TUBERCULOSIS OF FEMALE GENITAL TRACT

Dr m.Indira mbbs dgo

1

Jr
IRT PMCH

INTRODUCTION
One

third of world population infected Life time risk of TB following infection ~5-10% Global emergency
India

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10 million new cases per year 3 million deaths every year

Drug

resistant TB HIV co-infection

14 million people 5-16% cases of infertility

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M TUBERCULOSIS

Aerobic bacillus Non-spore forming Non-motile Generation time: 12-20 hours

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Culture
3-6 weeks 1-2 weeks

SOURCE OF INFECTION

Always secondary. Primary focus- lungs, lymph node, urinary tract, bones and joint. Long latent period -10- 15 years . Menarche- increased chance of genital tuberculosis.

MODE OF SPREAD

Blood spread most common -90%. Direct spread from peritonium- bowel lesion lymphatics from mesentric nodes- 7%. Sexually transmitted- 1%.

PATHOLOGY
Fallopian tube 90% Uterus 60% Ovaries 30 % Cervix 1-2 % Vulva and vagina 1%

FALLOPIAN TUBE TUBERCULOSIS

By

blood spread Mostly bilateral Tuberculous endosalphingitis Submucosal layer of ampullary part Wall thickened enlarged tortous Initially fimbrial end open Caseation in the wall of the tube pyosapinx

FALLOPIAN TUBE
Tuberculous exosalphingitis Direct extension Peritoneal surface studded with miliary tubercles Tobacco pouch appearance-dilated distal end.

PATHOLOGY

UTERUS
70% Spread from tube Cornual end Tubercle situated basal layer Ashermans syndrome -Endometrial ulceration adhesion Pyometra- caseation material collects

OVARIES

Tubercles on the surface Adhesion Thickening of capsule Caseating abcess

CERVIX

5-10% Descending infection Intermenstrual bleeding or post coital bleeding Ulcer or red papillary erosion DD ca cervix Biopsy

VULVA&VAGINA

Rare Shallow painful ulcer undermined edge Hypertrophic Diagnosis by histology

CLINICAL FEATURES
Asymptomatic 10 Infertility 35-65 Menstrual abnormalities Menorrhagia Amenorrhoea Pain, dysmenorrhoea Tender fixed adnexal mass,abdominal mass Repeated PID Vaginal discharge Post coital bleeding

HYSTEROSALPINGOGRAM FINDINGS
Suspected genital TB avoid HSG Rigid non peristaltic pipe like tube. Beaded appearance ,calcification of tube Bilateral cornual block Jagged fluffiness of tubal outline Vascular lymphatic extravasation. Tobacco pouch appearance.

HYSTEROSALPINGOGRAM VIEW

Figure : 28-year-old woman with genital tuberculosis. 16 Hysterosalpingogram shows bilateral tubes convoluted and fixed. There is a loculated spill (small arrows) on the right side suggestive of adhesions.

RADIOGRAPHIC VIEW

Fig. 6. Radiograph demonstrates lymphatic extravasation, a deformed uterine cavity, and a narrow-rigid fallopian tube with a dilated and closed fimbrial end on the right side.

Fig. 8. The entire fallopian tube appears rigid and exhibits small terminal sacculations.
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DIAGNOSIS OF GENITAL TB
Mantoux ,ESR. Dilatation and curettage Cornual end Premenstrual HPE , BACTEC culture, PCR Diagnostic laparoscopy Biopsy X-RAY chest ,sputum AFB HIV ELISA

MANTOUX TEST
Diagnostic role of a positive Mantoux (PPD) is controversial Almost 45% of infertile women with strong indirect evidence of pelvic TB, such as laparoscopic findings (thickened tubes, areas of caseation, etc) - negative Mantoux In 27 infertile women with a positive Mantoux, only 11 had clear laparoscopic findings suggestive of FGTB Mantoux test in women with laparoscopically diagnosed tuberculosis sensitivity - 55% specificity - 80%

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MICROSCOPIC APPEARANCE OF TUBERCULAR LESION

Typical granuloma formed by lymphocytes,multinucleated giant cells,epitheloid cells, Surrounding central area of caseation.

TUBERCULOUS SALPINGITIS

Fig.. Tuberculous salpingitis. Chronic salpingitis due to tuberculosis presents the characteristic histologic features of the tuberculous granuloma: lymphocytes, epithelioid cell granulomata, and giant cells of both the Langerhans and the foreign body type are seen. Tuberculous infection of the fallopian tube often results in an adenomatous proliferation of the lining epithelium. This is seen on the left of this photomicrograph and may give rise to confusion with adenocarcinoma. (100.)

Fig Tuberculous salpingitis may contain Schaumann bodies, which are more characteristic of sarcoidosis than tuberculosis. These are conchoidal, laminated, calcified structures, usually surrounded by foreign body 21 giant cells. (100.).

TUBERCULOUS ENDOMETRITIS

Fig. 4. Tuberculous endometritis. Photomicrograph of a single tuberculous granuloma is seen on the left, consisting of central epithelioid cells, with a Langerhans-type giant cell surrounded by a cuff of lymphocytes. No central caseation is present. The surrounding endometrium appears completely normal; the glands are proliferative, and there is no infiltrate in the stroma, seen on the right. (100.)

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DIFFERENTIAL DIAGNOSIS
Ovarian cyst Pelvic inflammatory disease Ectopic pregnancy Carcinoma cervix Elephantiasis vulva Pregnancy

TREATMENT OF GENITAL TB
CHEMOTHERAPY WITH ATT INITIAL PHASE 2 MONTHS Isoniazid 5mg/kg Rifampicin 10mg/kg Pyrazinamide 25mg/kg Ethambutal 15mg/kg

CONTINUATION PHASE 4 MONTHS Rifampicin and INH biweekly Resistant cases with HIV -1 year

TREATMENT OF GENITAL TB
Patient considered cured if 2 histological and bacteriological reports are negative. DRUGS USED IN RESISTANT CASES Capreomycin Kanamycin Ethionamide Para-amino salicylic acid cycloserine

SURGICAL TREATMENT
INDICATIONS Progression of disease Persistent active lesion Pyosalpinx Pyometra Persistence of symptoms Persistence of fistula Surgery followed by full course chemotherapy.

SURGICAL TREATMENT
Totalhysterectomy oopherectomy Vulvectomy.

with

bilateral

salpingo

TUBOPLASTY IS CONTRAINDICATED Reactivation Fertility cannot be restored ART- IVF

PROGNOSIS
CURE RATE 90% FERTILITY 10% TUBAL PREGNANCY VERY HIGH ABORTION ALSO OCCUR ONLY 2 PERCENT HAVE LIVE BIRTHS

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