Tuberculosis (TB) is a very common disease worldwide including India. Tuberculosis of the female genital tract is common enough to be found in 1% of women with DUB (Sutherland 1949) and in 4% of adolescent with excessive menstrual loss (Sutherland 1953). The commonest site of involvement is the fallopian tubes (90e100%). The next common site is endometrium (60%). The infection is from the tubes either by lymphatics or direct spread through continuity. Symptoms vary according to the severity site and stage of the disease. Anti tuberculosis chemotherapy is the mainstay of tt. Initially drugs are used for 2 months. These are isoniazid, rifampicin, pyrazinamide and ethambutal. Treatment is continued for another 4 months with isoniazid and rifampicin.

1. Genital tuberculosis

2. Apollo Medicine 2012 September
Volume 9, Number 3; pp. 224e227 Review Article
Genital tuberculosis
Harmeet Malhotra
ABSTRACT
Tuberculosis (TB) is a very common disease worldwide including India. Tuberculosis of the female genital tract is
common enough to be found in 1% of women with DUB (Sutherland 1949) and in 4% of adolescent with excessive
menstrual loss (Sutherland 1953). The commonest site of involvement is the fallopian tubes (90e100%). The next
common site is endometrium (60%). The infection is from the tubes either by lymphatics or direct spread through
continuity. Symptoms vary according to the severity site and stage of the disease. Anti tuberculosis chemotherapy is
the mainstay of tt. Initially drugs are used for 2 months. These are isoniazid, rifampicin, pyrazinamide and ethambutal.
Treatment is continued for another 4 months with isoniazid and rifampicin.
Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
Keywords: Genital tuberculosis, Fallopian tube, Endometrium, Interferon
INTRODUCTION
More than 2 billion people equal to one third of world’s
population are infected with Tuberculosis bacilli. Tubercu-losis
exists in two forms: Pulmonary and extra pulmonary.
Genital tuberculosis is a form of extra pulmonary tubercu-losis
that affects 12.1% of patients with pulmonary tubercu-losis
and represents 15e20% of extra pulmonary
tuberculosis. It is estimated that 5e13% of patient in infer-tility
clinics have genital tuberculosis. Majority are in age
group of 20e40 year.1
Tuberculosis of the female genital tract once common
enough to be found in 1% of women with DUB (Sutherland
1949) and in 4% of adolescent with excessive menstrual
loss (Sutherland 1953) had shared in a general dramatic
decline in the incidence of tuberculosis disease that had fol-lowed
introduction of ATT.2
The exact incidence of genital tuberculosis is difficult to
assess as it is not well reported like pulmonary tuberculosis
and many times it is asymptomatic and due to not readily
available laboratory test which is easy to perform and reli-able.
The disease is not common in US (1%) but reported
much more in different parts of India (Studd 18),3 Asia
and Africa. Genital tuberculosis is still seen in parts of Scot-land,
immigrant population of poor social strata of UK.
There has been a 2e3 fold increase in tuberculosis cases
in Sub Saharan Africa due to infection with HIV.
PATHOGENESIS
Almost invariably tuberculosis of the genital tract is
secondary to a primary lesion elsewhere and the latter is
usually quiescent by the time pelvic involvement is diag-nosed.
Sexual transmission from a male partner with Tuber-culous
epididymitis is extremely rare. Another mode of
involvement of ovaries, tubes and serosa and uterus is perito-neal
spread from an intra abdomen lesion in minority of cases.
But generally infection reaches the genital tract (tubes in most
cases) by blood spread usually from a pulmonary lesion.
A vulval lesion secondary to intestinal infection by
bovine or human Mycobacterium tuberculosis is a rarity
commonly infecting organism is human mycobacterium.
From the tubes infection reaches the endometrium where
Sr. Consultant, Obst & Gynae, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110076, India.
email: drharmeet2002@yahoo.co.in
Received: 16.6.2012; Accepted: 3.7.2012; Available online: 10.7.2012
Copyright 2012, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2012.07.013

3. Genital tuberculosis Review Article 225
either it persists in the basal layer or reinfection occurs from
the tube following menstruation. The infection can also
spread from the tube to the peritoneal cavity and ovaries.
In untreated cases, caseating peritonitis with fistula forma-tion
in rarely seen.2
PATHOLOGY
The commonest site of involvement is the fallopian tubes
(90e100%) and both tubes become involved almost invari-ably.
2 Infection begins in the mucosa and then spreads
through the tubal wall to the peritoneal surface. The macro-scopic
appearances are similar to those of non tuberculous
chronic salpingitis with tubal thickening, fibrosis and adhe-sions.
Military nodules may form on the surfaces of the tubes.
When thickening becomes segmented, it is known as salpin-gitis
isthmica nodosa. If the ends of the tubes get blocked, it
leads to formation of pyosalpinx. In some cases, fimbrial end
is open but tube remains rigid and narrow. Mucosal folds are
destroyed and sometimes diverticula and crypts develop in
the lumen of the tube. Due to these changes there is failure
of tubal function leading to infertility.
The ovaries may be involved with adhesions and mili-tary
nodules. Miliary spread may be seen to the surface
of uterus and peritoneum.
HISTOLOGICAL EXAM
Shows typical tubercles with giant epitheloid and round cells
known as Langhans cells. Caseation is common in advanced
cases especially in a pyosalpinx or a tuberculosis to abscess.
Reinfection from the tube may not occur during every cycle.2
The next common site is endometrium (60%). The infec-tion
is from the tubes either by lymphatics or direct spread
through continuity. Cormual ends are commonly involved.
After the endometrium is shed at each menstruation, reinfec-tion
occurs fromthe lesion in the basal layer or fromthe tubes.4
Synechiae formation can occur following ulceration of
endometrium leading to infertility, secondary amenorrhoea
or recurrent abortion, the infection can spread to myome-triums.
A pyometra can result due to caseation especially
in postmenopausal women. The ovary, cervix, vagina and
vulva are infected much frequently.5 The ovaries are
involved about 30% cases of Tubercular salpingitis,4 the
lesion on ovary may show as surface tubercles adhesions
or may form a tubo ovarian abscess especially following
caseation. Tubercular cervicitis can present as an ulcer
resembling ectopy or like a proliferative lesion resembling
carcinoma cervix. Tubercular cervicitis is uncommon.1
The affection of vulva vagina is rare 1%. The lesion can
be annular or a growth. Pelvic peritonitis is present in
40e50% cases and can be executive type or adhesive type.4
CLINICAL FEATURES
Symptoms vary according to the severity site and stage of
the disease many a times patient may be asymptomatic,
with no abnormal signs.
d Other extreme presentation is formation of a large pelvic
mass.
d There may be symbol of chronic PID.
d Menstrual abnormalities, eg. A menorroea, menorrhagia,
hypomen, polymenorhoea, postmenopausal bleeding
oligomen.
d Excessive vagdisch is common.
d C/O pelvic pain in some cases.
d General symptoms typical of tuberculosis may be
present eg. weight loss, anorexia, pyrexia.
d Patients of genital tuberculosis may present as infertility
which may be primary or secondary.
d 5e10% of infertility patients suffer from genital tubercu-losis
involving fallopian tubes, endometrium and
causing ovarian damage.
DIAGNOSIS
There is no one particular test in all cases. There are varie-ties
of tests which may be required to make the diagnosis of
genital tuberculosis. Clinical suspicion should always be
there especially in high prevalence areas, since it is a pauci-bacillary
disease so demonstration of tuberculosis is many
times quite difficult.
The various tests can be done as follows:
1. Chest x-ray can show current and past infection.
2. CBC e a raised ESR, lymphocytosis, anaemia may be
found.
3. MX test e its role is not definite as the positive reaction
shows that the person is infected with M. tuberculosis
but doesn’t indicate active disease. In severe tuberculosis
and immunosuppressant Mx test may be negative. The
tuberculin skin test (TST) is widely utilized for detection
of M. tuberculosis infection but it has limitation. The
TST can cross react with non tubercular mycobacteria,
and BCG vaccine.
4. Serological test e this is an ELISA test based on antigen
of M. tuberculosis. These tests are not sensitive and
specific.
5. Nucleic acid amplification Rapid Molecular techniques
using nucleic acid and amplification can detect
M. tuberculosis DNA within 48 h of infection can be

4. 226 Apollo Medicine 2012 September; Vol. 9, No. 3 Malhotra
used to any sample and can increase the yield of pauci-bacillary
disease. It has a sensitivity of 87e100% speci-ficity
of 92e98%. In addition PCR can detect genes that
confer resistance to drugs. This process allows early
identification of MDR or extensively drug resistant
(XDR) tuberculosis. Cannot be relied upon to start or
stop ATT.
6. Interferon Y (IFN-Y) release away (IGRAS).
7. HSG e radiological findings of tuberculosis salpingitis
can be e rigid pipe stem narrowing of isthmus
d Punctuate opacification of crypts and diverticulae in
the lumen of the tube.
d Clubbed ampulla.
d Calcification in the tubes/ovaries.
d Beaded app typical of salpingitis isthmica nodosa.
d Bilateral cornual block.
d HydrosalpinxHSG contra indicated in a known case of
genital tuberculosis.
d Distorted uterine contour due to synchiae formation.
8. USG: it can pick up adnexal masses due to tuberculosis.
9. CT scan of MRI has a role to play in cases of abdominal
masses, pelvic ascities.
10. EB e endometrial curettings are examined microscop-ically
for the presence of tubercle and demonstration
of M. tuberculosis by ZiehleNeelsen staining and
a positive culture specifically for T. bacilli. Even
a PCR test can be done on the endometrium. A positive
guinea pig inoculation is diagnostic tuberculosis endo-metriotis
has been seen in 13.6% of infertile women,
undergoing routine EB. Endometrial biopsy should be
done in the premenstrual phase menstrual blood on
day of onset of menses in unmarried girls can be sub-jected
to PCR testing and for mycobacterial smear
and culture.2
Hysteroscopy
There may be presence of intra uterine adhesions in 30%.
Sometimes areas of scarring and occasionally narrowing
of the uterine cavity. But for confirmation histological
evidence is must.
Laparoscopy
Laparoscopy may reveal tubercles on the peritoneum, serosa
of fallopian tube uterus. It may show fluid in POD. There may
be adnexal masses, thickened tubes, peritubal adhesions,
hydrosalpinx. There may be evidence of blocked tubes on
CPT. Genital tuberculosis can be seen in 5e33.8% cases of
infertility on routine laparoscopy. There may also be peri
ovarian, omental and intestinal adhesions.2
TREATMENT
Anti tuberculosis chemotherapy is the mainstay of tt. Initially
drugs are used for 2 months. These are isoniazid, rifampicin,
pyrazinamide and ethambutal. Treatment is continued for
another 4 months with isoniazid and rifampicin.
These drugs may be used during pregnancy and lacta-tion.
Treatment of tuberculosis in HIV-positive women is
same with little change.
Surgical treatment
The need for this has reduced since the introduction of effec-tive
ATT. However, surgery may be required in case of:
1. Peritent or increase in pelvic adhexal masses inspite of 9
months of ATT.
2. Recurrence of tuberculosis of the endometrium.
3. Persistence or reoccurrence of abnormal pain or bleeding
inspite of 9 months treatment (ATT)
4. Persistent tuberculosis sinus or fistula.
5. Non healing wound.
Surgery can be done TAH BSO or adnexectomy surgery
can be hazardous and difficult. Pregnancy is rare (5e10%),
chances of ectopic pregnancy is 40%.
Treatment for fertility
It can be in the form of tuboplasty or ART. 9 months ATT
is must before tuboplasty or ART. The infected area in
endometrium heals by fibrosis. So, even ART results are
poor in such cases. Interferon-gamma (IFN-Y) release
away (IGRAS) such as the commercially available Quanti-
FERON-tuberculosis gold. In tube (QFTeGIT) test has the
potential to overcome some of TSTs limitations. QFTeGIT
detects M. tuberculosis infection by measuring in vitro IFN-Y
release following stimulation of lymphocytes will anti-gens
specific to M. tuberculosis. Recently CDC (US)
provided guidance that IGRAS are an acceptable alter
routine to TST for the detection of M. tuberculosis infection
and is the preferred option in BCG vaccinated population as
well.6 while many research studies have been conducted to
assess IGRA test performance, there is limited information
about the implementation of these tests in the context of
public health tuberculosis control programmes.7
CONCLUSION
More than 2 billion people equal to one third of world’s
population are infected with T. bacilli. Even though the
diagnosis of genital tuberculosis is possible by the demon-stration
of mycobacterium in the genital tract, the

5. Genital tuberculosis Review Article 227
characteristic radiographic appearances on HSG are reliable
indicators of genital tuberculosis. Almost 60e70% cases of
genital TB present with infertility. In India almost 5%e
10% of all infertility is caused by genital TB. Medical treat-ment
may restore fertility in early cases.
CONFLICTS OF INTEREST
The author has none to declare.
REFERENCES
1. Saraswat P, Swarankar ML, Bhandari A, Soni R. Detection of
active female genital tuberculosis by molecular method. Int J
Pharm Bioscience. OcteDec 2010;1(4):B-238.
2. ER Whitefield. Pelvic Infection dew hurts Textbook of Gynae
for Post graduates.
3. Jai B Sharma. Tuberculosis and Obs Gynae. Practice, Prog-ress
in Obs Gynae (18).
4. Shirish N Daftary, Ameet Patki. Reproductive Endocrinology
and Infertility.
5. DC Dutta. Textbook of Gynaecology.
6. Mazurek GH, Jereb J, Verhon A, et al. Updated guidelines for
using interferon gamma, release assay to detect mycobacterium
tuberculosis infection-United States, 2010. MMWR Recomm
Rep. 2010;59:1e25.
7. Grinsdale JA, HOCS, Banonvong H, Kawamura LM. Program-matic
impact of using QuantiFERON (R) e TB gold in routine
contact invest activities. Int J Tuberc Lung Dis. 2011;15:
1614e1620.

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