4. INTRODUCTION
A disease of young women
80% of these diagnosed between 20-40 years of age.
TB is endemic in India
5-10% of infertile women suffer from TB
6. MODE OF SPREAD
-Haematogenous
-most common route (90%)
-Lymphatics
-Direct spread
- from infected abdominal organ or affected
peritoneum
-Ascending
-Direct contact with infected sputum
-sexual contact
7. Pathogenesis
Colonisation of genital tract
Formation of granulomata(viable TB bacilli)
Remain silent for longer periods in genital organs
Reactivation of focus at menarche
8. Genital infection acquired in childhood remains dormant till
puberty
At menarche
Active growth and Increase in
blood supply to genital organs
Reactivation and establishment of disease process
11. Tubercle bacilli infect susceptible host
Primary reaction
Polymorphonuclear inflammatory exudate
After 48 hrs
Replaced by mononuclear cells
Cellular immunity
Destruction of tubercle bacilli
Caseation necrosis
Reactivation classic granulomatous lesion
12. Classical granulomatous lesion
Central caseous necrosis with concentric layers of
epitheloid cells,giant cells, peripheral lymphocytes
,monocytes and fibroblasts
13. FALLOPIAN TUBE
-Involvement – 90 -100 %
-central channel for initiation and dissemination of infection
- Most common part affected – Ampulla
-Least or no involvement – fimbrial and interstitium
-Spread– haematogenous ,lymphatic and transperitoneal
extension from nearby structures.
-Endosalpingitis Tubal mucosa – favourable nidus –
transluminal spread
-Exosalpingitis – diffusely spread miliary tubercles on serosal
surface
14. • Tube – thickened, whip-like
consistency
• TOBACCO-POUCH
APPEARANCE
ampulla dilated
sparing of fimbrial end
pouting
15.
16.
17.
18. ON EXAMINATION
-Tubes enlarged in diameter
-External surface roughened – adhesions & greyish
miliary tubercles
-Sometimes tube elongated with retort shape
structure(20%)
ON CUTSECTION
-Yellowish grey caseous matter or Haematosalpinx or
pyosalpinx
MICROSCOPY
-Involves full thickness of tubal wall
-Ampulla – focal or wide spread reactive adenomatous
hyperplasia
19. Violin string adhesions between right fallopian tube &
under surface of liver – FITZ – HUGH - CURTIS SYNDROME
-Leakage of infected matter
into peritoneal cavity
- Peritubal abscess
- Tubercular peritonitis
- Ascites
20. Reactive fibrosis (Sapingitis isthmica nodosa)–
occlusion of tubes as disease advances
Mucosa exhibits hyperplastic adenomatous pattern
with complex network of fused papillae
There by increasing incidence of ectopic
pregnancies
21. TB-ENDOMETRIUM
ON EXAMINATION
-No remarkable changes in most of the cases – due to cyclical menstrual
shedding
-Occasionally ulcerative , granular or fungating lesions
-Sometimes uterine cavity appears smooth & devoid of endometrium
-Destruction of endometrium may lead to amenorrhea
-Uterine cavity – shrunken due to underlying fibrosis(Asherman syndrome)
-Tubal ostia appear recessed and narrowed – GOLF HOLE APPEARANCE
-Involves 50 -60 %
-Descending infection
-CORNUAL ENDS – first to get affected
22.
23. TUBERCULOSIS OF OVARY
-Involves 20 -30 %
-Spread
1) from adjacent tubes PERIOOPHORITIS ovary
encased in adhesions
2) haematogenous spread caseating granulomas in
parenchyma
24. TB OF CERVIX
- Involves 5 – 15 %
SPREAD
- Primary source – Husband
- Secondary – descending infection from uterine cavity (most common)
ON EXAMINATION
-Polypoidal hypertrophic lesion mimics cancer cervix
-Ulcerative lesions - yellowish brown offensive discharge – may bleed on
touch
-Reactive hyperplasia of glandular epithelium papillae formation
MICROSCOPY
- Scarce granulomatous lesions with many lymphocytes
29. CLINICAL FEATURES OF GENITAL TB
10 – 15 % - Asymptomatic
General symptoms – wt.loss , fatigue , low grade
fever,litlessness should raise the suspicion of
unsuspected TB.
Others – 1) infertility – 35 – 60 %
2) menstrual irregularities – 10 – 40 %
3) pain abdomen or chronic pelvic pain
4) vaginal discharge
5) abdominal mass
6) ectopic pregnancy
7) fistula formation
30. INVESTIGATIONS
CBP – presence of lymphocytosis
ESR – Raised – non-specific
Mantoux - + test indicates exposure to TB bacilli in
past
QuantiFERON – superior to mantoux
USG – Reveals abdominal mass, USG guided FNAC
can be done
Chest X-Ray – to detect site of primary lesion
Tissue biopsy – local excision tissue biopsy from
lesions of lower genital tract on histology diagnoses
TB
31. Endometrial histology
-Done in late premenstrual phase
-Tissue obtained from D &C or Hysteroscopic biopsy
-Classical granulomatous lesion seen in endometrial
samplings on DAY 24 – 26 of cycle or within few
hours of onset of menstruation
32. Endometrial scrapings divided into 3 portions:
1) for Histopathology
2) - for PCR testing – rapid , sensitive & specific to
detect mycobacterial DNA. Results obtained in
24hrs.
-can detect fewer than 10 organisms in clinical
specimen compared to 10,000 necessary for smear
positivity
3) Guinea pig inoculation and culture
33.
34. • CBNAAT – Catridge based Nucleic Acid
Amplification Technique –Results within 2 hrs -
molecular test
35. Hysterosalpingography
- Performed in asymptomatic women
- Contraindicated if suspected of genital TB – Risk of
spread of infection
Features –Beading & filling defect
Cornual blocks
Jagged fluffiness of tubal outline
Calcification of tube
Tobacco pouch appearance of
hydrosalpinx or pyosalpinx
Rigid non-peristaltic pipe like tube
(LEAD PIPE APPEARANCE)
36.
37.
38. LAPAROSCOPY
-To establish the diagnosis of abdomino-pelvic
TB
- TB lesions can be seen on parietal
peritoneum,intestinal serosa , omentum ,
uterus & tubes , hydrosalpinx ,
pyosalpinx,tubo-ovarian mass .
-Histology and PCR testing from selected tissue
biopsy helps in diagnosis.
39.
40. Other tests are
Gas chromatography – direct demo of components
of mycobacterium
SAFA (Soluble Antigen Fluorescence Antibody)
BACTEC – Rapid culture method
- radioactive carbon labelled substrate
palmtic acid or formic acid used
- takes 5 -7 days
Semen culture – in presence of vulvo vaginal
lesions
41. CONT…
-Gene expert:
-new test introduced for diagnosis of drug resistant
TB
-Its based on PCR
- Biochemical markers – ascitic fluid for Adenosine
deaminase . Highly specific & sensitive
-ELISA – for IgG & IgM
-X-rays of bones and joints
42. DIFFERENTIAL DIAGNOSIS
-Ovarian cyst,broad ligament cyst,encysted fluid
-PID
-Ectopic pregnancy
-Carcinoma cervix
-Elephantiasis of vulva
-Pregnancy
-puberty menorrhagia and post menopausal bleeding
-Fungal infections and Sarcoidosis
45. DOT – SHORT COURSE THERAPY – 6 months
Initiation phase – 2 months – HRZE – 3 times a
week
Continuation phase – 4 months – HR Only
Resistant cases – 8 months
First 2 months – HRZE + S
3RD month – HRZE
Remaining 5 months – HRE
46. SURGERY
INDICATIONS - despite the chemotheray if
- Persistent active lesion
- Progression of disease
- Persistent large inflammatory mass
(pyosalpinx,pyometra)
- Persistent symptoms – pain , menorrhagia
- Persistence of fistula
CONTRAINDICATIONS
- Active lesions elsewhere
- Adhesions of bowel
- Chemotherapy – given several weeks before & full course
after surgey
47. Types of surgeries
- Removal of adnexal mass
- Total hysterectomy with B/L salpingoopherectomy
- Drainage of pyometra
- Vulvectomy – hypertrophied vulva
- Fistula repair
Follow –up
- 5 years
- Yearly or when indicated early curettage –to check
reactivation
- HSG –CONTRAINDICATED – reactivates dormant
infection
48. PROGNOSIS
• Fertility – only in 10 %
• 1/3rd abort
• 50% ectopic pregnancies
• Only 2 % will have live births
49. TAKE HOME MESSAGE…..
-The physician should be conscious of the entity
-One should suspect and exclude genital TB in the
following :
-unexplained infertility or amenorrhea
-Recurrent episodes of pelvic infection not
responding with usual course of antibiotics
-presence of pelvic mass with nodules in POD
