GENITAL TUBERCULOSIS - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANI

1. Dr. Shashwat Jani.
M. S. ( Obs – Gynec ) , FIAOG.
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. TUBERCULOSIS- A MAJOR THREAT
TO DEVELOPING COUNTRIES
 Annual cases of T.B world wide - 8 million.
 95% occur in developing countries.
 Prevalence worldwide is 16-20 million, with 8-10 million
being sputum +ve.
 No. of people infected with T.B bacilli approximately,
1.7 billion & 1.3 billion live in developing countries
 Greatest burden of T.B.( incidence &mortality) in adults
aged 15-60 years
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3. CONT….
• In India 40% adults infected with T.B , 1.5
million on Rx every year
• 5,00,000 deaths from T.B occur every year .
• Each smear +ve pt. can infect 10 -15 persons.
Central T.B division -DGHS, Ministry of health
&Family welfare,New Delhi (June, 2000 )
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4. INTRODUCTION
General Incidence – India -- FGTB
• Most common extra pulmonary TB
• 30 % of all extrapulmonary TB
• 18% of infertile women
• 11% of hematospermia
• 5-25 year after primary pulmonary TB
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5. Causative Organism
• Mycobacterium tuberculosis
• Human: 90-95%
• Bovine: 5-10%, higher incidence in rural India,
unpausterised milk
• Atypical strain, rarely
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6. Modes Of Infection
• Primary: rare, vulva & Cx, coitus?
• Secondary: always,
Pulmonary (9-10%),
Extra-pulmonary-bone, LN, urinary system, peritoneum
• Early transmission, slow course, 10-12yrs
• Hematogenous : 80%, Mainly tube
• Lymphatic: from peritoneum & mesenteric LN
• Direct: Peritoneum, pelvis, urinary system, Ls
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7. SITES OF INFECTION
• Tub. Salpingitis: almost 100%, primary
focus, often bilateral
• Uterus(Corpus): 50-60%, often
secondary to tube
• Cervix: 4-6%
• Ovaries: 20-30%
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8. Diagnosis
• Despite availability of various diagnostic
techniques, diagnostic dilemma still exists,
especially for genital TB.
• Hence, FGTB needs a thorough systematic
clinical examination with high degree of
suspicion and use of intensive investigations.
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9. 9
FGTB – DIAGNOSTIC MODALITIES
CLINICAL RADIOLOGICAL LABORATORY
Reliability increases
with
• Progression of
disease
• Multisystem
involvement
Early changes
• Needs confirmation
Advanced disease
• Almost diagnostic
Valuable for
• Early disease
diagnosis
• Rapid diagnosis
• Drugs sensitivity
INVASIVE – Endoscopy / Biopsy / Dye study
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10. SYMPTOMATOLOGY
• Asymptomatic
• Constitutional Symptoms- Anorexia ,
Malaise, Evening Rise Of Temperature,
Weight Loss
• Infertility Due To Tubal Closure.
Primary -75% Cases
Secondary -14% cases following an
abortion , ectopic or normal delivery.
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11. • Schaffer- Two types
a) Silent / Latent type: Symptomless, no clinical finding,
proliferative changes in endosalpinx, adhesions
between rugal folds, labyrinthine mases
b) Advanced: palpable masses
Menstrual Disorders-
• Normal menstruation in 50-85% early cases
• Dysmenorrhoea
• Menorrhagia, menometrorrhagia due to ulcerative
T.B. endometritis
• Late : Oligo-hypomenohea
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12. Contd...
• Amenorrhoea- (7% cases )
Due to destruction of endometrium & ovaries
- Io Amenorrhoea (40%)following 10
peritoneal T.B. in childhood
- II0Amen. (60%) following scanty periods
Diag.: SSC well developed, No response to EP,
No endometrium on D&C, HSG helpful
• Puberty Menorrhagia
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13. Contd..
• Pain - Vague Abdominal Discomfort (Tb Peritonitis Or
Abscess), Ascitis, Ectopic, Intestinal Obstruction.
• Blood Stained Vaginal Discharge
• Leucorrhea
• Post Coital Bleeding
• Dyspareunia
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14. Diagnosis
• Age/ Parity/ suggestive Symptoms
• Fever
• Pain, distension
• Past, Family H/O
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15. • G.E: Poorly built/nourish, anemia,
evidence of TB in lungs, LNs
• PA: ‘N’, Tender mass, doughy feel, ascitis
• PV: ‘N’, Thickened tubes, TO mass, RV fix
Ut,
• PR
• PS
• Local exam.
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16. Imaging Modalities
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17. X - Ray
• Though it’s secondary ,
but 75 % cases CXR –
Normal .
• May show old healed
lesion in lungs.
• X – ray Spine is also
important for Tb Spine.
• More Confirmatory -
HSG
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18. Tubal changes HSG
• Non specific findings like hydrosalpinx
• Multiple constrictions giving a beaded appearance
• Occlusion either at the isthmus or ampulla
• Pipestem appearance
• Cobblestone appearance
• Leopard skin appearance
• Tubal calcifications
• Golf club appearance - Bilateral distal isthmic obstruction
• Peritubal adhesions
• Caseous ulceration of the mucosa of the tube gives it an
irregular contour and diverticular outpouching surround the
ampulla giving it a tufted appearance
• Same process in the isthmic region gives the typical
appearance of Salpingitis isthmica nodosa (SIN).
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19. Uterine changes on HSG
• Endometritis, Intrauterine adhesions and asymmetrical
cavity- All non specific.
• Collar-stud abscess- Specific
• Tuberculosis T-shaped uterus
• Pseudounicornuate uterus- Unilateral obliteration
followed by unilateral scar in uterine cavity
• Small uterine cavity with irregular contour and resembling
septate appearance
• Complete obstruction of uterine cavity with glove’s finger
appearance
• Due to progressive endometrial lesion contrast medium
may passed through lymphatic and venous systems- Dye
extravasation to vascular channels
• Pelvic node calcification also may be detected
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20. Pipe stem appearance Septate appearance
with small cavity
Salpingitis isthmica nodosa
Golf club appearance Glove’s finger appearance Dye extravasation to
vessels
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21. USG
• Adnexal mass in an adolescent girl (Not
sexually active) especially with ascitis
• Small uterus
• Atrophic endometrium/ calcifications in the
endometrium
• Encysted ascitis
• Saline salpingogram/ sonohysterogram
showing adhesions, tubal block etc.,
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22. CT and MRI and PET scan
• Peritoneal tuberculosis and tubo-ovarian
lesions have usually minimal findings at CT and
frequently misdiagnosed with peritoneal
carcinomatosis.
• MRI is useful for the diagnosis of tubo-ovarian
lesions.
• Regular pattern of small nodularities along the
peritoneum at MRI are helpful findings.
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23. Remember
• In spite of significant technological advances
in imaging noted with ultrasonography, CT and
MRI;
HSG remains the gold standard in
evaluating the internal architecture of
the female genital tract and fallopian
tubes.
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24. Laparoscopy Findings
• Tubercles on the peritoneal surface
• Inflamed or blue-coloured uterus
• Salpingitis, oophoritis or a tubo-ovarian mass
• Tubal occlusion with hydrosalpinx
• Dye dripping (instead of free flowing) from the
fimbreal opening on chromopertubation
• Free peritoneal fluid looking like blood
• Caseation in the Pouch of Douglas
• “Frozen pelvis”
• Omental adhesions
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25. Right upper quadrant showing dense adhesions of the liver to the anterior abdominal wall
(Fitz-Hugh-Cutis syndrome )
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26. Hysteroscopy Pictures
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27. Laboratory Investigations
• CBC & ESR
• Sputum, Urine & G .I Aspirate
• Endometrial biopsy or curettage-
detects latent endometrial T.B.
Premenstrual phase
• Biopsy - Cornual regions show tubercle follicles.
Pseudopregnancy with progesterone ,cyclical
shedding prevented –
biopsy then show tubercles (KISTNER METHOD).
‘‘Absence of signs of T.B endometritis in any
one biopsy is not proof of absence of disease”
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28. Contd..
• Bacteriological examination-
Material- uterine secretions , endometrial biopsy
direct smears-Z N staining
Pap Fluorescein staining
• Guinea pig inoculation -
Best Confirmatory results are with endocervical
secretions
• Culture of menstrual discharge & Cervical mucus -
D2 of menses collected in isotonic saline &
cultured in Loewenstein’s or Petragnani’medium
• Tuberculin Skin Test- indicates presence of prior
infection. + ve results in 90% of cases.
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29. CURRENT TRENDS
SCREENING TESTS -
• ADA [ adenine deaminase activity]in body fluids
• Mycobacterium IgG, IgM & IgA antibodies.
• AFB smear by fluorescent microscopy .
• AFB by Zeihl Neilsen stain, Auramine Rhodamine
stain
CONFIRMATORY TESTS -
• RNA detection by Improved PCR
• Radiometric culture by BACTEC.
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30. CURRENT TRENDS
• PCR - Detects DNA of mycobacterium T.B.
-Useful for diagnosis paucibacillary forms of
pulmonary or extra pulmonary T.B.
• SEROLOGICAL TESTS-
• IgM & IgG ( immunoblot assay )
98% specificity 40% sensitivity.
• Elisa & sandwich Elisa technique- use of polyclonal
antibodies as primary capture antibodies.
Can detect smear -ve T.B
Rapid ,inexpensive , simple to perform.
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31. CURRENT TRENDS
PCR
• Detects Live & dead bacteria
• Nucleic Acid detected: DNA
• False +ve issues encountered very often
• Testing Time : 8-12 hours
• Cannot be used as a therapy monitoring tool,
detects both live&dead bacteria
• +ve Predictive value <75% due to problems of
contamination.
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32. CURRENT TRENDS contd...
RNA detection by Improved PCR
• Detects Live bacteria
• Nucleic Acid Detected: r RNA
• No false +ve issue , no contamination
• Testing time : 3 hours
• Can be used as a therapy monitoring tool,because it
detects live bacteria
• +ve Predictive value:100%
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33. CURRENT TRENDS (cont)
• BACTEC 460 ( Mycobacterial culture )
- A liquid media with radiometric growth detection.
- Identification of isolates by nucleic acid probes.
-  time required for isolation to 2-3 wks
( routine culture -4-8 wks)
• DNA finger printing from BACTEC for diagnosis of false
+ve cultures.
• Drug Susceptibility Test
-Used for pts who fail to respond to initial therapy or
relapse after Rx.
-Direct testing on liquid medium ( 3 wks).
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34. QuantiFERON-TB Gold
QFTG
• In vitro laboratory diagnostic test
• Indirect test for M. tuberculosis complex
M. tuberculosis
M. bovis, M. africanum, M. microti, M.
Canetti infection
• 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
evaluations
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35. QuantiFERON-TB Gold ( QFTG )
• 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
• 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%)
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36. D & C
One must do a thorough curettage, including both
cornual regions (common sites for TB endometritis)
Entire endometrium is collected and divided in two
parts:
Half in for formalin: for histopathological
examination to look for tuberculous granulomas.
Other half in saline for smear / culture / guinea pig
inoculation. Smear: Ziehl Neelson stain.
In unmarried adolescent girls menstrual discharge
collected within 12 hours of onset of menses can be
used for culture.
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37. 24-Dec-17
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38. 24-Dec-17
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39. Keystones In Management
• Sound Understanding Of Disease
• Proper Evaluation
• CAREFUL PLANNING OF Rx
• Help Of Specialists
• Counselling / Reassurance
• Dietary Modification
• Advice -Long Term Follow Up
• OPHTHALMIC EXAMINATION ( Due To ETHAMBUTOL)
Treatment of FGTB is similar to Pulmonary TB.
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40. The Essential Anti Tb Drugs
Recommended dose (mg/kg)
Intermittent
Essential Anti-
TB drugs Mode of
action Potency
Daily
3/ wk 2/ wk
Isoniazid (H) Bactericidal High 5 10 15
Rifampicin (R) Bactericidal High 10 10 10
Pyrazinamide(Z) Bactericidal Low 25 35 50
Streptomycin (S) Bactericidal Low 15 15 15
Ethambutol (E) Bavteriostatic Low 15 30 45
Thiacetazone (T) Bacteriostatic Low 3 Not applicable
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41. Drugs Used In The Treatment Of Tuberculosis
Drug Daily dose (adult) Major toxicity
Isoniazid (INH) 300 mg oral Hepatitis, peripheral
neuropathy
Rifampicin 450-600 mg oral Hepatitis, flu-like syndrome,
interstitial nephritis,
thrombocytopenia (rare)
Streptomycin 0.75-19 IM Deafness, renal failure,
vestibulopathy
Pyrazinamide 1.5-29 oral Hepatitis, hyperuricaemia
Ethambutol 5mg/kg oral Optic neuritis (rare at this
dose)
PAS 12mg oral Diarrhoea, hepatitis, ,
hypersensitirity reactions
Ethionamide 19 oral Hepatitis
Cycloserine 19 oral Depression, personality
changes psychosis, seizures
Thiacetazone 150 mg oral Exfoliative dermatitis,
hepatitis
Kanamycin 19 IM Deafness, renal failure,
vestibulopathy (rare)
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42. Basic Protocol
• Intensive Phase:
3-4 drugs for first 2-4 months
• Maintenance Phase:
2 drugs for 5-12 months
• Change of drugs acc. To response,
severity, toxicity, sensitivity report
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43. Alternative Treatment Regimens For Each
Patient Treatment Category
TB treatment
category
TB pateitns Alternative TB treatment
regimens
Initial phase Continuation
phase
1 New smear positive
PTB & seriously ill
extrapulmonary or
(smear TB)
2SHRZ (EHRZ)
2SHRZ (EHRZ)
2SHRZ (EHRZ)
2E3H3R3Z3*
6HE
4HR
4 H3R3
4 H3R3*
2 Sputum smear
positive relapse
Treatment failure &
return after default
2 SHRZE/1 HRZE
2 SHRZE/1 HRZE
2S3H3R3Z3/
1 H3R3Z3E3*
5H3R3E3
5 HRE
5H3R3E3*
3 Smear negative PTB
& extra pulmonary
TB (less severe)
2HRZ or 2 H3R3Z3
2HRZ or 2H3R3Z3
2HRZ or 2H3R3Z3
2 H3R3Z3*
6HE
2HR/4H
2 H3R3/4H
4 H3R3*
4 Chronic case
(still sputum positive
after supervised
treatment)
Not applicable
(refer to special centre if second-
line drugs available)
* Directly observed treatment regimens applied in the Revised National Tuberculosis
Programme in India.
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44. WHO Regimen
• Genital TB ( severe) Category-1:
2SHRZ 4H3R3
• DOT 2(EHRZ)3 4H3R3
• Category-3, Less severe:
2HRZ 2H3R3/4H
• DOT 2(HRZ)3 4H3R3
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45. Drug Resistant T.B.
• Usually the result of monotherapy or the negligence
of the pt
• Resistance to INH & R’cin commonest
• Chosen regime must include mixture of essential
and second line drugs
• ESSENTIAL ANTI TB DRUGS:
Streptomycin, Pyrazinamide, Ethambutol
& Thiacetazone.
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46. • Role of steroids-in combination with
AKT
50mg cortisone / 5mg Prednisolone daily in
conjunction with AKT X 3-4 months particularly to
preserve tubes
Treatment of occluded tubes in T.B. Salpingitis
Transuterine insufflation of 50-100mg of
Hydrocortisone+Streptomycin(1gm).
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47. Supportive Treatment
General health improvement
HPD- good diet, hematinics, vitamins
Environmental improvement
Psychological support
Personal / family counseling
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48. Schaefer And Sutherland Criteria For
Surgical Intervention
• Persistence of adnexal mass after 4-6 months
of antibiotic therapy
• Persistent pelvic pain
• Primary unresponsiveness to akt
• Difficulty in obtaining patient cooperation for
long term therapy
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49. Desiring Pregnancy ?
• Tuboplasty contraindicated in badly affected tubes
• In partially occluded tubes with a past H/O of
abdominal T.B, tubal cannulation (salpingoscopy)
possible with help of Laparo-hysteroscope.
• HYSTEROSCOPIC adhesiolysis in cases of dense
uterine synechiae (after AKT completion) HRT for
2-3 cycles helps in regeneration of endometrium
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50. Prevention
 Aim to decrease overall incidence of TB MT screening
 BCG immunization
 Detection of TB mothers in pregnancy & treatment
 Routine health check up (schools, community)
 Suspected cases - MT / X Ray chest
 Early diagnosis - timely treatment
 Therapeutic Trial - ?
 Prevention of AIDS
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51. 24-Dec-17 51
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