19歳で発症した膀胱結核 : 我が国の新しい結核医療の基準に沿った尿路結核の治療  [in Japanese] A CASE OF BLADDER TUBERCULOSIS WITH ONSET AT THE AGE OF NINETEEN : TREATMENT OF URINARY TRACT TUBERCULOSIS IN ACCORDANCE WITH THE NEW JAPANESE TUBERCULOSIS TREATMENT GUIDELINES  [in Japanese]

24歳男性.19歳時より年に数回,肉眼的血尿と排尿痛の増悪を認めていたが放置していた.21歳時当科初診し急性膀胱炎の診断で抗生剤を投与された.しかし,症状持続するも放置していた.24歳時頻尿増悪し,紹介医を受診,難治性のため検査を施行された.経直腸超音波検査で膀胱壁の肥厚・右側膀胱頚部の陥凹・左膀胱頚部から側壁の腫瘤状所見を認め当科紹介.紹介医から尿結核菌陽性との報告を受け,リファンピシン(RFP),イソニアジド(INH),ピラジナミド(PZA)の3剤を2ヵ月,続いてRFP,INHの2剤を4ヵ月投与した.治療開始1ヵ月後より頻尿が著明に改善され,4ヵ月後の膀胱容量は420mlであった.現在外来経過観察中であるが再発を認めていない.私共が調べ得た限りでは,自験例は10代発症の尿路結核として1995年以降9例目であった.結核予防法施行規則第22条の規定により,結核医療の中核をなす化学療法,外科的療法等については厚生労働大臣の定める「結核医療の基準」によることとされており,2004年に改正されている.しかし,医師の「結核医療の基準」に対する意識の低さが指摘されている.尿路結核を診る機会が激減した現在,我々泌尿器科医は尿路結核の冶療もこの基準に準拠することを認識しなければならない.

A 24-year-old man experienced gross haematuria and dysuria several times a year from the age of 19, presenting to this Department for the first time at age 21, when he was given standard antibiotic treatment for acute cystitis. Although urinary symptoms persisted, he failed to attend for follow-up. He attended another clinic at the age of 24 with increased urinary frequency. Transrectal ultrasonography revealed thickening of the bladder wall, concavity of the right bladder neck, and nodular changes extending from the left bladder neck to the left bladder wall, so he was referred to this department for further investigation. Mycobacterium tuberculosis was detected in the urine by the referring doctor, so the diagnosis was made of bladder tuberculosis (TB). We treated him with rifampicin (RFP), isoniazid (INH) and pyrazinamide (PZA) triple therapy for 2 months, followed by RFP and INH dual therapy for 4 months. His urinary frequency improved markedly after one month, and his bladder capacity was 420ml after 4 months of treatment. After 2 and half year follow-up he remains well without any signs of relapse. To our knowledge, this is only the ninth case of teenage onset of urinary tract TB in Japan since 1995. As specified in Clause 22 of the Enforcement Regulations of the Tuberculosis Control Law, chemotherapy and surgical treatment of TB, the mainstays of treatment, should be administered in accordance with the 'Standards for the Treatment of Tuberculosis', issued by the Japanese Minister of Health and revised in 2004. The level of recognition of the 'Standards for the Treatment of Tuberculosis' is low, however. Although the incidence of TB of the urinary tract has dropped dramatically, as urologists we must be aware that treatment of this condition must be given in accordance with the Standards.