Vulvar tuberculosis

　　1. Etiology

　　Vulvar tuberculosis usually originates from genital tuberculosis or renal tuberculosis, or may be infected through external contact such as sputum or sexual intercourse (primary vulvar tuberculosis). A few cases of vulvar tuberculosis may not find an original tuberculosis focus. Vulvar tuberculosis in children is often due to parental tuberculosis and contact infection. Tuberculosis bacilli from internal tuberculosis foci can spread directly to the vulvar mucosa through blood vessels, the lymphatic system, or adjacent tuberculosis foci. When there is active tuberculosis in the viscera and the patient has a low resistance to tuberculosis, tuberculosis bacilli in the body excretions can infect oropharyngeal cavities through skin or mucosal injuries.

　　2. Pathogenesis

　　Pathological changes commonly show macrophages and caseous necrosis. Smears or cultures of pus can detect acid-fast bacilli. Tuberculosis bacilli are aerobic and have high nutritional requirements. Under good conditions, they still grow slowly, taking 18-24 hours to reproduce one generation (usually bacteria reproduce every 20 minutes). The pathogenic bacteria are human and bovine tuberculosis bacilli, with the former first infecting the lungs and the latter initially infecting the gastrointestinal tract, then spreading to other parts of the body through various routes, including the vulva. When the inguinal lymph nodes are involved, they can become suppurative and then form scars. Lesions transmitted through sexual contact due to the spouse having epididymal tuberculosis or renal tuberculosis often occur on the labial frenulum. The body's resistance to tuberculosis bacilli, allergic reactions, the number of bacteria侵入, and their toxicity are related to the severity of the disease.

　　Vulvar tuberculosis is divided into two types: ulcerative and proliferative. Vulvar ulcers often appear and do not heal for a long time. Vulvar tuberculosis commonly occurs on the labia minora or vaginal mucosa, developing slowly. The ulcerative type initially presents as red papules or a localized small nodule, but quickly breaks down to form an ulcer. The edges are soft, thin, and irregular. Or present as harder elliptical ulcers with an uneven base. The ulcer surface is covered with pale granulation tissue overlying yellow caseous material. The lesion can spread to the perineum, urethra, and anus, forming fistulas and causing deformation of the labia.

　　Local lymph nodes often swell, or secondary vulvar and lower limb lymphedema may occur. Vulvar tuberculosis itself does not cause pain, but friction or urinary stimulation can trigger severe pain.

　　It often occurs with visceral tuberculosis, such as pulmonary tuberculosis, renal tuberculosis, and infertility.

　　Vulvar tuberculosis is divided into two types: ulcerative and proliferative. Vulvar ulcers often appear and do not heal for a long time. Vulvar tuberculosis commonly occurs on the labia minora or vaginal mucosa, develops slowly, and the ulcerative type initially presents as red papules or a localized small nodule, but quickly breaks down to form an ulcer. The edges are soft, thin, and irregular, or present as harder elliptical ulcers with an uneven base. The ulcer surface is covered with pale granulation tissue overlying yellow caseous material. The lesion can spread to the perineum, urethra, and anus, forming fistulas and causing deformation of the labia. Local lymph nodes often swell, or secondary vulvar and lower limb lymphedema may occur. Vulvar tuberculosis itself does not cause pain, but friction or urinary stimulation can trigger severe pain. The proliferative type resembles vulvar elephantiasis, with thickening and swelling of the vulva, difficulty in urination, and sexual inconvenience or pain during intercourse.

　　1, Supportive therapy: Acute patients need to rest in bed for 3 months, chronic patients can engage in some light work, but attention should be paid to the combination of work and rest, strengthen nutrition, and participate in appropriate physical exercise.

　　2, Early prevention and vaccination: Exercise the body, enhance the body's resistance, and prevent infection with tuberculosis bacilli.

　　3, Prognosis: After careful and comprehensive treatment, there is no adverse prognosis.

　　1, Pus smear:Tuberculosis bacilli can be found, the tuberculosis test is positive, the white blood cell count shows an increase in lymphocytes, the erythrocyte sedimentation rate is fast during the active stage, and pathological tissue examination can be diagnosed if tuberculous lesions are seen in the sections. However, if there are no tuberculous lesions but giant cell systems are present, it cannot be denied that tuberculosis does not exist. A re-examination after 3 months is required, and if the endometrial examination is negative for 3 times, it can be considered that there is no endometrial tuberculosis.

　　2, X-ray examination:Chest X-ray: Necessary to take X-rays of the gastrointestinal and urinary systems to detect the primary focus of the disease, but some patients may have healed primary foci when they have genital tuberculosis.

　　First, the dietary therapy for vulvar tuberculosis:

　　1, Almond and coix seed egg soup

　　Almond 30 grams, coix seed 60 grams, fresh eggs 3, fish-mercury grass 50 grams, jujube and honey as needed. Wash the coix seed, almond (mashed), and jujube (with the seeds removed) and place them in a pot, add 1000 milliliters of water, bring to a boil over high heat, then simmer over low heat for 1 hour; boil the fish-mercury grass in another pot for 30 minutes, strain the juice into the eggs and honey, mix with the coix seed, almond, and jujube soup, stir well and set aside. Serve with meals, 1-3 times a day, 150-200 milliliters each time. It can clear lung heat and nourish lung Yin. It is suitable for lung pain caused by dryness (symptoms include expectoration of sputum mixed with blood, persistent cough, chest pain, restlessness, thirst, dry throat, night sweats, and weight loss); it is commonly used in the treatment of tuberculosis, lung abscess, emphysema, bronchiectasis, and chronic bronchitis in patients with dry heat and excessive phlegm, and lung Yin injury.

　　2, Lily and white fungus beef soup

　　Lily, white fungus each 60 grams, jujube 15 pieces, beef 400 grams, ginger 5 slices, a little salt. Rinse the beef with boiling water, cut into thin slices; remove the shell of the white fungus, soak in hot water to remove the outer film, then rinse with clean water; wash the lily, jujube (with the seeds removed), ginger (5 slices) and place them in a pot, add 500 milliliters of water, boil over high heat first, then add the lily, jujube, white fungus, and ginger slices, and cook the lily over medium heat until it is tender, add the beef, continue to simmer until the beef is cooked, and add salt to taste. Serve with meals, 1-3 times a day, 150-200 milliliters each time. It can nourish the blood and Yin, moisten the lungs and tonify Qi, stop asthma and涩 essence. It is commonly used in the treatment of tuberculosis due to spleen and lung Qi deficiency, with symptoms such as coughing and expectoration, insufficient middle Qi, hoarseness, frequent nocturnal urination, irregular menstruation, and excessive leukorrhea.

　　3, Sheep Lung Persimmon Frost Almond Soup

　　1 sheep lung (about 500 grams), 30 grams of persimmon frost, 30 grams of almonds, 30 grams of ghee, 60 grams of honey. First, peel the almonds and grind them into fine powder, mix them with persimmon frost and ghee in a bowl, add honey and mix well, then add a little clear water while mixing, wait until the above four drugs are evenly mixed into a thick juice for later use; wash the sheep lung clean with clear water, squeeze out the blood, and then pour the above thick medicine juice into the sheep lung, add 600 milliliters of water, steam-bake it until it is cooked. It can be eaten with meals, 1-3 times a day, 150-200 milliliters each time. It can nourish yin and moisten dryness, clear heat and stop coughing, invigorate the qi and nourish the blood; suitable for long-term illness, Yin deficiency and internal dryness, lung heat caused by lung damage, dry lips, and emaciation, and so on; it is often used in clinical food therapy for pulmonary tuberculosis, emphysema, bronchitis, bronchial asthma, and cardiopulmonary disease.

　　4, White-bud Silver Ear Soup

　　30 grams of white-bud, 50 grams of silver ear, 30 grams of almonds, 300 grams of water caltrop, 30 grams of water caltrop powder, and an appropriate amount of rock sugar. First, wet the water caltrop powder and rock sugar with water, peel and wash the water caltrop, cut it into small pieces; soak the silver ear, almonds, and white-bud in water for 2 hours, wash them clean, put them into a pot, add 500 milliliters of clear water, boil it with high heat first, then simmer it for 4 hours with low heat, and then add the water caltrop pieces, wet rock sugar, and water caltrop powder in order. It can be eaten with meals, 1-3 times a day, 150-200 milliliters each time. It can clear the lung and moisten dryness, consolidate the lung and stop coughing; suitable for patients with pulmonary tuberculosis (with symptoms such as shortness of breath, sputum with blood, shortness of breath, weakness, or accompanied by low fever).

　　5, Bird's Nest Rock Sugar Soup

　　6 grams of bird's nest, 12 grams of rock sugar. First, put the bird's nest in a bamboo steamer, add warm water to soak it soft, use tweezers to pick out the bird's feathers, wash it clean with clear water, drain the water, tear it into thin strips, and place it in a bowl; dissolve rock sugar with about 200 milliliters of boiling water, filter out impurities, and boil with the bird's nest in a pot. It can be eaten with meals, 1-3 times a day, 150-200 milliliters each time. It can nourish the lung and moisten dryness, resolve phlegm and stop coughing; suitable for symptoms such as Yin deficiency and lung dryness, dry mouth and nose, emaciated cough, and sputum with blood丝; it is often used in clinical treatment for food therapy in pulmonary tuberculosis, bronchiectasis, and lung abscess.

　　6, Sheep骨髓生地羹

　　The composition includes 50 grams of sheep spinal cord, 50 grams of honey, 10 grams of raw earth, 15 grams of cooked sheep lard oil, 25 grams of yellow wine, a small amount of ginger strips, and a small amount of table salt. The preparation method is to first put the sheep spinal cord and raw earth into the pot, cook the soup until it is well-cooked, remove the medicinal residue, and then add cooked sheep lard oil, table salt, ginger strips, yellow wine, honey, and heat until boiling. The indications are nourishing yin and clearing heat, stopping cough and resolving phlegm. It is suitable for symptoms such as low fever, cough, and sputum in pulmonary tuberculosis. The usage is to eat in one sitting or in several sittings.

　　7. Silver ear pigeon egg porridge

　　The composition is 2 grams of silver ear, 20 grams of rock sugar, and 1 pigeon egg. The preparation method is to soak the silver ear in water for 20 minutes, knead it into pieces, add 400 grams of water, boil with high heat, then add rock sugar, and simmer with low heat until it is tender; then crack the pigeon egg, steam it with low heat for 3 minutes, and then put it into the cooked silver ear porridge, and boil it. Indications include nourishing yin and moistening the lungs, benefiting the stomach and generating fluid. Suitable for dry cough in tuberculosis. The usage is to drink the soup and eat the silver ear and pigeon egg.

　　8. Carrot honey soup

　　The composition is 1000 grams of carrot, 100 grams of honey, and 3 grams of alun. The preparation method is to clean and slice the carrots, add 350 grams of water, boil for 20 minutes, remove the residue, add honey and alun, stir well, and then boil for a moment. Indications include reducing phlegm and stopping cough. Suitable for symptoms such as white sputum cough and hemoptysis in tuberculosis. The usage is to take 3 times a day, 50 grams each time.

　　9. Turtle yin soup

　　The composition is 250 grams of turtle meat, 9 grams each of baical Skullcap, Cortex mori, and Anemarrhena, 24 grams of raw rehmannia, and an appropriate amount of table salt. The preparation method is to scald the turtle to death in a pot of boiling water, cut off the head and claws; peel off the hard shell, remove the internal organs, clean them, and cut them into 1 cm square pieces. Then, put them together with the cleaned baical Skullcap, Cortex mori, Anemarrhena, and raw rehmannia into a pot, add an appropriate amount of water, boil with high heat, then switch to low heat to simmer for 2 hours, and add table salt for seasoning. Indications include nourishing yin and clearing heat, anti-aging. Suitable for yin deficiency with symptoms such as night sweats, feverishness, and hot palms and soles. The usage is to take it with meals, 1 dose per day.

　　10. Chicken liver and oyster coral decoction

　　The composition is 1-2 chicken livers, 15-24 grams of fresh oysters, and 12-15 grams of coral. The preparation method is to clean and cut the chicken livers, crush the fresh oysters and coral; first decoct the oysters and coral for 60 minutes, then add the chicken liver, and after the chicken liver is cooked, remove the soup for drinking. Indications include tonifying the liver and kidneys, resolving phlegm and reducing sputum. It is suitable for chronic cough with fever, malnutrition, tuberculosis, lymphatic tuberculosis, etc. The usage is to take 1 dose per day.

　　Second. What foods are good for the body when consuming vulvar tuberculosis?

　　1. Eat more foods rich in protein and carbohydrates. For example: milk, soy milk, eggs, meat, etc.

　　2. Drink plenty of water and eat fresh fruits and vegetables, such as apples, pears, bananas, strawberries, kiwi, cabbage, green vegetables, rapeseed, mushrooms, seaweed, and kelp, etc.

　　3. For pain, eat cuttlefish, red crabs, lobsters, sea cucumber, bream, beetroot, mung beans, radish, chicken blood, etc.

　　4. For itching, eat amaranth, cabbage, rapeseed, taro, seaweed, purple seaweed, chicken blood, snake meat, pangolin, etc.

　　5. Prefer cool blood and detoxifying foods, such as mung beans, glutinous rice, cucumbers, bitter melon, portulaca, green tea, etc.

　　Three. What foods should be avoided for vulvar tuberculosis?

　　1. Avoid foods that activate the body, such as fish, shrimp, crab, chicken heads, pork heads, goose meat, chicken wings, chicken feet, etc., as they can worsen itching and inflammation in the vaginal area.

　　2. Avoid astringent and涩敛 foods, as they are prone to cause blood stasis and qi stagnation. Spicy and warm foods are beneficial for promoting blood circulation, and can be consumed, but not excessively, as excessive spiciness and stimulation can worsen pain.

　　3. It is recommended to eat less or no spinach. If it is unavoidable, you can blanch the spinach in boiling water first to dissolve some oxalic acid into the water, then remove it for consumption. This can reduce the intake of oxalic acid by the human body to some extent.

　　4. Avoid eating greasy, smoked, and fried foods, avoid smoking and drinking, and avoid eating warm-acting foods such as rooster and lamb.

　　5. Avoid eating fried and greasy foods. Such as oil sticks, butter, butter, chocolate, etc., these foods have the effect of promoting dampness and increasing heat, which can increase the secretion of leukorrhea and is not conducive to the treatment of the disease.

　　6. Quit smoking and drinking. Smoking and drinking are very irritating and can exacerbate inflammation.

　　First, precautions before the treatment of vulvar tuberculosis

　　Before treatment: It is necessary to have a detailed understanding of the symptoms of the disease and related contraindications.

　　Second, traditional Chinese medicine treatment methods for vulvar tuberculosis

　　The prescription is: 15g of raw earth, 15g of kelp, 15g of seaweed, 10g of bletilla striata, 10g of white peony, 10g of toon wood, 15g of hawthorn, 15g of salvia miltiorrhiza, 15g of pericarpium perillae, 15g of lycium barbarum, 10g of tortoise shell, 15g of patrinia scabiosaefolia, 15g of red peony, 1 dose/d, taken in 2 to 3 doses.

　　Third, Western medical treatment methods for vulvar tuberculosis

　　1. General treatment

　　The treatment of tuberculosis should follow the principles of early treatment, combination, regularity, appropriate dosage, and full course. In recent years, the combination of rifampicin, isoniazid, ethambutol, and pyrazinamide, among other antituberculosis drugs, has shortened the treatment course to 6 to 9 months, achieving good efficacy. Common antituberculosis drugs are as follows:

　　(1) Rifampicin: It has a significant bactericidal effect on Mycobacterium tuberculosis. Its action is similar to that of isoniazid, stronger than that of streptomycin and ethambutol, and has no cross-resistance with other antituberculosis drugs. It is often used in combination with isoniazid and ethambutol to enhance and delay the development of resistance. It is absorbed orally at 90% to 95%, with a half-life of 2 to 5 hours and effective serum concentration maintained for 6 hours. The dose is 450 to 600mg/d, taken in one dose before breakfast for easy absorption. Adverse reactions are mild, mainly liver damage, and there is a potential risk of fetal malformation in pregnant women, so it should be avoided in the early stages of pregnancy.

　　The action, efficacy, and adverse reactions of rifapentine are similar to those of rifampicin, with a dose of 150 to 200mg/d, taken in one dose before breakfast. It has cross-resistance with rifampicin. Pregnant women should also avoid its use.

　　(2) Isoniazid: It has a strong bactericidal effect on Mycobacterium tuberculosis, with a small dose, minor oral adverse reactions, low cost, and is a widely used antituberculosis drug. When used in combination with other antituberculosis drugs, it can reduce the development of resistance and has a synergistic effect, improving efficacy. The dose is 300mg/d, taken in one dose.

　　(3) Streptomycin: Intramuscular injection, once a day. It is easy to develop resistance when streptomycin is used alone and is often used in combination with other antituberculosis drugs. Long-term use may cause dizziness, numbness of the mouth and limbs, tinnitus, and in severe cases, deafness. Elderly women should use it with caution.

　　(4) Ethambutol: It has inhibitory effect on Mycobacterium tuberculosis, has no cross-resistance with other antituberculosis drugs, and can enhance efficacy when used in combination, delay the development of resistance, and is absorbed orally at about 80%. The dose is 0.5 to 0.75g/d. The main adverse reaction is posterior optic neuritis, with an incidence rate of 0.8%, which is more likely to occur at high doses and can usually recover after discontinuation.

　　(5) Pyrazinamide: dose of 1.5g/d, taken in 3 doses orally. It has a high toxicity, is prone to develop drug resistance, and has less antibacterial effect than streptomycin. However, it is effective against slowly growing tuberculosis bacteria within cells, and can shorten the treatment course when used in combination with other antituberculosis drugs.

　　The currently implemented short-course treatment plan:

　　① Take streptomycin, rifampin, isoniazid, and pyrazinamide together every day for 2 months, and then take isoniazid and rifampin continuously for the next 4 months.

　　② Take streptomycin, rifampin, isoniazid, and pyrazinamide together every day for 2 months, then take isoniazid, rifampin, and ethambutol 3 times a week for 6 months.

　　③ Take streptomycin, rifampin, isoniazid, and ethambutol orally every day for 2 months, then take isoniazid and rifampin 3 times a week for 4 months. This includes systemic supportive therapy and antituberculosis drug treatment. Antituberculosis drug treatment, such as streptomycin, isoniazid, and para-aminosalicylic acid, is effective, and the two drugs or three drugs can be used together. Streptomycin is injected intramuscularly at 0.5g, twice a day, for 2-3 months, and then injected 2-3 times a week, with the total dose depending on the condition, with a minimum of 30g. Isoniazid is taken orally at 100mg, 3 times a day, and can be used for 1 year. The dosage of para-aminosalicylic acid is 8-12g/d, taken in 4 doses. Pay attention to the side effects of the drugs during the treatment process.

　　2. Local treatment

　　Locally keep dry, clean, and try to avoid secondary infection by other pathogens; if the lesions can be completely removed in one operation, local lesion resection should be performed on the basis of systemic antituberculosis treatment.

　　3. Surgical treatment

　　Surgical resection should be performed when necessary.

　　(1) Timing and preparation for surgery: Generally, antituberculosis drugs are used for 1-2 months before surgery to prevent the spread of infection during surgery. Due to the adhesions caused by genitourinary tuberculosis, they are often extensive and tight, so enteric disinfection drugs should be taken orally and clean enemas should be performed before surgery.

　　(2) Postoperative medication: Generally, patients have already taken 1 course of chemotherapy before surgery. If the uterus and both sides of the adnexa are completely removed during surgery, in addition to the need to continue antituberculosis drug treatment for pulmonary or other organ tuberculosis, general postoperative medication can be given for about 1 month.