3. Introduction
TB was recognized as a
clinical entity as far back
as 1000 BC.
1744 Morgagni - described
the first case of genital TB
The word tuberculosis was first
used in 1834
4. Major health problem in many developing countries.
TB affects almost 50% of the population in Third
World countries.
An estimated 30 million persons have active TB, and
7–10 million people die each year of TB.
5. Incidence
11% of patients are asymptomatic and the disease is
discovered incidentally.
5- 10 % in infertile cases
6. Pathogenesis
Mycobacterium tuberculosis is the infective organism
Always secondary to primary extra – genital infection (50%
from lungs)
Invariably fallopian tubes are involved first.
7. Mode of Spread
Haematogenous spread
• 90 % infection
spreads through
blood
• genital organs gets
infection - puberty,
during growth spurt
• Infection becomes
dormant until the
clinical features seen
Lymphatic spread
• Involves
directly from
adjacent lymph
node or through
lymphatics from
peritoneum,
bowel or
mesenteric
lymph nodes
9. Pathology
Fallopian tube:
These are involved first.
Both tubes are affected simultaneously.
Sub- mucosal layer of ampullary part of tube is the initial site of
infection muscular layer of the tube fibrosis .
Walls become thick, calcified and ossified.
Involves mucosa – swollen - destroyed
Fimbriae are everted, abdominal ostium usually remains patent
10. Tubes- elongated, distorted, sometime segmented.
Tubal block is due to adhesion.
Pouring of caseous materials from brust tubercle, leads to
pyosalpinx
Tubercles are seen on the surface of the tubes
Tubes will be red, edematous and swollen (50% tubes are
normal looking)
Infection sometime spreads outwards and causes perisalphingitis
with exudation resulting dense adhesions with surrounding
organs – tubercular tubo- ovarian mass
11. Pathology….
Uterus:
Cornual ends are affected mostly
Tubercles are situated in basal layer and comes to surface
premenstrually and sheds in menstruation
Reinfection occurs from basal layer
Endometrial ulceration leads to adhesion or synechiae
formation, if caseation occur it leads to pyometra in
postmenopousal female
12. Pathology….
Cervix:
Less common, rarely due to sexual contact ulcerative lesion,
nodular which bleeds on touch (confused with carcinoma)
Vagina and Vulva:
Rare
lesion is shallow, superficial and ulcerative with undermined
edges
13. Pathology cont..
Ovary:
Involve in 30% of cases
Lesions are surface tubercles, thickened capsule or caseating
surface abscess and adhesion
Fistula and Sinuses:
It involves abdominal wall, tubes, uterus, vagina, bladder and
bowel which forms spontaneously
14. Peritoneum:
Pelvic peritoneum involves in 30- 40% cases and 2
types
a. Dry variety (adhesive type)
b. wet variety (exudative type)
Microscopically it consists of granuloma with ch.
Inflammatory cells and multinuceated gaint cells
(Langhans Cell) with or without caseation necrosis
15. Clinical features
80% to 90% of cases diagnosed in patients 20–40 years old,
often during workup for subfertility.
Although in many developing countries, genital TB is more
common among younger women, in developed countries
most patients are older than 40 years.
16. Symptoms
• Vulvar lesions are painful and tender
• Vaginal ulcers are painless and, often causes
blood stained discharge
Vulva or Vaginal
tuberculosis
• Painless lesion with blood stained discharge ,
• sometime postcoital bleeding,
• Few are cauliflower like lesion
Cervical
18. Clinical Features
• It occurs in 70% of cases. It is due to abnormal
endometrial and tubal functionInfertility
• Common if lesion healed recently
Ectopic
Pregnancy
• occurs in 20- 30 % of cases.
• It may be associated with tubo- ovarian mass
• General ill health like malaise, loss of appetite,
loss of weight, night sweat and pyrexia
Chronic pelvic
pain
19. Signs
Most series suggest physical examination can be normal in up
to 50% of cases of female genital TB.
Normal
Abdominal mass
Pelvic mass
Adnexal mass
Abdominal tenderness
Pelvic/adnexal tenderness
Ascites
Excessive vaginal discharge
Ulcer in the vulva, vagina, and cervix
Enlarged uterus with pyometra
Fistula
20. Diagnosis
a) Blood- TC, DC, ESR
b) Mantoux Test- Negative test excludes the tuberculosis
c) Chest x-ray
d) Endometrial biopsy (premenstrual) – Tissue is send for
culture (Lowenstein- jensen media) , Histopathological
examination of the ch. Inflammatory cells and foreign body
Giant cell reaction ; bacilli can be identify by Ziehl-
Neelsens stain
e) First day menstrual blood culture for TB bacilli (Guineapig
inoculation) – negative result cannot exclude disease
21. Diagnosis
f) TB PCR of Endometrial tissue- Sensitive but not specific, it
will give positive result with dead bacilli or with other
Mycobacterial infection
g) Ultrasound Scan- reveal only TO mass
h) Laparoscopy – Reveal peritoneal tubercles, TO mass, nodular
tubes and can take biopsy
i) Sputum AFB to rule out pulmonary TB
j) Lymph node biopsy if Lymph nodes are enlarged
22.
23.
24. Treatment
General
• Pulmonary TB perse –no need of admission
• Except in acute exacerbations
• Improve body resistance
• Regular diet
• Correct anaemia
• until infection is controlled, husband should use condom during
intercourse- prevent urogenital TB
25. Chemotherapy
INTIAL PHASE-
• 4 drugs are used for 2
months-
• red bacterial population
• prevent emergence of drug-
resistance
Drugs-
• Isoniazid
• Ethambutol
• Rifampicin
• Pyrazinamide
• Ethambutol-prev
treated/immunocompromised
26. Continuation phase
• Treatment is continued for a period of further 4mnths with
isoniazid, rifampicin
• About a year of treatment, diagnostic endometrial curretage
is to be done….
• Positive- treatment contd..
• Negative- endometrium is examined at interval of six
months…
27. considered cured
• At least 2 reports including histological and bacteriological
examination becomes negative
• Majority of pts respond well to chemotherapy
28. Multidrug resistant TB
• Infection with Mycobacterium TB that is resistant to 2 or
more agents including isoniazid
• HIV negative patients who are MDR have high mortality
rate
• Such patients treated with-5 drug regimens(CDC)
30. SURGERY
INDICATIONS
• Unresponsiveness of active disease in spite of adequate anti-
tubercular treatment
• Tubercular pyosalphinx
• Ovarian abscess
• Pyometra
• Persistent menorrhagiachr pelvic pain causing deteriorating
health status
31. Contraindication
• presence of active TB in
extragenital region
• favorable response with
decrease in mass size
• Accidental discovery of
tubercular tubo ovarian mass
on laprotomy in young pt.-
abdomen is closed after
taking tissue for biopsy
Precautions
• Anti-TB treatment should be
started at least 6wks prior to
surgery
• Continued 6wks after surgery
32. Types of surgery-
• TAH+BSO –rare today
• Hypertrophied vulva-
vulvectomy
• Removal of adnexal mass in
young woman
• Drainage of pyometra
• Fistula repair
Tuboplasty-Contraindication
• Any surgery on tube will
reactivate disease
• Fertility cannot be restored
when tubal walls are
damaged
33. PROGNOSIS
90%-cured
Only 10%-fertility restored
Of these who conceived 50% -tubal pregnancy
20-30%-abort
Only 2%-live births
TB was recognized as a clinical entity as far back as 1000 BC.
However, it was not until 1744 that Morgagni,1 following a postmortem examination of a 20-year-old woman who died of TB and whose uterus and fallopian tubes were found to be filled with caseous material, described the first case of genital TB.
The word tuberculosis was first used in 1834, although Koch did not discover the tubercle bacilli until 1882.
TB remains a major health problem in many developing countries, and in these areas, genital TB is responsible for a significant proportion of females presenting with infertility.2 TB affects almost 50% of the population in Third World countries. An estimated 30 million persons have active TB, and 7–10 million people die each year of TB.
It is estimated that world over 5-10% of infertile women have genital tuberculosis
Genital TB is almost always secondary to TB elsewhere in the body—usually pulmonary and sometimes renal, gastrointestinal, bone, or joint; occasionally it is part of a generalized miliary disease process.
If the bacilli are not eradicated, there is a lifelong risk of reactivation
mode of spread is usually hematogenous or lymphatic and occasionally occurs by way of direct contiguity with an intraabdominal or peritoneal focus
The clinical diagnosis of genital TB requires a high index of suspicion.
About 20% of patients with genital TB give a history of TB in their immediate family.5
As a rule, they were exposed to an adult with TB during childhood. Approximately 50% of patients might have had tuberculous pleurisy, peritonitis, erythema nodosum, or renal, osseous, or pulmonary TB.
A history of primary infertility in a woman in whom examination reveals no apparent cause and who gives a family history or personal history of TB should arouse suspicion of genital TB.
A history of poor general health persisting over months or years and associated with weight loss, undue fatigue, low-grade fever, or vague lower abdominal discomfort is often elicited in patients with genital TB.
When abnormal findings are present, they usually consist of adnexal masses or signs of ascites.
