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جامعة بابل المرحلة الخامسة⁄ بطلا ةيلك
د
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نسرين مالك
Gynaecology
Genital Tract Tuberculosis:-
Genital tract tuberculosis is a chronic disease that is caused by Mycobacterium tuberculosis , it is
often presents with low grade symptomatology and very few specific complaints. Presenting
symptoms are generally varied; infertility being the most frequent clinical presentation (43-74%).
Other clinical presentations include oligomenorrhoea (54%), amenorrhoea , hypomenorrhea,
menorrhagia ,abdominal pain dyspareunia ,and dysmenorrhoea.
The actual incidence of genital TB cannot be determined accurately in any population because it is
estimated that at least 11% of patients are asymptomatic and the disease is discovered incidentally.
Pathogenesis:-
Genital TB is almost always secondary to TB elsewhere in the body, usually pulmonary and
sometimes renal, gastrointestinal, bone, or joint; occasionally it is part of a generalized miliary
disease process. If the bacilli are not eradicated, there is a lifelong risk of reactivation, especially in
conjunction with diseases or drugs that cause attenuation of T-cell response (e.g. Hodgkin’s
lymphoma, AIDS, steroids, stress, or malnutrition). The mode of spread is usually hematogenous or
lymphatic and occasionally occurs by way of direct contiguity with an intra-abdominal or peritoneal
focus. The focus in the lung often heals, and the lesion may lie dormant in the genital tract for years,
only to reactivate at a later time.
Frequency of tuberculosis in genital organ:-
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Frequency
Organ
Fallopian tubes 90-100
Endometrium 50-60
Ovaries 20-30
Cervix 5-15
Vulva and vagina 1
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Macroscopic appearance of genital tuberculosis:-
TB of fallopian tubes:-
Types of tuberculous salpingitis:- 1-Exudative 2-Productive Adhesive.
In subacute stage, there may be congestion, edema and adhesions in pelvic organs with multiple
fluid-filled pockets. There are miliary tubercles, white yellow and opaque plaques over the fallopian
tubes and uterus.
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In chronic stage, there may be following abnormalities
1-Yellow small nodules on tubes (nodular salpingitis).
2-Short and swollen tubes with agglutinated fimbriae (patchy salpingitis).
3-Unilateral or bilateral hydrosalpinx with retort-shaped tubes due to agglutination of fimbriae.
4-Pyosalpinx or caseosalpinx: The tube usually bilateral is distended with caseous material with
ovoid white yellow distension of ampulla with poor vascularization.
5-Caseous nodules may be seen.
Tuberculosis of the endometrium:-Grossly, the size and shape of the uterus may appear normal.
The tuberculous process generally is localized to the endometrium, is most extensive in the fundus,
and decreases toward the cervix. The myometrium is not usually involved. In premenopausal
patients, much of the infected tissue is shed during the menstruation, only to have the endometrium
reinfected from the tubes with each cycle. Endoscopic visualization of the uterine cavity in genital
TB may show a normal cavity (if no endometrial TB or early stage TB) with bilateral open ostia.
More often, however, the endometrium is pale looking, and the cavity is partially or completely
obliterated by adhesions of varying grade (grade 1 to grade 4) often involving ostia There may be a
small shrunken cavity.
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Tuberculosis of the ovary:-
Usually, the involvement is bilateral, although this cannot always be recognized with certainty at
laparotomy. Two forms of ovarian TB are described: perioophoritis, in which the ovary may be
surrounded by or encased in adhesions and studded with tubercles caused by direct extension from
the tube; and oophoritis, in which infection starts in the stroma of the ovary, presumably from a
hematogenous source that produces a caseating granuloma within the parenchyma.
Tuberculosis of the cervix:-There are no macroscopic changes in the cervix that are specific for TB.
The cervix may appear normal or inflamed, and its condition may resemble invasive carcinoma, both
grossly and with the colposcope. The most common type is the ulcerative form, although
papillomatous and miliary forms may also occur.
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Tuberculosis of the vulva and vagina:- In the vulva, it begins as a nodule on the labia or in the
vestibular region, which breaks down and forms an irregular ragged ulcer, sometimes with sinuses
discharging caseous material and pus. TB of Bartholin’s gland is rare. Rarely, a vulvar lesion
presents as a hypertrophic, irregular warty growth, or sometimes resembling elephantiasis.
A tuberculous lesion in the vagina may simulate carcinoma in its gross appearance.
The microscopic appearance is similar to TB occurring throughout the genital tract, with
granulomatous inflammation tending to cause central caseation and an associated chronic
inflammatory infiltrate
Tuberculous peritonitis:- is seen in combination with female genital tract TB approximately 45% of
the time and is thought to be responsible for the extensive adhesions seen in patients with pelvic TB.
Clinical findings:-
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Physical signs in genital tuberculos
1-Normal.
2-Abdominal mass.
3-Pelvic mass.
4-Adnexal mass.
5-Abdominal tenderness.
6-Pelvic/adnexal tenderness.
7-Ascites.
8-Excessive vaginal discharge.
9-Ulcer in the vulva, vagina, and cervix.
10-Enlarged uterus with pyometra.
11-Fistula.
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Symptom
1-Systemic: low grade fever,fatigue,weight loss.
2-Symptoms related to genital tuberculosis:
Infertility:- Primary, Secondary.
:
Menstrual disturbances
Amenorrhea,
Oligomenorrhea
Menorrhagia
Metrorrhagia,
3--Abdominal swelling.
4-Postcoital bleeding.
5-Vaginal discharge.
6-Dyspareunia.
Diagnosis:-
The diagnostic approach used is family history of TB or history of antituberculous
therapy (ATT) in a close family member or a past history of TB or ATT in the patient may show
recrudescence of TB in the genital region. History of HIV positivity is also important. Detailed
general physical examination for any lymphadenopathy and any evidence of TB at any other site in
body (bones, joints, skin, etc.), chest examination (PTB), abdominal examination (abdominal TB),
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examination of external genitalia (vulvar or vaginal TB), speculum examination (cervical TB),
bimanual examination (endometrial or fallopian tube TB) help in the diagnosis of genital TB
Investigations to confirm the diagnosis of genital TB:-
Blood tests:
1-Complete blood count (Anemia, leucocytosis with lymphocytosis) and raised ESR; nonspecific
2-Serological tests like ELISA are not very sensitive and specific
3-Moderate rise in levels of CA 125 in genital TB
4-Serologic tests(interferon-gamma based assays.
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specificity
poor sensitivity and
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x (tuberculin) test
Mantou
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Imaging:
1-Chest X-ray
2-Hysterosalpingography Endometrial TB can cause synechiae formation, a distorted, obliterated or
T-shaped cavity and venous and lymphatic intravasation
3-Ultrasonography
4-Computerized axial tomography (CT) scan
5-Magnetic resonance imaging (MRI)
6-Positron emission tomography (PET) scan
The (3,4,5,6) imaging tests for detection of tubercular tubo-ovarian
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lioid granuloma:
Biopsy and Histological examination for demonstration of epithe
1- Cervical cytology 2-Endometrial, curettage or aspirate 3-Peritoneal biopsy
Microbiological study (Culture for Mycobacterium tuberculosis)
1-Menstrual blood culture 2-Peritoneal fluid culture
for collected fluid
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:
Polymerase Chain Reaction,Gen expert
Hysteroscopy ,laproscopy
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Endoscopy :
Deferential diagnosis:-
Granulomatous lesion other than TB are:-
1-Sarcoid. 2- Crohn’s disease. 3-Actinomycosis,
4- Leprosy. 5-Granuloma inguinale. 6-Lymphogranuloma venereum,
7-Syphilis. 8-Histoplasmosis. 9-Brucellosis.
10-Berylliosis. 11-Silicosis 12-Tularemia.
13- Foreign body reaction. 14-Schistosomiasis. 15-filariasis.
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Complications of genital tuberculosis:-
1-Subfertility or Sterility, 2-Ectopic Pregnancy. 3-Rarely congenital tuberculosis.
Management:-
The treatment of genital tract TB, is the same as the treatment of pulmonary TB.
Thus, the current standards in the treatment of tuberculosis are:-A 6-month regimen consisting of
isoniazid (INH), rifampin (RIF) Ethambutol (EMB) and pyrazinamide (PZA) for 2 months, followed
by INH and RIF for 4 months, is the preferred treatment for patients with a fully susceptible
organism. Add pyridoxine 25−50 mg daily to regimens that include INH.
Other drugs used against mycobacterium tuberculosis:-
Other drugs that have been used against M. tuberculosis and are currently being used, especially in
multidrug-resistant disease, are para-aminosalicylic acid (PAS), cycloserine, capreomycin,
kanamycin, thiacetazone, amikacin, ciprofloxacin, and ofloxacin.
Surgical Treatment
:-Indications for surgical intervention in the management of pelvic TB :-
(1) Persistent and recurrent disease or pelvic masses after 6 months of adequate therapy.
(2) Persistent or recurrent symptoms such as pelvic pain and abnormal bleeding.
(3) Persistent non healing fistula.
(4) Multidrug-resistant disease.
(5) Concomitant genital tract neoplasia or other pathology.
When surgery is advocated, the patient should be given drug therapy for at least 1–2 weeks
preoperatively, and the drugs should be continued for 6–12 months postoperatively. Under
antituberculous treatment, surgery is technically much less difficult, and morbidity and mortality are
significantly reduced. When TB is first diagnosed postoperatively after histological examination,
antituberculous treatment is given immediately and continued for 6–12 months.
The operation of choice in severe and extensive genital tract TB is total abdominal hysterectomy
with bilateral salpingo-oopherectomy followed by hormone replacement therapy, especially in a
premenopausal woman. If the patient is premenopausal and the ovaries look normal, they may be
conserved.