Genital tract TB

كلية الطب ? جامعة بابل المرحلة الخامسة
د-نسرين مالك
Gynaecology
Genital tract TB
Is a chronic disease that is caused by Mycobacterium tuberculosis , it is often presents with low grade symptomatology and very few specific complaints. Presenting symptoms are generally varied; infertility being the most frequent clinical presentation (43-74%). Other clinical presentations include oligomenorrhoea (54%), amenorrhoea, menorrhagia ,abdominal pain dyspareunia ,and dysmenorrhoea.
The actual incidence of genital TB cannot be determined accurately in any population because it is estimated that at least 11% of patients are asymptomatic and the disease is discovered incidentally.

Pathogenesis:-
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, especially in conjunction with diseases or drugs that cause attenuation of T-cell response (e.g. Hodgkin’s lymphoma, AIDS, steroids, stress, or malnutrition). The mode of spread is usually hematogenous or lymphatic and occasionally occurs by way of direct contiguity with an intra-abdominal or peritoneal focus. The focus in the lung often heals, and the lesion may lie dormant in the genital tract for years, only to reactivate at a later time.

Frequency of tuberculosis in genital organ:-

%Frequency Organ

Fallopian tubes 90-100

Endometrium 50-60

Ovaries 20-30

Cervix 5-15

Vulva and vagina 1
Macroscopic appearance of genital tuberculosis:-
Types of tuberculous salpingitis:-
1-Exudative:-In the exudative type, the tube may be significantly enlarged. Although a large pyosalpinx may form, these tubes show few adhesions and usually are reasonably mobile if surgery is needed
2-Productive-Adhesive:-In the productive-adhesive form, which is found most frequently at laparoscopy or laparotomy, the tubes are studded with tubercles and are densely adherent to the surrounding organs.
Tuberculosis of the endometrium:-Grossly, the size and shape of the uterus may appear normal. The tuberculous process generally is localized to the endometrium, is most extensive in the fundus, and decreases toward the cervix. The myometrium is not usually involved. In premenopausal patients, much of the infected tissue is shed during the menstruation, only to have the endometrium reinfected from the tubes with each cycle..
Tuberculosis of the ovary:-
Usually, the involvement is bilateral, although this cannot always be recognized with certainty at laparotomy. Two forms of ovarian TB are described: perioophoritis, in which the ovary may be surrounded by or encased in adhesions and studded with tubercles caused by direct extension from the tube; and oophoritis, in which infection starts in the stroma of the ovary, presumably from a hematogenous source that produces a caseating granuloma within the parenchyma.

Tuberculosis of the cervix:-There are no macroscopic changes in the cervix that are specific for TB. The cervix may appear normal or inflamed, and its condition may resemble invasive carcinoma, both grossly and with the colposcope. The most common type is the ulcerative form, although papillomatous and miliary forms may also occur.

Tuberculosis of the vulva and vagina:- In the vulva, it begins as a nodule on the labia or in the vestibular region, which breaks down and forms an irregular ragged ulcer, sometimes with sinuses discharging caseous material and pus. TB of Bartholin’s gland is rare. Rarely, a vulvar lesion presents as a hypertrophic, irregular warty growth, or sometimes resembling elephantiasis.
A tuberculous lesion in the vagina may simulate carcinoma in its gross appearance.
The microscopic appearance is similar to TB occurring throughout the genital tract, with granulomatous inflammation tending to cause central caseation and an associated chronic inflammatory infiltrate
Tuberculous peritonitis:- is seen in combination with female genital tract TB approximately 45% of the time and is thought to be responsible for the extensive adhesions seen in patients with pelvic TB.
Clinical findings:-

Physical signs in genital tuberculosis
1-Normal.
2-Abdominal mass.
3-Pelvic mass.
4-Adnexal mass.
5-Abdominal tenderness.
6-Pelvic/adnexal tenderness.
7-Ascites.
8-Excessive vaginal discharge.
9-Ulcer in the vulva, vagina, and cervix.
10-Enlarged uterus with pyometra.
11-Fistula.

Symptoms
1-Systemic: low grade fever,fatigue,weight loss.
2-Symptoms related to genital tuberculosis:
Infertility:- Primary, Secondary.
: Menstrual disturbances
Amenorrhea,
Oligomenorrhea
Menorrhagia Metrorrhagia,
3--Abdominal swelling.
4-Postcoital bleeding.
5-Vaginal discharge.
6-Dyspareunia.

Diagnosis:-The diagnosis of TB is based on the identification of M. tuberculosis or others like M. bovis, M. africanum, and M. microti in culture. Isolation of mycobacteria from clinical specimens in pure cultures represents a challenge, because of the prolonged period of cultivation required for most of them.
Investigations to confirm the diagnosis of genital TB:-
1-Complete blood count and ESR. 9-Peritoneal biopsy histology
2-Chest radiograph. 10-Menstrual blood for culture.
3-Tuberculin test. 11-Cervical cytology .
4-Ultrasonograph. 12- laproscopy
5-Endometrial curettage(biopsy). 13- Serologic tests(interferon-gamma based assays).
14-Polymerase Chain Reaction,Gen expert 6- Histological examination.
for collected fluid. 7-Culture for Mycobacterium tuberculosis.
8-Peritoneal fluid for biochemical and
Microbiological study.
Deferential diagnosis:-Granulomatous lesion other than TB are:-
1-Sarcoid. 2- Crohn’s disease. 3-Actinomycosis,
4- Leprosy. 5-Granuloma inguinale. 6-Lymphogranuloma venereum, 7-Syphilis. 8-Histoplasmosis. 9-Brucellosis. 10-Berylliosis. 11-Silicosis 12-Tularemia.
13- Foreign body reaction. 14-Schistosomiasis. 15-filariasis.
Complications of genital tuberculosis:-
1-Subfertility or Sterility, 2-Ectopic Pregnancy. 3-Rarely congenital tuberculosis.
Management:-The treatment of genital tract TB, is the same as the treatment of pulmonary TB. Thus, the current standards in the treatment of tuberculosis are:-A 6-month regimen consisting of isoniazid (INH), rifampin (RIF) Ethambutol (EMB) and pyrazinamide (PZA) for 2 months, followed by INH and RIF for 4 months, is the preferred treatment for patients with a fully susceptible organism. Add pyridoxine 25?50 mg daily to regimens that include INH.
Other drugs used against mycobacterium tuberculosis:-
Other drugs that have been used against M. tuberculosis and are currently being used, especially in multidrug-resistant disease, are para-aminosalicylic acid (PAS), cycloserine, capreomycin, kanamycin, thiacetazone, amikacin, ciprofloxacin, and ofloxacin.
Surgical Treatment:-Indications for surgical intervention in the management of pelvic TB :-
(1) Persistent and recurrent disease despite adequate treatment.
(2) Persistent or recurrent pelvic masses after 6 months of adequate therapy.
(3) Persistent or recurrent symptoms such as pelvic pain and abnormal bleeding.
(4)Persistent non healing fistula.
(5) Multidrug-resistant disease.
(6) Concomitant genital tract neoplasia or other pathology.
When surgery is advocated, the patient should be given drug therapy for at least 1–2 weeks preoperatively, and the drugs should be continued for 6–12 months postoperatively. Under antituberculous treatment, surgery is technically much less difficult, and morbidity and mortality are significantly reduced.When TB is first diagnosed postoperatively after histological examination, antituberculous treatment is given immediately and continued for 6–12 months.
The operation of choice is total abdominal hysterectomy with bilateral salpingo-oopherectomy followed by hormone replacement therapy, especially in a premenopausal woman. If the patient is premenopausal and the ovaries look normal, they may be conserved.