2. Epidemiology
• Genital tuberculosis still prevails in
developing countries and is usually a
secondary spread to the genital organs
from a primary in the lungs.
• It can present a long time after the
primary focus has healed.
3. Incidence
• Almost 1% of all gynecological
admissions are due to genital
tuberculosis.
• It is seen in 2-10% of all patients of
infertility with positive endometrial
aspirations in 4%.
• Infertility is a presenting feature in 90%
of cases and only 10% have conception
after treatment.
4. Etiology
• Genital tuberculosis is almost always a
secondary infection with the primary
focus in the lungs, lymph nodes, urinary
tract, bones and joints.
• The mode of spread could be via the
blood stream, from the peritoneum, by
direct sexual contact or through the
lymphatics.
• The most frequent site of infection is
the fallopian tube(90%).
6. Clinical presentation
• Infertility – 35-60% . Past history
obtained in only 50%, pelvic findings
are negative, and no tubal testing
should be done till a negative
endometrial histology is obtained.
• Menstrual disorders- Menorrhagia in
40% and sec. amenorrhea in 10%.
• Pain – after secondary infection sets in-
pain, nausea, vomiting, fever, tender
fixed lymph nodes
7. Clinical presentation
• Vaginal discharge-blood stained,
post coital bleeding, leucorrhoea and
painful ulcers
• Abdominal masses- immobile mass
fixed to uterus and appendages
• Fistula formation –Persistent fistula
after a surgery for an abscess.
8. Clinical presentation
of extra pulmonary
tuberculosis
• Miliary tuberculosis - Tubercle bacilli in
the granulomas of liver, lungs and bone
marrow
• Tuberculous Meningitis Inc. proteins in
CSF, low sugar concentrations and
moderate lymphocytosis. The ELISA
test is -- 80-90% sensitivity.
• Genitourinary Tuberculosis 2-3%Urinary
AFB smears and cultures are positive in
50-70%.
• IVP and cystoscopy reveal calyceal
dilatation, parenchymal calcification,
cavitations, ureteral strictures and
bladder contraction.
9. Clinical presentation
of extra pulmonary
tuberculosis
• Bone and joint tuberculosis Chronic
mono-articular arthritis, Para spinal
abscess, open joint biopsy or
arthroscopy for tissue diagnosis.
• Genital Tuberculosis 30%Infertility,
menstrual disturbance, abdominal pain
and leucorrhoea. The menstrual blood
is positive for bacilli in 90% of cases.
• Abdominal tuberculosis blind needle
biopsies of the peritoneum, calcified
lymph nodes, ascetic tap smear and
culture
10. Clinical signs
• General condition , abdomen doughy
• Encysted cyst- immobile and tender
• Pelvic masses-small and fixed or large
and mobile or matted together and fixed
• Recurrent PID – without leukocytosis
• Old healed extra-genital lesion
• Pyometra or postmenopausal bleeding
11. Diagnostic tests for
tuberculosis
• Clinical Diagnosis
• Radiological Diagnosis – X-ray chest
(apicograms or lateral decubitus films),
Bronchography, CT Scan , Ultrasound
• Laboratory- conventional
demonstration of tubercle bacilli or
smear or animal inoculation studies
• Newer Techniques- serological,
chemical , genetic probes, microphage
typing
• Tuberculin testing
12. Investigations
• D&C/E.A – Endometrial sampling –histology, PCR, cornual
sample, tubercles, g. pig innoc
• HSG- tubes may have the following changes- Lead pipe
rigidity, non-peristaltic
• Beaded
• Calcifications
• Cornual block
• Jagged tubal outline
• vascular or lymphatic intravasation of the dye
• Hydrosalpinx (bilateral)
• The HSG should be avoided if there is strong suspicion of genital
tuberculosis
•
13. Investigations
• Diagnostic laparoscopy –Tubercles
• Adhesions, tubes with multiple blocks
or hydrosalpinx, TO masses, abscesses,
ascites.
• Ultrasound
• Mantoux test
16. Investigations-
ultrasound
• The tubercular mass is seen as a variegated
appearance with cystic and solid areas besides
the uterus and may be difficult to differentiate
from other tubo-ovarian masses due to a pelvic
inflammatory disease or a chronic ectopic
pregnancy
17. In genital tuberculosis
Magnetic resonance imaging
Magnetic resonance imaging (MRI) findings in genital tuberculosis (TB).
MRI Film showing bilateral tubo-ovarian masses in a confirmed case of
genitalTB
18. hysteroscopy
• This is seldom done as diagnosis is confirmed by other
methods.
• However, if done for undiagnosed infertility cases, the
findings are of a pale endometrial lining and stenosis
of the tubal ostia.
19. Laparoscopy
• Laparoscopic findings in genital tuberculosis.
Laparoscopy showing multiple tubal block with
beaded appearance in a proven case genital Koch’s
22. Treatment
• Medical treatment- chemotherapeutic
agents
• First line- Isoniazid, rifampicin,
ethambutol
• Second line-
Aminoglycosides,cycloserine, Para-
aminosalicylic acid, ethionamide
• MDRS- Tb- combined resistance to
rifampicin and isoniazid
23. Treatment
• Surgery
• Indications
• Progression of disease
• Persistent active lesions
• Large inflammatory masses
• Persistence of symptoms
• Persistence of fistula
25. Surgery
• Total hysterectomy with bilateral
removal of ovaries and fallopian tubes.
• Follow-up- At least five years
• An annual curettage to check for
reactivation if uterus is still present.
• Prognosis- 90% cure with
chemotherapy
• Decreased fertility restored in 10% of
cases
• 50% tubal pregnancy and 20-30% abort
with 20% having live births.
26. Controversial issues
in genital
tuberculosis
• Differential diagnosis
• Duration of chemotherapy
• Chemotherapy versus surgery
• Combined chemotherapy
• Resistance
• Role of laparoscopy
