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Methodological Instructions for Students

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Methodological Instructions for Students

Theme: Tuberculosis of kidneys.

Aim: Students should know how to diagnose and specific principles for the treatment the patients suffering from tuberculosis of uro-genital organs and should know methods of operation used for treatment.

Professional Motivation:

Tuberculosis of uro-genital organs is noted in 10-15% of patients suffering from tuberculosis. Clinical findings of tuberculosis were written in 1841. First operation of this disease was successfully done in 1872.

Basic Level:

1. Anatomy, physiology of urinary-sexual system.

2. Etiology, pathogenesis, morphological changes in kidney urinary bladder in the case of tuberculosis.

3. X-ray, functional, instrumental, laboratory, endoscopic methods of investigation.

4. Principles in treatment of patients suffering from tuberculosis in urology.
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        Student's Independent Study Program

I. Objectives for Students' Independent Studies

You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:

1. Etiology and pathogenesis of tuberculosis of kidneys.

A process is predetermined by the specific exciter — microbacteria of tuberculosis (by the Koch stick). Basic by diffusion of tubercular infection there is hematogenical. At first buds are struck, and from there the infection on the blood vessels gets in the kidney bowl, ureter, urinary bladder. Infication takes place in the period of primary or secondary generalisation of tubercular process from the basic cell in the lungs, lymphatic nodes, bones and muscles. Although the tubercular cells develop in both kidneys, but in 70 % cases it is unilateral. Only after the unfavourable terms to the clinical symptoms of tuberculosis of one kidney the secondary symptoms join and second kidney which was until now considered healthy also suffers. That it is the principal reason of transformation of milliar tuberculosis of crust matter of kideny in the destructive damage of cerebral matter.

2. Classification of kidney's tuberculosis with the help of X-ray, clinical findings.

In practice they make use of the сlinical-roentgenologic classification of tuberculosis of buds offered by М. О. Lopatkin with coll (1977): I stage — non destructive (infiltrative) tuberculosis of bud; II — initial destruction (papillitis or small, by diameter about 1 cm, single cavities); III — measured destruction (cavity of largenesses or policavernosical tuberculosis one of bud segments); IV — total or subtotal destruction (policavernose tuberculosis of two segments, tubercular pyonefrose, calcification buds).

3. Pathological anatomy of tuberculosis of kidney and urinary tract.

In acute form of tuberculosis of kidneys in the crust matter the typical lymphoidal or epitheliodal cellular humps, that have characteristic giant cages, similar to the Pirogov-Lanhgance cages arise up. In chronic form of tuberculosis of kidneys humps are disposed at first in the crust and cerebral matter, mainly in area of kidney papillae and pyramids. Gradually they take shelter by ulcers, are added disintegration and form the cavities, which unite with the kidney bowl.

Petrification of those cells or substitution of them by the fibrose fabric can take place in some cases, in other ones — form plural cavities, which often unite between itself. Round cavities the inflammatory changes arise up and the humps appear, that testifies to combination of different stages of motion of tubercular process. These changes can be completed by full destruction of bud with development of pyonefrose. Gradually the tubercular process engulfs a fibre, and then fatty capsule of bud, that results in development of sclerosic or festering paranefritis.

4. Symptomatology and course of tuberculosis of kidney and urinary tract.

On the early stages of disease, when in parenhima the first tubercular humps appear, sometimes general weakness, indisposition, rapid fatigue, reduction of body mass, losing of appetite, dull pain in the lumbar area, subfebrile temperature of body exist. In the case of the process sharpening, penetration of tubercular cell in the kidney bowl the chill can appear. The temperature curve gains a hectic character, sharp or dull pain appear in the lumbar area, disurical discords exist. The kidney pain exists at the corking by ureter rawsimilar (caseosic) the masses. On the late stages of process, especially in case of bilateral defeat, all signs of chronic insufficiency of buds appear.

5. Diagnose of kidney's tuberculosis.

In the initial stages of disease the pathological changes on excretory urograms can’t be fixed if there are the same violations, however in unspecific pyonefritis or necrotic papillitis — seen uneven contours in area of small bowls. As far as progress of process in excretory urograms expose single or plural cavities, which have uneven edges. At the productive stage of bud tuberculosis on urograms it is possible to expose a defect of the filling, compression or amputation of bowl. The expansion often exists and even obliteration of kidney bowl. In the case of diffusion of tubercular process on ureter pulls, even narrowing and expansion of it without the visible peristaltic waves are marked. After wards the plural narrowing of ureterus appears.

6. Laboratory diagnosis of kidney's tuberculosis.

The most reliable and objective sign of tuberculosis of urinary organs is an exposure in sediment of urine of micobacteria of tuberculosis. For this purpose they apply bacterioscopical, bacteriological, biological methods of research, a frequent sowing of urine and other.

7. X-ray and endoscopical diagnose kidney's tuberculosis.

The cystoscopy is the most informative method of diagnostics of tuberculosis of urinary bladder. In the early stages of tuberculosis of urinary bladder the mucus membrane can be normal. On background pink coloued mucus shell expose small areas of hyperemia and hemorrhages. Near the opening of the ureterus staggered bud it is possible to expose a shallow primrose or grey-yellow tubercular humps with the reddish rim on periphery. The opening ureterus is pulled in, deformed, it has the shape of crater.

8. Differential diagnosis of kidney's tuberculosis.

Chronic nonspecifik cystitis or pyelonephritis may mimik tuberculosis perfectly, especially since 15-20% of cases of tuberculosis are secondarily invaded by pyogenik organisms. If nonspecific infections do not respond to adequate therapy, a search for tubercle bacilli should be made. Painless epididymitis points to tuberculosis. Cystoscopic demonstration of tuberculosis and ulceration of the bladder wall means tuberculosis. Urograms are usually definitive.

Acute or chronic nonspecific epididymitis may be confused with tuberculosis, since the onset of tuberculosis is occasionally quite painfull. It is rare to have palpatory changes in the seminal vesicles with nonspecific epididymitis, but these are almost routine findings in tuberculosis of the epididymis.

9. Convincing symptoms of kidney's tuberculosis.

To including X-ray examinaition, endoscopic and laboratory method.

10. Conservative methods of treatment and prognosis of tuberculosis of kidneys.

They usually apply simultaneously three specific antituberculouse preparations of different mechanism of action. To preparations of Ist row belong streptomycin, sodium of paraaminosalicylatis, isoniasid (tubasin) and its marching (phtivasid, metasid, salusid, larusan, inga-17І). To preparations IInd row belong aetionamid, cycloserine, tyoacetason, aetoxid, pirasinamid and florimycin sulfate.

The primary course of continuous medical treatment by the antituberculouse preparations does notproceed le than n year. It is carried out under surveillance of urologist-phtisiatrist. The antirecidive courses by duration the 1,5— 2 months are conducted during the 3—4 years in the spring-autumn periods. For the medical treatment they use one of the marching tubasidum in combination with aetoxidum or to sodium of paraaminosalicylatis.

11. Operative treatment of tuberculosis of kidneys.

If the destructive tuberculosis of bud has a limited nature, shown cavernotomy, cavernectomy, resection of bud. Cavernectomy and cavernotomy aren’t now practically applied. In case of the single narrowing of ureterus on the small distance they execute the resection of this area and they impose anastomosis after type end in end, at stricturas of pyeloureteral segment — resection with imposition of anastomosis after the Anderson-Haync method or Coachman. In the case of stricturas pelvic part of ureterus necessary direct or indirect ureterocystoneostomy. At plural stricturas ureterus they execute an operation of substitution by its a thin bowel on mesenterium, that is the intestinal plastic of ureterus. After operations a sick is to get antituberculosic preparations for a year.

12. Complications of tuberculosis of kidneys.

A. Renal Tuberculosis. Perinephrik abscess may cause an enlarging mass in the flank. A plain film of the abdomen will show obliteration of the renal and psoas shadows. Sonograms and CT scans may be more helpful. Renal stones may develop if secondery nonspecific infection is present. Uremia is the end stage if both kidneys are involved.

B. Ureteral Tuberculosis : Scarring with strcture formation is one of the typical lesions of tuberculosis and most commonly effects the juxtavesical portion of the ureter. This may cause progressive hydronephrosis. Complete ureteral obstruction may cause complete nofunion of the kidney.

C. Vesical Tuberculosis: When severely damaged, the bladder wall becomes fibrosed and contracted. Stenosis of the ureteres or reflux occurs, causing hydronephrotic atrophy.

Key words and phrases:

tuberculosis, aseptical piuria.
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        II. Tests and Assignments for Self-assessment

1. Biological tests of microbacteria experimented on:

A: mice.

B: guinea-pigs.

C: flies.


E: rats.

2. Symptom of tuberculosis in urine-excretory system which is noted in urography is:

A: deposits of calcium in kidney.

B: shadow in renal pelvis projection.

C: increase of kidney in size.

D: smoothing of transverse muscle.

E: decrease of kidney's size.

3. Symptom of tuberculosis in urine excretory system which is noted in retrograde cystoscopy is?

A: increase of size of urinary bladder.

B: deffect in filling.

C: microcyst, bladder-urinary reflex.

D: diverticulum of urinary bladder.

E. protuberant in neck of urinary bladder.

Real life situation to be solved:

1. Patient C., at the age of 54, complains of periodical dysuria which brings pain and problem during urine excretion. Usage ofuroseptics didn't bring any improvement. What type of disease gives this type of symptoms? What should we do for absolute diagnosis for this patient?

2. Patient C., at the age of 51, complaints on dysuria. In analysis of urine microhaematuria is noted; in cystocopy the volume of bladder is 110 ml; in the region of right ureter's opening the mucous is hypertrophied, dropsical.

Which disease can be the patient suffering from?

Which extra methods are needed for absolute diagnose?

III. Answers to the Self-assessment.

The correct answers to the tests:

l. B.

2. A.

3. C.

The correct answers to the real life situations:

1. Tuberculosis; normal ulcer, cancer of urinary bladder. We must do cystoscopy.

2. We should think of tuberculosis urine-excretory system. We must do few times B. K and excretory urography.

Students' Practical Activities:

Students must know:

1. Etiology and pathogenesis of kidney's tuberculosis.

2. Clinical X-ray classification of kidney's tuberculosis.

3. Pathological anatomy of tuberculosis of kidneys and urinary tract.

4. Symptomatology and treatment of tuberculosis of kidneys and urinary tract.

5. Diagnosis of kidney's tuberculosis.

6. Lab diagnose of tuberculosis of kidneys.

7. X-ray and endoscopic diagnose of kidney's tuberculosis.

8. Differential diagnose of kidney's tuberculosis.

9. Convincing symptoms tuberculosis of kidneys.

10. Conservative treatment and prognosis tuberculosis of kidneys.

11. Operative treatment tuberculosis of kidneys.

12. Complications of kidney's tuberculosis.

13. Peculiarities of dysuria and piuria in case of kidney's tuberculosis.

14. Aseptical piuria and diagnostic importance.

Students should be able to:

1. To note symptoms and syndromes of tuberculosis of kidneys, urinary bladder.

2. To diagnose tuberculosis of kidneys and urinary tract.

3. To diagnose different stages of tuberculosis of kidneys and urinary tract.

4. To formulate and explain a clinical diagnosis.

5. To define tactics of treatment in case of tuberculosis of kidneys and urinary tract.

6. To study X-ray of patients suffering from tuberculosis of kidneys and urinary bladder.


Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

Methodological Instructions for Students iconMethodological Instructions for Students

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