Urogenital schistosomiasis
Introduction
Introduction to genitourinary schistosomiasis The genitourinary schistosomiasis is mainly caused by Schistosoma japonicum. The main cause is schistosomiasis in Japan. The eggs are deposited on the testicular sheath, the scrotum wall, the epididymis, the spermatic cord and the corpus cavernosum. Its pathological feature is that the eggs stimulate the host's immune response, causing the egg granuloma to damage the organs. Urinary male genital schistosomiasis mainly occurs in the bladder, kidney and reproductive system are rare. Bladder schistosomiasis is a parasitic schistosomiasis parasitic in the blood vessels of human bladder and pelvic venous plexus. The eggs are deposited under the bladder mucosa and nearby urinary tract. Genital organs, bladder diseases caused by eosinophilic granuloma, most commonly in the bladder triangle, the entire bladder wall is invaded during chronic infection, fibrosis and scar formation, bladder capacity becomes smaller, causing bladder contracture. The lesion involves the ureteral orifice resulting in ureteral obstruction or vesicoureteral reflux. The main pathological change is egg granuloma, which often occurs in the trigone of the bladder, which is characterized by thickening of the bladder mucosa and ulceration. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: fecal spread Complications: Chronic pulmonary heart disease
Cause
The cause of genitourinary schistosomiasis
(1) Causes of the disease
The male schistosomiasis of males is 10-15 mm long, the widest point is 0.8-1 mm, the surface is covered with small nodules, and the testicles are 4-5. After the abdominal suction cups, they are arranged one after the other, and the end of the vas deferens expands into a seminal vesicle. In the middle of the body, a single dry blind tube is synthesized and extended to the end. The female is about 20 mm long and 0.25 mm wide at the widest point. It has a slender tubular shape. Both suction cups are small, and there are small nodules at the front and rear ends of the body surface. After the middle part, it has a long elliptical shape; the positional relationship of other reproductive organs is like Schistosoma japonicum; the uterus contains 20 to 30 eggs, the digestive tract is male, and the egg size is (131 ~ 183) m × (40 ~ 70) m. End thorn, egg shell acid-fast staining negative, while other schistosomiasis egg shells are positive for acid-fast staining, adult parasitic in the human bladder and pelvic venous plexus, and even parasitic in the portal system, females lay 200 to 500 eggs per day Adults live in the human body for 3 to 6 years, and each can live for 30 years (average 3.4 years). A pair of adults lay eggs between 250,000 and 600,000 in their lifetime.
The schistosomiasis of Egypt has two stages of sexual reproduction and asexual reproduction. The former is carried out in the human body. After the females discharge the eggs, some of them are deposited in human tissues, and some are excreted. When the eggs are exposed to water in vitro, the eggs are quickly hatched. And swim into the water, and quickly find its specific intermediate host snail, and from the soft tissue of the snail into the snail to develop into the mother cell, the scorpion scorpion and the scorpion, each cell can produce 20 to 40 or more Cytoplasmic, each cell sputum produces 200 to 400 scorpions, and the time required for the burrs to penetrate the snail to the scorpion is 5 to 6 weeks.
After the scorpion escapes from the snail, it floats on the surface of the water to find the final host. After encountering the mammal, it digs into the skin horny according to its head, and its tail swings and the body expands and contracts. The scorpion is drilled in seconds to minutes. The skin mucosa, and according to its secretions, assists the worm into the capillaries or lymphatic vessels and then enters the lungs, passes through the pulmonary capillaries into the systemic circulation, and finally settles in the venous plexus of the bladder and pelvis. The Schistosoma japonicum and other schistosomiasis have their own The mechanism of the colonization site has not yet been elucidated. In 1990, authors reported that different species of schistosomiasis such as indirect schistosomiasis, Schistosoma japonicum, etc. in animals, snail hybridization can change the oviposition site of adult worms, escape method and reproduction of cercariae Forces have also changed.
The pathogenic effect of schistosomiasis on human body is obvious, and the pathogenic parts of various schistosomiasis are different. It is confirmed in experimental animals that about 20% of the eggs of Egyptian schistosomiasis are present in hollow organs, and some eggs can be excreted from urine or feces. The eggs are deposited locally or along the bloodstream to the lungs, liver, etc., and tiny emboli are formed in the local small blood vessels. If they are deposited locally, they are destroyed in the host's granulation tissue reaction, and other eggs are calcified. Accumulated in organs, each female calculates approximately 90 to 100 calcified eggs per day.
(two) pathogenesis
A large number of eggs are deposited in the bladder and distal ureteral mucosa and muscle, causing eosinophilic granuloma, and soon the bladder mucosa thickens and ulcers. In chronic infection, the entire bladder is invaded, fibrosis and scar formation. As the fibrous tissue shrinks, the bladder capacity becomes smaller, and the bladder contracture is formed. The ureteral orifice may lose the flap due to stenosis or dilation of the bladder fibrosis, causing obstruction or urinary reflux, leading to ureter and hydronephrosis, and the ureter may also be caused by eggs. Deposition of granuloma causes ureter stenosis, fibrolipoma can be formed around the ureter and bladder, and compression of the ureter can increase ureteral obstruction. For example, secondary bacterial infection can cause pyelonephritis or even pus and kidney, affecting renal function, about 10%. The patient may have a kidney, a ureter or bladder stone due to obstruction and infection, a fistula may occur between the genitourinary tract or between the small intestine of the urinary tract.
Egyptian schistosomiasis can also affect the prostate, seminal vesicles, cervix, vagina, labia, ovary or fallopian tubes. Eggs can also be deposited in the cecum, colon, rectum, liver, lung, brain and spinal cord. It has been reported due to schistosomiasis. Oval-induced lymphatic obstruction leads to elephantiasis in the external genitalia. The eggs reach the lungs with the blood circulation, which can cause miliary granuloma in the lungs. Chronic pulmonary hypertension and pulmonary heart disease caused by repeated embolization of pulmonary arterioles. Although the egg discharge is reduced after puberty in the endemic area, if the disease is not treated, the lesion can continue to develop, and the bladder is more common due to the long-term involvement of the bladder.
Prevention
Urogenital schistosomiasis prevention
Snail
In Africa, the combination of water conservancy construction and the use of snail-killing drugs has been adopted. The intermediate host density of snails has been greatly reduced in the rivers during the dry season, but there are still a few snails that lurk in the soil voids or shades. After the dry season, Re-breeding and becoming a medium of communication, the work of snail-killing must be repeated.
2. Large-scale treatment
In Egypt, chemotherapy (praziquantel), which has been used for a large population, has not been successful in eradicating this disease, mainly because it cannot prevent reinfection, and it is administered orally with praziquantel 40 mg/kg. Good curative effect and less toxic side effects are effective for social control of this disease.
3. Improve environmental sanitation
Such as strengthening the management of manure, to achieve safe water, to prevent human-spiral infection, but it is not easy to do, and it is expensive.
The prevention and treatment of this disease requires long-term publicity and education for residents in the epidemic areas. People are the only source of infection. Therefore, it is responsible for maintaining the life cycle of schistosomiasis in Egypt. Only on the basis of social and economic improvement, can we control and eliminate this disease.
Complication
Urogenital schistosomiasis complications Complications Chronic pulmonary heart disease
The main complications of this disease include upper urinary tract hydrops caused by ureteral obstruction, infection and stones, and bladder contracture and reproductive system lesions. Schistosomiasis eggs can enter the brain and spinal cord with the circulatory system to produce ectopic damage, which can be complicated by severe neurological complications; the eggs that enter the lung through the collateral circulation can be complicated by pulmonary arteritis and even pulmonary heart disease.
Symptom
Urinary genital schistosomiasis symptoms common symptoms dysuria abscess weight loss urinary frequency urine acute desire to reduce bacterial infection urinary incontinence loss of appetite vaginal discharge
1. Occipital dermatitis The cercaria penetrating skin is often not found, but when a large number of cercariae enter the human body at one time, skin allergic reactions may occur, skin itching, erythema or urticaria may occur for several days.
2. Invasion or toxemia refers to the process of development of adult worms into adults. About 2 weeks, there are seasonal differences. If a large number of worms reach the lungs at the same time, it can cause spastic cough, asthma, chest pain and other symptoms. , but often because of mild symptoms, short-term and not noticed, more common is long-term high fever, up to 38 ~ 40 ° C, with chills, sweating, headache, back pain, etc., lasted for several days to 3 to 4 months When the high fever lasts for a long time, there is mental wilting, unresponsiveness, loss of appetite, weight loss and anemia, indicating that the condition is critical, physical examination: liver, spleen moderate swelling, may have tenderness.
3. Symptoms The genitourinary symptoms that occur during this period are caused by adult ovulation in the bladder, ureteral wall and reproductive system. The granuloma is formed by the infiltration of large numbers of eosinophils, macrophages and histiocytes. Surrounded by this, the granulation tissue is gradually invaded by fibroblasts to form scars, followed by the death and calcification of the eggs, causing serious diseases of the genitourinary organs, such as urinary tract stenosis and bladder contracture.
(1) Bladder lesions: early symptoms are microscopic hematuria, gradually develop into frequent urination, dysuria, urgency, suprapubic and low back pain, heavier hematuria, typical end-stage hematuria, whole-course hematuria, bladder lesions Can be divided into 3 stages:
Stage 1: Stress bladder, bladder muscle hypertrophy, susceptible to irritability contraction, temporary compression of the wall ureter, ureteral fistula contraction, increased ureteral and renal pelvis pressure, causing non-calculus renal colic.
Stage 2: Bladder weakness, bladder muscle fibrosis affects bladder contraction. If the lesion continues to develop, the bladder wall becomes thinner and dilates, forming a posterior sag of the triangle. If the bladder neck becomes fibrotic and becomes narrow, it is more difficult to urinate. The bladder wall has pseudo-diverticulosis. When the detrusor is decompensated, residual urine begins to form. When there is too much excess urine, pseudo-urinary incontinence occurs, and the posterior sag of the triangle is formed.
Stage 3: The contracture bladder shrinks due to fibrosis and scar formation of the bladder wall, and the bladder capacity gradually becomes smaller. At this time, frequent urination, increased dysuria, and severe bladder neck contraction may have retrograde ejaculation, bladder, bladder neck, The ureter can have calcification.
(2) ureteral lesions: the most common ureteral invasion of the bladder wall segment, can also invade the lower ureter, ureter fibrosis, stenosis, ureteral dilatation, distortion, regurgitation and calcification, fibrous fat around the bladder and ureter Tumor disease, compression of the ureter, aggravation of stenosis, ureter and hydronephrosis above the stenosis, 96% of schistosomiasis in Egypt have vesicoureteral reflux, more serious ureter and hydronephrosis, kidney formation scar, atrophy, calcification and stone formation, About 84% of the bacterial infections lead to pyelonephritis, and severe cases form pus.
(3) urethral lesions: vaginal nodules and ulcers may appear in the posterior urethra; anterior urethra may cause stenosis due to secondary infection, inflammation around the urethra, abscess around the urethra and urinary fistula.
(4) genital lesions: the muscle wall of the seminal vesicle may have schistosomiasis egg deposits, which can enlarge the seminal vesicle, form and harden the nodules, and the lesions extend to the mucosa of the sac wall. When the ulcer occurs, the blood is fine, and the secondary infection is followed by fiber. Chemical, the seminal vesicle becomes smaller, atrophy, calcification, can lead to infertility.
Schistosomiasis eggs can also be deposited in the prostate, mostly in the urethral mucosa of the prostate. The venous plexus of the prostate can also have schistosomiasis nodules. These nodules are often misdiagnosed as stones, tuberculosis or malignant changes. Most of the symptoms are low back pain, perineal pain and urethra. Pain, advanced prostate fibrosis, loss of libido, premature ejaculation and erectile dysfunction, easily misdiagnosed as chronic prostatitis, often requiring prostate biopsy to confirm the diagnosis.
Occasionally epididymis, testicular schistosomiasis granuloma, Egyptian schistosomiasis more common in adult female vulva and lower vagina, can also be found in the cervix, uterus, ovary and fallopian tubes, lesions are mostly ulcers and granuloma, symptoms are purulent vaginal discharge, sexual intercourse After bleeding.
Examine
Examination of genitourinary schistosomiasis
Urine microscopy showed red blood cells, white blood cells, 24h urine or terminal urinary centrifugation, urinary sediment can find schistosomiasis eggs; fecal sedimentation method can sometimes find eggs.
Cystoscopy
The bladder capacity is reduced, and the schistosomiasis of the bladder mucosa is specifically changed. The eggs deposited in the early bladder submucosa are scattered in gray-white particles such as sand-like particles, and the mucosa around the particles is congested. Each particle is equivalent to a granulation with eggs as the core. Swelling, the calcification of the late egg is pale, and the bladder mucosa is frosted or erythematous. It may have ulcers, the edge of the ulcer is not complete, the base is pale, the surrounding mucosa is congested, and there may be a tumor-like granuloma, which is round and has Stipple or no pedicle, redness, easy bleeding, mostly occurs in the bottom of the bladder or in the triangle. Due to long-term chronic stimulation, the mucosa produces proliferative lesions such as cystic cystitis, cystitis glandularis, multiple schistosomiasis polyps, etc. Malignant changes, bladder neck contracture narrowed, bladder mucosa can form trabeculae and pseudodural diverticulum, often combined with bladder stones, late bladder mucosa thickening, mucosal polyps-like changes, ureteral opening is small, or dilated into a hole.
2. A biopsy can be confirmed by cystoscopy.
3. X-ray inspection
KUB flat film, bladder and ureter can be line-like calcification is a characteristic change of this disease, when the bladder is empty, it is wide and narrow horizontal calcification; when the bladder is full, it is eggshell-like calcification, ureteral calcification often coincides with bladder calcification Exist, more common in the lower ureter, sometimes can affect the full length of the ureter, ureteral wall is line-like calcification, also spotted or plaque calcification, occasionally renal pelvis, renal calcification, often combined with urinary calculi.
4. Venous urography
Often showing renal retardation, hydronephrosis, ureteral tortuosity, dilatation, and even as thick as the small intestine, ureteral wall segment or lower stenosis.
5. Cyst angiography
When there is a schistosomiasis granuloma or a polypoid change, nodular filling defects of varying sizes can be seen, the bladder capacity is reduced and the ureter has reflux.
6. Urethral angiography
Visible urethral stricture or urinary fistula.
Diagnosis
Diagnosis and identification of genitourinary schistosomiasis
diagnosis
The purpose of diagnosis is as follows: whether the patient is in the current infection or is infected in the past; is schistosomiasis or schistosomiasis in Germany; determines whether it is active or inactive; clear the degree of infection; evaluate the severity of sequelae And complications.
Differential diagnosis
Acute pyelonephritis
Also manifested as fever, low back pain, fatigue, loss of appetite and other systemic symptoms and urinary tract irritation, but the patient has no history of exposure to water, physical examination of normal kidney size, urine routine examination of pus cells and a large number of white blood cells can not find eggs.
2. Renal amoebiasis
Also manifested as frequent urination, urgency, dysuria with chills, high fever, but can have rice soup urine, jam-like urine, and persistent dull pain or severe pain in the kidney, amebic trophozoites or cysts can be found in the urine And no eggs.
3. kidney tuberculosis
Also manifested as repeated frequent urination, urgency, pyuria, hematuria accompanied by hypothermia and weight loss, but patients often have a history of tuberculosis, erythrocyte sedimentation rate (erythrocyte sedimentation rate) and urinary sediment smear acid-fast staining can be found acid-fast bacilli, but in No eggs were found in the urine.
4. Ureteral stones
There are typical signs of ureteral obstruction such as renal colic and hydronephrosis. It must be differentiated from renal colic caused by schistosomiasis and ureteral lesions. The patients have a history of kidney stones and a history of stone discharge. Most of them have sudden onset, urine. Check for red blood cells, but can not find schistosomiasis eggs, X-ray or B-ultrasound can be found in the ureter increased density or light group, no ureteral stenosis changes.
5. Acute cystitis
There are also frequent urination, urgency, dysuria, hematuria and suprapubic area pain symptoms, similar to schistosomiasis bladder lesions, but often tired, cold after the onset, without kidney, ureteral hydrops and bladder shrinkage, The patient has no history of exposure to water, urine can not find schistosomiasis eggs, no thickening of cysts, ulcers, egg granuloma and polyps, bladder biopsy can provide a basis for identification.
6. Bladder amebiasis
Also manifested as hematuria, frequent urination, urgency, dysuria, but echinococcosis patients may have rice soup-like urine, jam-like urine, in the urine can be found in the amebic trophozoites or cysts without eggs.
7. bladder tuberculosis
Frequent urination, urgency, dysuria and hematuria symptoms, may be accompanied by kidney, ureteral hydrops and bladder contracture signs, similar to schistosomiasis bladder disease, but patients often have a history of tuberculosis, no history of exposure to water, bladder irritation Progressive aggravation with pyuria, continuous urinary sediment smear acid-fast staining can be found in acid-fast bacilli, X-ray, B-ultrasound, CT and other examinations show side renal tuberculosis lesions, cystoscopy can find tuberculous nodules.
