hyperemia and papules with a diameter of 5 to 17 mm, which indicates the immunity to tuberculosis. If after the introduction of purified tuberculin, a papule with a diameter of more than 17 mm (hyperergic reaction) or a positive reaction for the first time after the negative appeared on the forearm, the child is considered to be infected: he is to be monitored in an anti-TB dispensary.

Hyperergic reaction or turn of a tuberculin test in a small child is evidence of an epidemic trouble in the family.

That is why the information on the presence in the family of children with a bend of the Mantoux reaction or hyperergic breakdown is considered informationally significant.

[9]

Laboratory diagnosis of tuberculosis of the genitourinary system

Routine laboratory studies are poorly informative in the diagnosis of tuberculosis of the genitourinary system. At torpid flow of the process, the hemogram parameters remain within normal limits, and with an active, rapidly progressing process, changes occur that are characteristic of any inflammation: an increase in ESR, leukocytosis, and a stab-shift shift of the leukocyte formula.

Urinalysis for tuberculosis of the genitourinary system can be normal only if the kidney parenchyma is affected in children. Concerning the specific trait (even when combined with nonspecific pyelonephritis), consider an acid reaction of urine (pH = 5.0-5.5). In a number of regions of Russia, endemic for urolithiasis, the acid reaction of urine is characteristic of the population. Nevertheless, this is an important symptom, and laboratories should be required to quantify the urine reaction.

Virtually all patients with destructive forms of nephrotuberculosis are noted to have pyuria (leukocyturia), although recently patients with kidney tuberculosis, characterized by monosymptomatic hematuria (with normal white blood cell count in urine sediment) are increasingly being observed. A.L. Shabad (1972) considered erythrocyturia as one of the leading symptoms of kidney tuberculosis and detected it in 81% of patients, although some researchers fixed this symptom only in 3-5% of patients with nephrotuberculosis.

Hematuria is an integral part of the triad of major urologic symptoms and the most manifest and alarming among them. When studying urine according to Nechiporenko, the norm is the detection of 2 thousand erythrocytes in 1 ml of urine. W. Hassen and MJ Droller (2000) in 9-18% of healthy volunteers recorded a microhematuria and came to the conclusion that when microscopy of urine sediment, the norm can be considered the detection of not more than three red blood cells in the field of vision.

N. Sells and R. Sokh (2001) observed 146 patients within two years after the macrogematuria of unclear etiology. All of them were carefully examined, but neither ultrasound nor excretory urography nor cystoscopy revealed any diseases of the genitourinary system causing macromembria. 92 patients in the future no complaints from the urogenital system were presented, and there were no changes in urine tests. In one of them, 7 months later, pelvic stones were found; five patients underwent a TUR of the prostate (three for her adenoma, and two for cancer). Fifteen people died during the observation period, but none of them caused a urologic or oncological disease. Only 33 (22.6%) of 146 patients had repeated episodes of macrogematuria.

N. Sells and R. Soh concluded that causeless macrogematuria is not uncommon in urological practice and requires an in-depth examination only when it recurs, which happens 20% of such patients.

According to the literature, nephrotuberculosis is combined with urolithiasis in 4-20% of cases. Often calcified areas of caseous in the kidney are mistaken for concrements. Departure of stones in the anamnesis, absence of pyuria, repeated colic, an increase in the content of salts in the urine is more evidence of urolithiasis. However, in any case, an active search for mycobacterium tuberculosis in the urine in these patients should be carried out.

Until now, the question remains open: what is primary. On the one hand, tuberculosis of the genitourinary system as a disease that heals through scarring and calcification, contributes to the violation of the passage of urine and calcium metabolism, thus creating favorable conditions for stone formation. On the other hand, urolithiasis, sharply disrupting urodynamics in an infected person, is a pathogenetic prerequisite for the emergence of nephrotuberculosis.

According to some reports, a combination of urolithiasis and kidney tuberculosis is observed in 4.6% of cases. The main clinical symptom in such patients is pain, which occurs more often with combined lesions and less pronounced with isolated nephrotuberculosis. This symptom with tuberculosis of the genitourinary system and urolithiasis has a common origin: chronic or acute retention of urine above the obstacle (stone, stricture, edema). The cause of the pain can be determined only after an analysis of all the clinical and radiological examination data.

It should be noted that the combination of urolithiasis and kidney tuberculosis significantly aggravates the course of the disease. So, if patients with isolated nephrotuberculosis had chronic renal insufficiency in 15.5% of cases, the development of urolithiasis led to impaired renal function in 61.5% of patients. In such patients, drug intolerance often arose, intoxication lasted longer, treatment effectiveness was lower. Among patients with co-morbidities, 10.2% developed an early relapse of kidney tuberculosis, while in the contingent of the dispensary the frequency of relapse of the same localization was only 4.8%.

Thus, the differential diagnosis between urolithiasis and nephrotuberculosis is difficult due to the similarity of the main symptoms and requires the doctor to be constantly wary of tuberculosis in patients with urolithiasis. Patients with renal tuberculosis in combination with urolithiasis are subject to longer follow-up in active outpatient clinics, as they have a higher risk of exacerbation and relapse of the disease.

Increased protein in the urine for nephrotuberculosis is not typical. As a rule, proteinuria in this disease is false, i.e. Is due to concomitant pyuria and hematuria.

Functional tests of the liver and kidneys for a long time are characterized by normal indices. Chronic kidney failure develops only in every third patient with nephrotuberculosis, with a long-gone process or when combined with a specific pyelonephritis and / or urolithiasis.

The main thing in the diagnosis of tuberculosis of the genitourinary system is bacteriological research. Urine is examined by performing seeding on various nutrient media (Anikina, Finn-2, Levenshtein-Jensen, "Novaya"). The same portion of urine is subjected to luminescent microscopy. Such a tactic makes it possible to establish the timing of the loss of viability of mycobacteria tuberculosis (when in fluorescent microscopy the pathogen is still detected, but does not give rise to growth on media).

In nephrotuberculosis, mycobacteriuria is meager, intermittent, and therefore difficult to detect. That is why it is necessary to perform at least 3-5 consecutive bacteriological studies (crops) of urine. Their fulfillment three times during one day increases the seeding of mycobacterium tuberculosis by 2.4 times.

It is necessary to pay attention to the need for sterile urine sampling, since contamination of the sample with a non-specific microflora can lead to a false negative result. Previously believed that the mycobacterium tuberculosis does not allow the development of intercurrent microflora in the urine, and even there was a symptom of tuberculosis of the kidneys - aseptic pyuria, i.e. The presence of pus in the urine in the absence of growth of nonspecific microflora. Currently, up to 75% of patients have at the same time specific tuberculosis and nonspecific inflammation of pelvis and kidney parenchyma, which also reduces the frequency of identification of mycobacteria tuberculosis.

In addition, as little time as possible between the fence of urine and its sowing (about 40-60 min) should pass. Non-compliance with these rules significantly reduces the effectiveness of bacteriological research.

Recently, DNA diagnostics has become widespread. In India, for example. 85% of patients with kidney tuberculosis are diagnosed on the basis of detection in the urine of Mycobacterium tuberculosis by PCR. In Russia, this method has limited application due to its high cost and not always a clear correlation with the results of crops. However, in general, the verification of mycobacterium tuberculosis with the help of DNA diagnostics is very promising, as hypothetically it can allow to significantly shorten the time of recognition of the genitourinary tract tuberculosis, and also immediately determine the sensitivity of mycobacteria tuberculosis to the main anti-tuberculosis drugs.

The microscopy of the urine sediment, colored by Tsiol-Nielsen, did not lose its value, although the sensitivity of this method is not high.

A biological sample (pathogens contaminated with guinea pigs) is not currently used.

Bacteriological examination of urine, secretion of the prostate, ejaculate, taken at the time of exacerbation of the underlying or any of the concomitant diseases, greatly increases the probability of detection of mycobacteria tuberculosis. However, the patient has a chronic disease that repeatedly took a lot of antibiotics (including tetracyclines, aminoglycosides and fluoroquinolones), the growth of mycobacterium tuberculosis may not be obtained without provocation with tuberculin or a laser.

Instrumental diagnosis of tuberculosis of the genitourinary system

In recent years, ultrasound diagnosis has become a common and generally available research method. The use of modern scanners has led to a sharp increase in the frequency of detection of various diseases, in particular tumors and kidney cysts. Sometimes it is difficult to differentiate the cavity formation and the cavern of the kidney. In this case, a pharmacological test may be useful: an intravenous injection of 20 mg of furosemide contributes to a reduction "or, conversely, to an increase in the size of the kidney cyst. The cavity does not change due to the rigid walls.

X-ray examination of the genitourinary system is one of the most significant methods of diagnosing any urological disease, including tuberculosis of the genitourinary system.

The study begins with an overview of the radiograph, which makes it possible to establish the presence or absence of shadows suspected of calculus, calcification in the kidney or mesenteric lymph nodes, and to orientate itself with regard to further tactics (for example, the need to perform an additional roentgenogram in a standing position).

To assess the secretory and excretory function of the kidneys, excretory urography with intravenous injection of 20-40 ml of RKV (yopromil) and subsequent execution of a series of pictures is used. In the absence or decline of secretory function, as well as in case of suspicion of evacuation violation, delayed images are performed after 30, 60.90 min, and according to indications - later.

According to the urographs, it is possible to evaluate the structure of the pelvis and calyces, to detect the presence or absence of their destruction or deformation, and to determine the ratio of the shadow on the overview radiograph and the calyxal-calculous kidney system. So, for example, a shadow, unambiguously interpreted as a concrement in a lowered kidney, on an excretory urogram looks like a calcified mesenteric lymph node. In the early stages of nephrotuberculosis, there are no characteristic radiographic signs. The destruction is visualized more clearly, the greater the amount of damage.

Modern digital X-ray machines allow postprocessing, choice of optimal physical and technical parameters, framing. Snapshots are performed not at the standard time, but at the time of the best contrasting of the cup-and-pelvis system. Considerable is the possibility of evaluating urodynamics in real time: only with the help of a digital X-ray machine can one catch urine reflux during a excretory urography. At the time of the study, several tomographic sections must also be performed, which eliminates the increased pneumatization of the intestine and provides additional information on the relationship between education in the parenchyma and the bowl-and-pelvis system.

CT allows to obtain an image without a summation effect, which significantly improves the quality of evaluation of the structure of the kidneys. With its help you can visualize the X-ray negative concrement, measure the density of the pathological focus and. Thus, to carry out differential diagnostics between liquid or soft tissue formation. Tuberculous papillitis in the phase of calcification on excretory urograms looks like compaction of the deformed papilla, while on computer tomograms it is visualized more clearly.

Retrograde pyelography is recommended with fuzzy contrasting of the cup-and-pelvis system on excretory urograms (it is very informative for tuberculosis of the kidneys). Thanks to this method of research, it is possible not only to better visualize the upper urinary tract and cavities, but also to detect obstruction of the ureter due to the formed (or emerging) stricture, which is fundamentally important for determining the tactics of patient management.

Mikstatsionnaya cystography allows you to determine the capacity of the bladder, the presence of its deformation and vesicoureteral reflux: it is possible to stitch the contrast agent into the cavities of the prostate, which additionally confirms the defeat of the genital organs. Given the high incidence of combination of tuberculosis of the kidneys and the prostate, all men with nephrotuberculosis are recommended to perform urethrography, which clearly shows the caverns of the prostate.

Radioisotopic diagnosis of tuberculosis of the genitourinary system

Radioisotope renography plays a certain role only after repeated execution during the provocative test (Shapiro-Grund test), in which deterioration of the functional parameters of the kidney indicates an exacerbation of the tuberculosis process caused by the introduction of tuberculin. It is also recommended for the determination of residual kidney function and treatment tactics.

Ureteropyeloscopy and cystoscopy are indicated for patients with persistent pyuria, hematuria or dysuria. If tubercular inflammation is limited to kidney damage, without involving the urinary tract in the process, then the mucosa of the bladder can be absolutely normal. At the initial stage of tubercular cystitis, the capacity of the bladder can be sufficient, although, as a rule, it is noted that it decreases. The cystoscopic picture of bladder tuberculosis was described above.

In case of severe inflammation of the bladder mucosa with bullous edema and contact hemorrhages, it is difficult to perform any diagnostic endovezic measures (for example, catheterization of the ureteral orifice, in this case, immediately after the visual cystoscopy and detection of the indicated signs, it is necessary to release an aseptic solution through the cystoscope drainage system, the bladder is administered 1-2 ml of a 0.1% solution of epinephrine in combination with 5-10 ml of a 2% solution of trimecaine (lidocaine) .After 2-3 minutes of exposure, The epinephrine causes a constriction of the vessels and a reduction in mucosal edema, which greatly facilitates the identification and catheterization of the ureteral orifice, and local anesthesia allows a larger amount of solution to be injected and, thus, it is better to dilate the walls of the bladder.

It should be noted that the method described above can not be used in primary, previously untreated patients, as premature administration of epinephrine and trimecaine will not allow obtaining true information about the capacity of the bladder and the state of its mucosa.

The presence of pathological elements on the mucous membrane and (or) dysuria is considered an indication for performing gipoplastic biopsies of the bladder wall with the capture of the submucosa. The biopsy is directed to pathomorphological and bacteriological research (sowing). There are observations when the histological conclusion indicated paraspecific inflammation, and when sowing, the growth of mycobacteria of tuberculosis was obtained.

Urethroscopy does not provide additional information; There is no known case of diagnosis of tuberculosis of the genitourinary system by this method. Moreover, there are clinical observations when patients underwent urethroscopy with biopsy of the seminal tubercle in connection with persistent prostatitis and colliculitis, while pathomorphologically determined signs of chronic inflammation. Nevertheless, it was later found out that these were masks of prostate tuberculosis.

Provocative tests

Since verification of the diagnosis with the help of bacteriological research is currently possible in less than half of patients, in a modern clinical practice, a complex of epidemiological, clinical-anamnestic, laboratory and roentgenological data in conjunction with the results of provocative samples is taken into account in differential diagnosis. Several methods have been developed that make it possible to establish a diagnosis of urinary tract tuberculosis more quickly and with high accuracy.

Indications for conducting a provocative test:

• epidemiological anamnesis: contact with tuberculosis patients by animals, presence of children with a turn or hyperergic reaction of tuberculin samples, previous tuberculosis (especially in childhood or disseminated);
• prolonged, prone to frequent relapses during pyelonephritis with clinical signs of cystitis;
• suspicion of destruction of calyx according to excretory urography;
• preservation of pyuria (leukocyturia) after a course of treatment with uroantiseptics.

Contraindications to the provocative test:

• obvious destruction, leading to a decrease or loss of kidney function:
• massive pyuria in the absence of growth of banal flora;
• marked intoxication;
• fever;
• severe and moderate severity of the patient, due to both expected nephrotuberculosis and intercurrent disease;
• malignant tumor of any localization;
• macrohematuria.

In the diagnosis of tuberculosis of the genitourinary system, two types of provocative samples are used.

Tuberculin test of Koch with subcutaneous injection of tuberculin

Determine the number of leukocytes in the urine sediment by Nechiporenko, perform a general blood test and conduct the thermometry every 2 hours. Subcutaneously, the purified tuberculin is injected subcutaneously into the upper third of the shoulder. Tuberculin - a product of the life activity of mycobacterium - provokes activation of latent tubercular inflammation. In some works there are recommendations to introduce tuberculin as close as possible to the presumed focus of tuberculosis inflammation: in pulmonary tuberculosis - under the scapula, with kidney damage - in the lumbar region, etc. However, studies have confirmed that a specific response does not depend on the site of tuberculin, standard subcutaneous administration.

Initially, a third dilution (1: 1000) of the so-called old tuberculin Koch (Alt-tuberculin Koch) was used for the subcutaneous tuberculin test. However, in connection with the insufficiently high purification of tuberculin, general reactions occurred. In addition, the complexity of preparing the solution required special training for nurses and did not exclude a mistake in dosing. It is now using purified tuberculin Linnikova, which is released in an ampouled form in a solution ready for use. Biological activity 1 ml of this solution corresponds to 20 tuberculin units.

As a rule, 50 tuberculin units are administered to conduct a provocative tuberculin test. It is possible to inject 20 tuberculin units with a history of a pronounced reaction or 100 tuberculin units - in the absence of a response to standard tuberculin diagnostics in the past. Within 48 hours after the introduction of tuberculin, the thermometry is continued every 2 hours and the general blood test and the Nechiporenko test are repeated twice. And also carry out bacteriological examination of urine and ejaculate. When evaluating the tuberculin test, the following indicators are taken into account:

• general reaction: deterioration of health, increase in body temperature, increased dysuria. Important changes are considered in the clinical analysis of the blood: with a positive tuberculin test, leukocytosis occurs or arises. Increases ESR, decreases the absolute number of lymphocytes:
• knock-off reaction: it is possible the formation of hyperemia and infiltration at the place of introduction of tuberculin;
• focal reaction: strengthening or occurrence of leukocyturia, hematuria, mycobacterium.

In the presence of focal and at least two other reactions - nasal and (or) general - it is possible to diagnose tuberculosis. Bacteriological verification of the diagnosis is possible much later, sometimes only after 3 months. Nevertheless, subcutaneous injection of tuberculin increases the seeding of mycobacterium tuberculosis in urogenital tuberculosis by 4-15%.

Laser provocation is contraindicated in differential diagnosis with the tumor process.

Upon admission after a clinical examination and determination of the indication for a provocative test, the patient is subjected to general urine and blood tests, Nechiporenko's test, urine culture on the mycobacterium tuberculosis and luminescent microscopy of the urine sediment smear.

Then, daily transcutaneous local irradiation is carried out using an infrared laser generating continuous radiation with a wavelength.

Possible combination of laser provocation with therapy ex juvantibus. If a patient has a nonspecific inflammation, then laser therapy implements such effects as improvement of urodynamics, improvement of blood supply to the kidney, increase in the concentration of drugs in the body, which. In the long run, will positively affect the results of treatment. If the patient had tubercular inflammation, then it is activated against the background of laser therapy and will be fixed by control laboratory tests.

The duration of ex juvantibus therapy of the first type is ten days. If after a complex nonspecific etiopathogenetic treatment complaints of pain in the kidney area and frequent urination are stopped, urine tests are normalized, then the diagnosis of tuberculosis of the genitourinary system can be rejected. Such patient is subject to supervision by the urologist of the general medical network. With incomplete improvement of laboratory indicators and preservation of complaints, it is recommended that the examination be continued.

Therapy ex juvantibus the second type - the appointment of 3-4 antituberculosis drugs of narrow-directed action. For the treatment of ex juvantibus of the second type, only the following drugs are suitable: isoniazid. Pyrazinamide, ethambutol, ethionamide (protionamide) and aminosalicylic acid.

Algorithm for diagnosis of urinary tract tuberculosis

The doctor of the general medical network should suspect tuberculosis of the genitourinary system and conduct the recommended minimum examination in such cases, and establish the diagnosis - the competence of the phthisiourologist (excluding the situation of pathomorphologic verification of the diagnosis after a biopsy or surgery performed, but in this situation it is necessary to view the micro-preparations by the pathomorphologist of an antituberculous institution. Experience in diagnosing tuberculosis).

So, a patient (or in three cases out of five - the patient), usually middle-aged, who has a history of a long-term ongoing pyelonephritis with frequent exacerbations, comes to the phthisiourologist for consultation.

At the first stage, a thorough examination, a patient interview and an analysis of the available medical records are carried out. Perhaps several options for further developments.

[10], [11], [12], [13]

First option

The patient has "stigma of tuberculosis" - retracted stellar scars on the neck after the transferred tuberculous lymphadenitis; there are other indications of the disease in the history or on the fluorogram there are pockets of calcification of the lung tissue and others; in analyzes - pyuria and (or) hematuria; on urograms - destructive changes. This patient usually has cavernous tuberculosis of the kidneys started, and he should immediately appoint a complex chemotherapy and pathogenetic treatment, against which a full clinical, laboratory, bacteriological and radiological examination is conducted to determine the extent of the lesion.

[14], [15], [16], [17]

The second option

The same patient, but according to the urograms, the kidney function is not determined. Assign etiopathogenetic treatment for polycoavernous nephrotuberculosis, in dynamics perform radioisotope renography. If after 3-4 weeks the kidney function is not restored, then a nephrectomy is performed. When pathomorphological verification of the diagnosis continues treatment, in the absence of signs of active tuberculosis inflammation of the patient is discharged under the supervision of a urologist at the place of residence.

The third option

The patient received a good antibacterial treatment in the medical institution, supplemented with a complex of pathogenetic therapy, but in the analyzes a moderate leukocyturia (up to thirty cells in the field of vision) is preserved. On urograms - timely contrasting of the calyx-pelvis system, there is a suspicion of destruction; possible retention. In this case, the patient is given a laser test.

If, at its conclusion, the increase in leukocyturia and erythrocyturia is recorded, a decrease in the absolute number of lymphocytes in the peripheral blood and mycobacterium is detected, then tuberculosis of the genitourinary system is diagnosed. The form and degree of lesion are established after a detailed radiographic and instrumental examination. If there is no improvement in the laboratory results, then ex juvantibus therapy of the first type is administered. With the onset of a significant improvement in ten days, nephrotuberculosis can be rejected; the patient is transferred under the supervision of a urologist or a therapist at the place of residence. At preservation of pathological changes in analyzes of urine follow the fifth variant.

The fourth option

Pyuria is found in the patient with moderate radiological changes in the kidneys. An inadequate therapy for chronic pyelonephritis has been performed in the treatment facility of the general network. In this case, prescribe ex juvantibus therapy of the first type, supplemented by simultaneous laser provocation.

At the expressed positive clinical and laboratory dynamics the diagnosis is removed, and the patient is transferred under supervision of the urologist or the therapist in a residence.

The fifth option

With preservation of pyuria, a subcutaneous tuberculin provocation test is performed. Positive result of provocation combined with clinical and anamnestic data allows to diagnose tuberculosis of the genitourinary system and start complex treatment: the degree of lesion will be determined in the course of further radiological and instrumental research.

Sixth option

A negative result of the Koch test is considered an indication for the treatment of ex juvantibus of the second type. In this case, there are two possible outcomes. Improvement of the patient's condition and sanitation of his urine testify to tuberculosis etiology and serve as the basis for establishing an appropriate diagnosis.

Seventh option

If after taking anti-tuberculosis drugs for 2 months the leucocyturia is maintained, then. Most likely, the patient suffers from nonspecific pyelonephritis. Such patient is subject to close monitoring by the urologist of the general medical network with a control examination, including urine cultures on mycobacterium tuberculosis every 3 months. As well as with exacerbation of underlying or concomitant diseases.

Thus, the differential diagnosis of tuberculosis of the genitourinary system involves four levels:

• laser provocation;
• trial treatment of the first type;
• provocative tuberculin test;
• trial treatment of the second type.

For the first level of research, 10-14 days are needed, the completion of the second level requires 2 weeks, the third - 1 week, and the fourth level takes 2 months. In general, the diagnosis may take about 3 months. Obviously, the diagnosis of tuberculosis of the genitourinary system is a time-consuming and time-consuming process that requires careful work with the patient in a specialized institution. However, it is clear that the earlier a phthisiourologist becomes a patient, the greater the chance of a favorable outcome.

Differential diagnosis

Differential diagnosis of tuberculosis of the genitourinary system is extremely difficult in the first place due to the absence of pathognomonic symptoms and a characteristic radiographic pattern. Modern phthisiourology has everything necessary for the complete cure of the tuberculosis patient with the genitourinary system, provided that it is detected early. The main problem is not even in the differential diagnosis of the disease, but in the selection of patients who are suspicious of urothuberculosis, as sometimes there are no prerequisites for this. Tuberculosis of the genitourinary system can be asymptomatic, latent, chronically and acutely under the mask of any urological disease. Especially difficult is the diagnosis of combination of nephrotuberculosis with chronic nonspecific pyelonephritis (75% probability), urolithiasis (up to 20% of observations), kidney development anomaly (up to 20% of cases), kidney cancer.

Verification of the diagnosis is carried out with the help of bacteriological, pathomorphological examination and on the basis of clinical-laboratory, x-ray and anamnestic data (including provocative tests and test therapy).

[18], [19], [20], [21]

Treatment of the tuberculosis of the genitourinary system

Obtaining a distinct positive dynamics of the clinical picture and laboratory indicators indicates a tuberculous etiology of the process and requires a change in the treatment regimen for the standard and the entire complex of etiopathogenetic measures.

To clarify the diagnosis, it is permissible to perform an open or puncture biopsy of the kidney, but. According to many authors. The risk from this intervention exceeds the possible benefits. The absence of kidney function, confirmed by excretory urography and radioisotope renography, is considered an indication for nephrectomy.

If there is a suspicion of tuberculosis, it is advisable to perform the operation under conditions of a phthisiurological hospital, with mandatory prescribing as preoperative preparation for anti-tuberculosis polychemotherapy for 2-3 weeks and with continuation of treatment after nephrectomy until the results of pathomorphological examination are obtained. If the tuberculosis of the genitourinary system is excluded, the patient stops taking medications: he is transferred under the supervision of a urologist at a polyclinic. If the diagnosis is confirmed, the patient is provided with anti-tuberculosis treatment in full.