Genital tuberculosis is a secondary infection that primarily affects the fallopian tubes and is a significant cause of infertility, with symptoms often presenting long after primary pulmonary infection has healed. Diagnosis involves a combination of clinical, radiological, and laboratory tests, while treatment typically requires chemotherapy and may necessitate surgical intervention for severe cases. The prognosis for fertility restoration is low, with only about 10% of patients achieving conception post-treatment.

1. GENITAL
TUBERCULOSIS
Dr. Mini Sood

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%).

5. Site of infection
• Fallopian tubes - 90%
• Endometrium - 50-60% caseating
lesions, pyometra
• Ovaries – 30%
• Cervix - 5-15%, erosions
• Vagina – 1% Shallow ulcers with
undermined edges

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

14. TuberculinTest
interpretation: ATS-
CDS
recommendations
•
Induration size
• Positive>5mm HIV Positive women with
Positive Clinical signs( chest x-ray)
• >10mm Health workers, steroids or on
other immunosuppressant drugs,
malnourished patients, Diabetes
Mellitus
• >15mm Low Risk group

15. Differential
Diagnosis
• Ovarian cysts
• PID
• Ectopic pregnancy
• Carcinoma cervix
• Elephantiasis

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

20. LAPAROSCOPY

21. ULTRASOUND
– OVARIAN
CYST
The cystic lesion seen on
the right side of the uterus
which is fluid filled and
anechoic.

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

24. Contraindications of
surgery
• Active lesions anywhere in the body
• Plastic adhesions of bowels.

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

27. THANKYOU