Gyne - Genital TB India

Female Genital Female Genital TuberculosisTuberculosis

by by Dr. Narayan M. PatelDr. Narayan M. Patel

M.D.,D.G.O.FICSM.D.,D.G.O.FICSProf.Emeritus ob./ gyn. Mun. medical Prof.Emeritus ob./ gyn. Mun. medical

collegecollegePostal addressPostal address :-- :--

Mahalaxmi institute of medical Mahalaxmi institute of medical teaching, Shantiniketan park, Nr. S.P. teaching, Shantiniketan park, Nr. S.P.

Colony,Colony,Ahmedabad -380014 Ahmedabad -380014 (Gujarat (Gujarat

State.) INDIAState.) INDIA Phone;-(079) 27682572 Cell 98252 95530Phone;-(079) 27682572 Cell 98252 95530

E mail : E mail : [email protected]@yahoo.com

Genital Tuberculosis

HistoryHistory First recorded case First recorded case tuberculosis of female tuberculosis of female genital organ was genital organ was described by described by Morgagni in year Morgagni in year 1961, at autopsy1961, at autopsy


Genital tuberculosisGenital tuberculosis Genital tuberculosis is always Genital tuberculosis is always

secondary to tuberculosis secondary to tuberculosis else where in body, usually in else where in body, usually in lungs, peritoneum, lymph lungs, peritoneum, lymph glands, bones etc.glands, bones etc.


Incidence in different countries in case of Incidence in different countries in case of InfertilityInfertility

CountryCountry AuthorAuthor YearYear IncidenceIncidenceIndiaIndia Nair hosp.Nair hosp. 19891989 14.7%14.7%IndiaIndia MukerjeeMukerjee 19671967 14.5%14.5%Saudi ArabiaSaudi Arabia 19851985 1 to 7%1 to 7%SpainSpain Botella lBotella l 19671967 10.6%10.6%JapanJapan ShinjawaShinjawa 19601960 5.5%5.5%EnglandEngland HainasHainas 19581958 4.0%4.0%U.S.A.U.S.A. FossFoss 19581958 0.6%0.6%AustraliaAustralia TownsendTownsend 19551955 0.7%0.7%Incidence of genital tuberculosis in U.S.A. is Incidence of genital tuberculosis in U.S.A. is

increasing due to increase in immigrant populationincreasing due to increase in immigrant population


Historical aspect.Historical aspect.

Kardos removed the tubes Kardos removed the tubes following medical treatment following medical treatment for tuberculosis for 10 for tuberculosis for 10 months.months.

Tuberculosis was active in Tuberculosis was active in 3.5% of cases3.5% of cases


Value of endometrial biopsyValue of endometrial biopsy

Absence of signs of tuberculous Absence of signs of tuberculous endometritis in any one biopsy, is not a endometritis in any one biopsy, is not a proof of absence of the disease.proof of absence of the disease.

Positive results follows one or more Positive results follows one or more negative results.negative results.

Kistner used progestron drugs to create a Kistner used progestron drugs to create a pseudo pregnancy, for 2 to 3 months and pseudo pregnancy, for 2 to 3 months and than did E.B. with good results for than did E.B. with good results for tuberculous endometritistuberculous endometritis


Types of TuberculosisTypes of Tuberculosis

Schefer has differentiated two types of Schefer has differentiated two types of genital tuberculosisgenital tuberculosis

MinimalMinimal :-symptom-less, except sterility :-symptom-less, except sterilityAdvanceAdvance:- genital T.B. with :- genital T.B. with palpable palpable

masses.masses.Cases of latent pelvic tuberculosis, far Cases of latent pelvic tuberculosis, far exceed those, showing definite clinical exceed those, showing definite clinical signssigns


Involvement of organs---NorriesInvolvement of organs---Norries

(1) Fallopian tubes------85 to 90%(1) Fallopian tubes------85 to 90% (2) Endometrium--------35 to 50%(2) Endometrium--------35 to 50% (3) Ovaries---------------- 5 to 6%(3) Ovaries---------------- 5 to 6% (4) cervix—-----------------3 %(4) cervix—-----------------3 % (5) Vagina & vulva -------2 %(5) Vagina & vulva -------2 %



Involment of tubes.Involment of tubes.

The involvement of The involvement of Fallopian Tubes in Fallopian Tubes in case of Tuberculosis, case of Tuberculosis, is mostly bilateralis mostly bilateral


Tuberculous pyosalpingxTuberculous pyosalpingx

Tuberculous pyosalpingx Tuberculous pyosalpingx is due to early closure of is due to early closure of the ostium and the ostium and accumulation of cheesy accumulation of cheesy exudate within the lumen. exudate within the lumen.

Green berg has described the Green berg has described the characteristic characteristic Tobacco-pouch orTobacco-pouch or mail pouchmail pouch appearance of the fimbriated appearance of the fimbriated extremity.extremity.

H.S.G. appearanceH.S.G. appearance

One should always differentiate One should always differentiate between Female genital toberculosis between Female genital toberculosis (F.G.T.) and pelvic tuberculosis.(F.G.T.) and pelvic tuberculosis.Involvement of the serosa of the tube Involvement of the serosa of the tube does not necessarily mean does not necessarily mean involvement of the tubal mucosalinvolvement of the tubal mucosal

Dr.GeorgeSchaeferDr.GeorgeSchaefer

F.G.T. & Pelvic tuberculosis


Peritonial Tuberculosis

In the peritoneal tuberculosis there In the peritoneal tuberculosis there is millary spread of tubercles in is millary spread of tubercles in omentum, on serosal surface of intestine omentum, on serosal surface of intestine and on pelvic viscera.and on pelvic viscera.Peritoneal tuberculosis does not involve Peritoneal tuberculosis does not involve the mucosa of pelvic organs and may not the mucosa of pelvic organs and may not impair reproductionimpair reproduction Dr.George SchaeferDr.George Schaefer


In F.G.T. there is involvement of In F.G.T. there is involvement of mucosa of fallopian tubes, with mucosa of fallopian tubes, with or without spread to the uterus.or without spread to the uterus.It is always secondary to It is always secondary to tuberculosis else where in the tuberculosis else where in the body, usually the lungs.body, usually the lungs.

Dr.George Dr.George SchaeferSchaefer

F.G.T.


In a report by Serum Institute of India :-In a report by Serum Institute of India :-

(1) There are 2.2 million new (1) There are 2.2 million new cases of Tuberculosis in India, cases of Tuberculosis in India, each year.each year.(2) About 5,00,000 people die of (2) About 5,00,000 people die of tuberculosis each year in Indiatuberculosis each year in India..

Incidence


HysterosalpingographHysterosalpingography,y, if properly performed if properly performed and interpreted, can be and interpreted, can be of great value in the of great value in the diagnosis of genital diagnosis of genital tuberculosis.tuberculosis.

HysterosalpingographyHysterosalpingography

The great value of H.S.G. The great value of H.S.G. lies in its revelation of thelies in its revelation of the

characteristic characteristic radiographic changes, radiographic changes, that are pathognomonicthat are pathognomonic


As per Mishell’s textbook of infertilityAs per Mishell’s textbook of infertilityThe most valuable diagnostic study isThe most valuable diagnostic study is hysterosalpingography.hysterosalpingography. The path gnomonic changes, often present on The path gnomonic changes, often present on H.S.G. are:- H.S.G. are:- (1) Rigid pipe stem tubes(1) Rigid pipe stem tubes(2) Ragged tubal counter(2) Ragged tubal counter(3) Small terminal tubal dilatation,(3) Small terminal tubal dilatation,(4) Calcifies lymph nodes.(4) Calcifies lymph nodes.(5) Partial or complete obliteration of (5) Partial or complete obliteration of

endometrial cavity. endometrial cavity.


The appearance of The appearance of Koch’s tubes is similar to Koch’s tubes is similar to bilateral tubal ligation.bilateral tubal ligation.

John John RichmondRichmondTerminal ends of tubes Terminal ends of tubes have similar look like that have similar look like that of sperm headof sperm head

Narayan PatelNarayan Patel



T.B. of cervix is rare and estimated T.B. of cervix is rare and estimated incidence is 3 to 8 %. The cervix may incidence is 3 to 8 %. The cervix may show frank papillary or ulcerative lesion, show frank papillary or ulcerative lesion, which may stimulate carcinoma cervix, which may stimulate carcinoma cervix, on gross examination.on gross examination.



At histology the typical tubercle At histology the typical tubercle follicle is composed of central zone of follicle is composed of central zone of epitheloid cells surrounded by, epitheloid cells surrounded by, lymphocytes and plasma cells.lymphocytes and plasma cells.

Giant cells may be present.Giant cells may be present. A central zone of caseation is A central zone of caseation is

present sometimespresent sometimes



Fallopian tubes are Fallopian tubes are involved in almost all cases of involved in almost all cases of endometrial tuberculosisendometrial tuberculosis



Culture of menstrual blood Culture of menstrual blood containing mucous and endometrial containing mucous and endometrial shreds, is recommended .shreds, is recommended .

Culture media recommended is Culture media recommended is Loewenstein’s or Petragnani’sLoewenstein’s or Petragnani’s

6 to 8 consecutive negative 6 to 8 consecutive negative culture is necessary in order to culture is necessary in order to exclude genital tuberculosis.exclude genital tuberculosis.



The infection may The infection may spread via blood stream or spread via blood stream or lymphatic or direct extension lymphatic or direct extension of the neighbouring organsof the neighbouring organs

In 80% it is In 80% it is haematogenous spread .haematogenous spread .



Differential DiagnosisDifferential Diagnosis (1)(1) Pelvic inflammationPelvic inflammation..(2)(2) EndometriosisEndometriosis(3)(3) Ovarian tumours.Ovarian tumours.(4)(4) Cervical cancer---in case of CxCervical cancer---in case of Cx(5)(5) Elephantiasis------in case of vulvaElephantiasis------in case of vulva(6)(6) Lymphoganuloma--- ”Lymphoganuloma--- ”


Tuberculous infection, in most of Tuberculous infection, in most of the cases is by human type of the cases is by human type of tuberculous bacilli (80%) and tuberculous bacilli (80%) and about 20% by bovine typeabout 20% by bovine typeMost common age for infection is Most common age for infection is between 20 to 40 years.between 20 to 40 years.It is vary rare before puberty.It is vary rare before puberty.


Menstrual irregularity in cases of Menstrual irregularity in cases of Genital TuberculousGenital Tuberculous (1) Normal------------11.8%(1) Normal------------11.8% (2) Oligomenorrhoea—36%(2) Oligomenorrhoea—36% (3)Menorrhagia-----------10%(3)Menorrhagia-----------10% (4)Amenrrhoea------------41%(4)Amenrrhoea------------41%

Dr.MalkaniDr.Malkani


Endometrial curettage Endometrial curettage still remains an important still remains an important diagnostic investigation in diagnostic investigation in India, where tuberculosis India, where tuberculosis is endemic.is endemic.


In the series reported by In the series reported by Dr.Shadhana Desai, in only 2 Dr.Shadhana Desai, in only 2 cases cases endometrial cultureendometrial culture shows mycobacterium shows mycobacterium tuberculosis and in one case, tuberculosis and in one case, Guinea pig inoculationGuinea pig inoculation, grew , grew tuberculous bacilli.tuberculous bacilli.


Reconstructive surgery has no Reconstructive surgery has no place in cases of tuberculosis of place in cases of tuberculosis of tubes. As per one of the report :-tubes. As per one of the report :-In 39 cases, who have undergone In 39 cases, who have undergone reconstructive surgery all 39 failed reconstructive surgery all 39 failed to conceive.to conceive.Reconstructive surgery is of no Reconstructive surgery is of no avail and should not be done avail and should not be done


When the endometrial tuberculosis When the endometrial tuberculosis is extensive, the endometrium is is extensive, the endometrium is destroyed and replaced by destroyed and replaced by hyalanised connective tissue, hyalanised connective tissue, thereby obliterating the cavity.thereby obliterating the cavity.Most of these patients are Most of these patients are ammenorricammenorric


Genital tuberculosisGenital tuberculosisNegative E.B. is however not Negative E.B. is however not an indication for discontinuing an indication for discontinuing treatment of A.K.T. particularly treatment of A.K.T. particularly as histological examination of as histological examination of endometrium does not endometrium does not necessarily, reflect the state of necessarily, reflect the state of the fallopian tubes.the fallopian tubes.


AmenorrhoeaAmenorrhoea

Amenorrhoea is Amenorrhoea is the eventual result the eventual result of the endometrial of the endometrial damagedamage

Genital tuberculosisGenital tuberculosisSurgery is reserved for Surgery is reserved for those patients who has those patients who has failed to respond to failed to respond to adequate trial of medical adequate trial of medical treatment.treatment.

Genital tuberculosisGenital tuberculosisHalberchart reported 20% Halberchart reported 20% of all patients treated of all patients treated medically for tuberculosis, medically for tuberculosis, sooner or latter, had ectopic sooner or latter, had ectopic pregnancy. pregnancy.

Genital tuberculosisGenital tuberculosisIf a virgin girl suffer from If a virgin girl suffer from a pelvic inflammatory a pelvic inflammatory mass, it is almost always mass, it is almost always Tuberculous in origin Tuberculous in origin


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Gyne - Genital TB India