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Apollo Medicine 2012 SeptemberVolume 9, Number 3; pp. 224e227 Review Article

Genital tuberculosis

Harmeet Malhotra

Sr. Coemail:ReceivCopyrihttp://d

ABSTRACT

Tuberculosis (TB) is a very common disease worldwide including India. Tuberculosis of the female genital tract iscommon enough to be found in 1% of women with DUB (Sutherland 1949) and in 4% of adolescent with excessivemenstrual loss (Sutherland 1953). The commonest site of involvement is the fallopian tubes (90e100%). The nextcommon site is endometrium (60%). The infection is from the tubes either by lymphatics or direct spread throughcontinuity. Symptoms vary according to the severity site and stage of the disease. Anti tuberculosis chemotherapy isthe mainstay of tt. Initially drugs are used for 2 months. These are isoniazid, rifampicin, pyrazinamide and ethambutal.Treatment is continued for another 4 months with isoniazid and rifampicin.

Copyright © 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

Keywords: Genital tuberculosis, Fallopian tube, Endometrium, Interferon

INTRODUCTION

More than 2 billion people equal to one third of world’spopulation are infected with Tuberculosis bacilli. Tubercu-losis exists in two forms: Pulmonary and extra pulmonary.Genital tuberculosis is a form of extra pulmonary tubercu-losis that affects 12.1% of patients with pulmonary tubercu-losis and represents 15e20% of extra pulmonarytuberculosis. It is estimated that 5e13% of patient in infer-tility clinics have genital tuberculosis. Majority are in agegroup of 20e40 year.1

Tuberculosis of the female genital tract once commonenough to be found in 1% of women with DUB (Sutherland1949) and in 4% of adolescent with excessive menstrualloss (Sutherland 1953) had shared in a general dramaticdecline in the incidence of tuberculosis disease that had fol-lowed introduction of ATT.2

The exact incidence of genital tuberculosis is difficult toassess as it is not well reported like pulmonary tuberculosisand many times it is asymptomatic and due to not readilyavailable laboratory test which is easy to perform and reli-able. The disease is not common in US (1%) but reported

nsultant, Obst & Gynae, Indraprastha Apollo Hospitals, Sarita Vihar,drharmeet2002@yahoo.co.ined: 16.6.2012; Accepted: 3.7.2012; Available online: 10.7.2012ght � 2012, Indraprastha Medical Corporation Ltd. All rights reservedx.doi.org/10.1016/j.apme.2012.07.013

much more in different parts of India (Studd 18),3 Asiaand Africa. Genital tuberculosis is still seen in parts of Scot-land, immigrant population of poor social strata of UK.There has been a 2e3 fold increase in tuberculosis casesin Sub Saharan Africa due to infection with HIV.

PATHOGENESIS

Almost invariably tuberculosis of the genital tract issecondary to a primary lesion elsewhere and the latter isusually quiescent by the time pelvic involvement is diag-nosed. Sexual transmission from a male partner with Tuber-culous epididymitis is extremely rare. Another mode ofinvolvement of ovaries, tubes and serosa and uterus is perito-neal spread from an intra abdomen lesion inminority of cases.But generally infection reaches the genital tract (tubes inmostcases) by blood spread usually from a pulmonary lesion.

A vulval lesion secondary to intestinal infection bybovine or human Mycobacterium tuberculosis is a raritycommonly infecting organism is human mycobacterium.From the tubes infection reaches the endometrium where

New Delhi 110076, India.

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Genital tuberculosis Review Article 225

either it persists in the basal layer or reinfection occurs fromthe tube following menstruation. The infection can alsospread from the tube to the peritoneal cavity and ovaries.In untreated cases, caseating peritonitis with fistula forma-tion in rarely seen.2

PATHOLOGY

The commonest site of involvement is the fallopian tubes(90e100%) and both tubes become involved almost invari-ably.2 Infection begins in the mucosa and then spreadsthrough the tubal wall to the peritoneal surface. The macro-scopic appearances are similar to those of non tuberculouschronic salpingitis with tubal thickening, fibrosis and adhe-sions.Military nodulesmay form on the surfaces of the tubes.When thickening becomes segmented, it is known as salpin-gitis isthmica nodosa. If the ends of the tubes get blocked, itleads to formation of pyosalpinx. In some cases, fimbrial endis open but tube remains rigid and narrow. Mucosal folds aredestroyed and sometimes diverticula and crypts develop inthe lumen of the tube. Due to these changes there is failureof tubal function leading to infertility.

The ovaries may be involved with adhesions and mili-tary nodules. Miliary spread may be seen to the surfaceof uterus and peritoneum.

HISTOLOGICAL EXAM

Shows typical tubercles with giant epitheloid and round cellsknown as Langhans cells. Caseation is common in advancedcases especially in a pyosalpinx or a tuberculosis to abscess.Reinfection from the tube may not occur during every cycle.2

The next common site is endometrium (60%). The infec-tion is from the tubes either by lymphatics or direct spreadthrough continuity. Cormual ends are commonly involved.After the endometrium is shed at each menstruation, reinfec-tion occurs from the lesion in the basal layer or from the tubes.4

Synechiae formation can occur following ulceration ofendometrium leading to infertility, secondary amenorrhoeaor recurrent abortion, the infection can spread to myome-triums. A pyometra can result due to caseation especiallyin postmenopausal women. The ovary, cervix, vagina andvulva are infected much frequently.5 The ovaries areinvolved about 30% cases of Tubercular salpingitis,4 thelesion on ovary may show as surface tubercles adhesionsor may form a tubo ovarian abscess especially followingcaseation. Tubercular cervicitis can present as an ulcerresembling ectopy or like a proliferative lesion resemblingcarcinoma cervix. Tubercular cervicitis is uncommon.1

The affection of vulva vagina is rare 1%. The lesion can

be annular or a growth. Pelvic peritonitis is present in40e50% cases and can be executive type or adhesive type.4

CLINICAL FEATURES

Symptoms vary according to the severity site and stage ofthe disease many a times patient may be asymptomatic,with no abnormal signs.d Other extreme presentation is formation of a large pelvic

mass.d There may be symbol of chronic PID.d Menstrual abnormalities, eg. A menorroea, menorrhagia,

hypomen, polymenorhoea, postmenopausal bleedingoligomen.

d Excessive vagdisch is common.d C/O pelvic pain in some cases.d General symptoms typical of tuberculosis may be

present eg. weight loss, anorexia, pyrexia.d Patients of genital tuberculosis may present as infertility

which may be primary or secondary.d 5e10% of infertility patients suffer from genital tubercu-

losis involving fallopian tubes, endometrium andcausing ovarian damage.

DIAGNOSIS

There is no one particular test in all cases. There are varie-ties of tests which may be required to make the diagnosis ofgenital tuberculosis. Clinical suspicion should always bethere especially in high prevalence areas, since it is a pauci-bacillary disease so demonstration of tuberculosis is manytimes quite difficult.

The various tests can be done as follows:1. Chest x-ray can show current and past infection.2. CBC e a raised ESR, lymphocytosis, anaemia may be

found.3. MX test e its role is not definite as the positive reaction

shows that the person is infected with M. tuberculosisbut doesn’t indicate active disease. In severe tuberculosisand immunosuppressant Mx test may be negative. Thetuberculin skin test (TST) is widely utilized for detectionof M. tuberculosis infection but it has limitation. TheTST can cross react with non tubercular mycobacteria,and BCG vaccine.

4. Serological test e this is an ELISA test based on antigenof M. tuberculosis. These tests are not sensitive andspecific.

5. Nucleic acid amplification Rapid Molecular techniquesusing nucleic acid and amplification can detectM. tuberculosis DNA within 48 h of infection can be

226 Apollo Medicine 2012 September; Vol. 9, No. 3 Malhotra

used to any sample and can increase the yield of pauci-bacillary disease. It has a sensitivity of 87e100% speci-ficity of 92e98%. In addition PCR can detect genes thatconfer resistance to drugs. This process allows earlyidentification of MDR or extensively drug resistant(XDR) tuberculosis. Cannot be relied upon to start orstop ATT.

6. Interferon Y (IFN-Y) release away (IGRAS).7. HSG e radiological findings of tuberculosis salpingitis

can be e rigid pipe stem narrowing of isthmusd Punctuate opacification of crypts and diverticulae inthe lumen of the tube.

d Clubbed ampulla.d Calcification in the tubes/ovaries.d Beaded app typical of salpingitis isthmica nodosa.d Bilateral cornual block.d HydrosalpinxHSG contra indicated in a known case ofgenital tuberculosis.

d Distorted uterine contour due to synchiae formation.8. USG: it can pick up adnexal masses due to tuberculosis.9. CT scan of MRI has a role to play in cases of abdominal

masses, pelvic ascities.

10. EB e endometrial curettings are examined microscop-ically for the presence of tubercle and demonstrationof M. tuberculosis by ZiehleNeelsen staining anda positive culture specifically for T. bacilli. Evena PCR test can be done on the endometrium. A positiveguinea pig inoculation is diagnostic tuberculosis endo-metriotis has been seen in 13.6% of infertile women,undergoing routine EB. Endometrial biopsy should bedone in the premenstrual phase menstrual blood onday of onset of menses in unmarried girls can be sub-jected to PCR testing and for mycobacterial smearand culture.2

Hysteroscopy

There may be presence of intra uterine adhesions in 30%.Sometimes areas of scarring and occasionally narrowingof the uterine cavity. But for confirmation histologicalevidence is must.

Laparoscopy

Laparoscopy may reveal tubercles on the peritoneum, serosaof fallopian tube uterus. It may show fluid in POD. Theremaybe adnexal masses, thickened tubes, peritubal adhesions,hydrosalpinx. There may be evidence of blocked tubes onCPT. Genital tuberculosis can be seen in 5e33.8% cases ofinfertility on routine laparoscopy. There may also be periovarian, omental and intestinal adhesions.2

TREATMENT

Anti tuberculosis chemotherapy is the mainstay of tt. Initiallydrugs are used for 2 months. These are isoniazid, rifampicin,pyrazinamide and ethambutal. Treatment is continued foranother 4 months with isoniazid and rifampicin.

These drugs may be used during pregnancy and lacta-tion. Treatment of tuberculosis in HIV-positive women issame with little change.

Surgical treatment

The need for this has reduced since the introduction of effec-tive ATT. However, surgery may be required in case of:1. Peritent or increase in pelvic adhexal masses inspite of 9

months of ATT.2. Recurrence of tuberculosis of the endometrium.3. Persistence or reoccurrence of abnormal pain or bleeding

inspite of 9 months treatment (ATT)4. Persistent tuberculosis sinus or fistula.5. Non healing wound.

Surgery can be done TAH BSO or adnexectomy surgerycan be hazardous and difficult. Pregnancy is rare (5e10%),chances of ectopic pregnancy is 40%.

Treatment for fertility

It can be in the form of tuboplasty or ART. 9 months ATTis must before tuboplasty or ART. The infected area inendometrium heals by fibrosis. So, even ART results arepoor in such cases. Interferon-gamma (IFN-Y) releaseaway (IGRAS) such as the commercially available Quanti-FERON-tuberculosis gold. In tube (QFTeGIT) test has thepotential to overcome some of TSTs limitations. QFTeGITdetectsM. tuberculosis infection by measuring in vitro IFN-Y release following stimulation of lymphocytes will anti-gens specific to M. tuberculosis. Recently CDC (US)provided guidance that IGRAS are an acceptable alterroutine to TST for the detection ofM. tuberculosis infectionand is the preferred option in BCG vaccinated population aswell.6 while many research studies have been conducted toassess IGRA test performance, there is limited informationabout the implementation of these tests in the context ofpublic health tuberculosis control programmes.7

CONCLUSION

More than 2 billion people equal to one third of world’spopulation are infected with T. bacilli. Even though thediagnosis of genital tuberculosis is possible by the demon-stration of mycobacterium in the genital tract, the

Genital tuberculosis Review Article 227

characteristic radiographic appearances on HSG are reliableindicators of genital tuberculosis. Almost 60e70% cases ofgenital TB present with infertility. In India almost 5%e10% of all infertility is caused by genital TB. Medical treat-ment may restore fertility in early cases.

CONFLICTS OF INTEREST

The author has none to declare.

REFERENCES

1. Saraswat P, Swarankar ML, Bhandari A, Soni R. Detection ofactive female genital tuberculosis by molecular method. Int JPharm Bioscience. OcteDec 2010;1(4):B-238.

2. ER Whitefield. Pelvic Infection dew hurts Textbook of Gynaefor Post graduates.

3. Jai B Sharma. Tuberculosis and Obs & Gynae. Practice, Prog-ress in Obs & Gynae (18).

4. Shirish N Daftary, Ameet Patki. Reproductive Endocrinologyand Infertility.

5. DC Dutta. Textbook of Gynaecology.6. Mazurek GH, Jereb J, Verhon A, et al. Updated guidelines for

using interferon gamma, release assay to detect mycobacteriumtuberculosis infection-United States, 2010. MMWR RecommRep. 2010;59:1e25.

7. Grinsdale JA, HOCS, Banonvong H, Kawamura LM. Program-matic impact of using QuantiFERON (R) e TB gold in routinecontact invest activities. Int J Tuberc Lung Dis. 2011;15:1614e1620.

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