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Genital T.B. 1st recognized by MORGAGNI
Incidence in infertility clinics:-
5% in world and 19% in India.
80% – 90% in females aged 20 – 40 years.
Almost always secondary usually primaries are
pulmonary other sites renal, GIT, bone, etc.
occasionally part of miliary T.B.
MODE OF SPREAD:- 1. Hematogenous
Evidence suggest if primary infection occurs
close to menarche increased chance of genital
Tubercular adenitis of mesenteric or pelvic
Superficial involvement of serosa does not
impair reproductive function.
Pelvic T.B. is not the same disease as Genital
Usually the ampullary region shows the earliest and most
The fimbrial processes become greatly swollen and Ostia
remain open or closed.
Gross appearance – 1. TOBACCO POUCH
Gross appearance varies and is non-diagnostic.
Microscopy, hyperplastic adenomatous pattern may be
confused with adenocarcinoma.
Gross size and shape of uterus may appear normal.
Endometrium on gross appearance may show
ulcerative, granular or fungating lesion resembling
Endometrial cavity may be obliterated with
Microscopy classic lesion is the non caseating
The granulomatous lesions are best recognized on 24
– 26 cycle days or within 12 hrs. of onset of menses.
High degree of suspicion.
20% have history of T.B. in immediate family.
4 major presenting complaints:-
3. Pelvic pain.
H/o primary infertility with no apparent cause on
examination & family H/o or personal H/o T.B.
H/o vague lower abdominal discomfort with low grade
fever/undue fatigue/persistent ill health over months to
years associated with weight loss.
Adolescent female presenting with ascites pain and low
Menopausal female enlarged uterus that is tense and
tender on examination (pyrometra formation)
Recurrent Pelvic inflammatory disease not responding
to antibiotic therapy.
Most common initial symptom.
In most large studies:
Infertility presenting c/o in 40% - 50%.
85% never became pregnant & 15%
developed symptoms of genital T.B.
within a year of last pregnancy.
Second common symptom.
Pain present for several months which is not usually
M/b associated with swelling of abdomen.
Episodes of acute lower abdominal pain owing to
secondary infection by pyogenic org.
In advanced disease pelvic pain becomes severe and
gets aggravated by coitus, exercise & mensus.
No. of women c/o pain is proportional to no. of women
having abdominal findings on physical examination.
Third common symptom.
Menorragia/ Menometrorragia/ Intermenstrual
bleeding/ Oligomenorrhoea/ Postmenopausal
Menstrual cycle may be normal. Superficial
T.B. Endometritis does not interfere with
secretory response of endometrium to
Advanced active pulmonary T.B. produce
amen. but concomitant genital T.B. is rare.
Complete destruction of ovary by genital T.B.
seldom occurs so ovarian failure is not the
End organ failure secondary to endometrial
Normal in 50%..
Bi manual examination-adenexal mass/fixation
of pelvic organs less tender.
Abdominal examination-doughy feeling.
Diagnostic role of a positive Mantoux (PPD) is
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
sensitivity - 55%
specificity - 80%
Decisive step for diagnosis, treatment &
control of TB
Combination of solid & liquid media- “gold
standard” for primary isolation
Recommended turn around time (CDC)
14 days (culture)
21-30 days (identification & susceptibility)
Continuously monitored non-radiometric
Revised antibiotic supplement kit
Medium - modified Middlebrook 7H9 broth
CO2 released by mycobacteria detected by sensor
Color changes - increase in reflectance units
Positive broth - 106-107 orgs/ml
Higher biomass - direct inoculation of
identification panels & susceptibility tests
In vitro laboratory diagnostic test (May ’05)
Indirect test for M. tuberculosis complex
M. bovis, M. africanum, M. Microti, M. Canetti
Tuberculosis disease OR latent tuberculosis infection
(LTBI)- cannot distinguish between them
Intended for use in conjunction with risk assessment,
radiography, and other medical and diagnostic
Single patient visit - whole blood sample - 4 ml of
heparinised whole blood
Must be transported to lab to allow initiation of
testing within 12 hours (viable lymphocytes)
Rapid results (within 24 hours)
No booster response (measured by subsequent tests -
which can happen with Mantoux)
No reader bias (cf Mantoux)
Not affected by prior BCG vaccination
Impaired or altered immune function
ST: 80-95% (Mantoux 75-90%)
SP: 95-100% (Mantoux 70-95%)
Rapid diagnosis in smear negative samples
65 kDA protein encoding gene
Differentiate M. tb / NTM
Species specific IS6110
Genetic markers for drug resistance
Rifampicin – rpoB
INH – codon 315 of katG
False positives & false negatives (inhibitors)
Negative result cannot rule out TB & positive result is
not always confirmatory
Based on hybridisation of nucleic acids
Selection of the hybrid
Detection of the hybrid
Mycobacteriophage detection system
M. smegmatis lytic cycle: 90 mins
Not expensive; safe
Viable bacilli, intact phage receptors
Affected by effective ATT – monitor trt success
Phage inhibitory substances
Analytical ST: 100-300 bacilli/ml
Good sp (96-99%)
Less st (70-87%)
Rigid pipe-stem tubes
A clubbed ampulla with retort-shaped
Vascular or lymphatic intravasation of contrast
Small shrunken uterine cavity with filling
Long and dilated cervical canal & dye in
Bilateral cornual block
Punctate opacification of crypts and
diverticulae in lumen of tubes
A combination of PCR with the other available
techniques is the best method of achieving sufficient
sensitivity and specificity for the diagnosis of female
PCR positive + culture negative – warrants therapy
as PCR can detect very few bacilli & even dead
PCR negative + culture positive – this result cannot
be dismissed as contamination carry false negative
rate of PCR. Culture remains gold standard.
Subfertility & Infertility- Residual damage of the
fallopian tubes is often irreversible even following
medical regimens, unless genital T.B. is diagnosed
and treated early in its course. Symptoms of pain and
menstrual disorder respond to medical treatment.
Ectopic pregnancy- Risk of ectopic pregnancy
following medical treatment is estimated to be 33%-
Congenital T.B.- Rare but potentially serious
complication. Over whelming systemic infection in
the new born has considerable morbidity &mortality.
Once diagnosed a gynecologist must consider
Rule out active T.B. at any other site.
Know the extent of genital lesion.
Will medical management cure the lesion?
Is pregnancy possible following treatment?
Experts suggest that it is easier to treat these
cases because they are paucibacillary.
3 basic principles for chemotherapy for T.B.
Regimen must contain multiple drugs to which
organism is susceptible.
Drugs are to be taken regularly.
Drugs should continue for a sufficient period of
For patients who are compliant and the
organism is fully susceptible.
INH+RIF+PZA--- 2 months
INH+RIF --- 4 months
For patients who cannot tolerate PZA
INH+RIF--- 9 months
Ethambutol or SM should be included in above
regimen till results of drug susceptibility are
Add pyridoxine 25-50mg in regimen including
Multi drug resistance drug used are-
Persistent & recurrent disease/pelvic masses/pelvic
pain/abnormal bleeding despite adequate treatment
Persistent non healing fistula
Multi drug resistant disease
Concomitant neoplasia of genital tract
Chemotherapy should precede surgery by 1-2 weeks.
Surgery should be done at mid cycle in premenopausal.
C.T. should be continued for 6-12 months post op.
Premenopausal-save ovaries if normal, otherwise TAH
with BSO followed by HRT.