GENITAL TB

INTRO-
1.TB continues to prevail as a major health problem in india.
2. Incidence among females attending infertility clinics is about 2 to 10%

SOURCES OF INFECTION-
1. Genital TB is almost secondary to a focus elsewhere in d body.
2. Focus is most often found in lungs(50%), lymph nodes(40%), urinary tract & bones & joints.
3. The focus is generally quiescent when d pt. presents.
4. Chances of tb increase when infection occurs near menarche.

MODE OF SPREAD-
1. Blood stream is d commonest method of spread.
2. Direct spread from peritoneum, bowel lesions or lymphatics from infected mesentery nodes.
3. Primary infection ascends to upper genital tract. It may be due to coitus with infected partner or when child sits accidently on infected sputum.

Maximum age at diagnosis is around 28 yrs with extremes of teens & 50s.

OBSTETRIC HISTORY-
1. Only 10% of women while presentation bear children while others are infertile.
2. Infertility is due to blockage of tube or loss of tubal function.

BACTERIOLOGY-
1. Bacilli are cultured from 90% of cases.
2. It is essential to culture d tissue to confirm d diagnosis.
3. PCR is being increasingly used.

PATHOLOGY-
A] Fallopian Tube
It is monst commonly involved part(90%)

1. Tuberculous endosalpingitis:
a) tube is thickened, enlarged & tortuous.
b) The periodic spill of tubal exudate into peritoneal cavity is responsible for acute exacerbation.
c) Caseation in d wall of tube & collection of cheesy material in lumen may form a pyosalpinx if bothe does get sealed by fibrosis.
d) Dense adhesion develop around it.
e) Secondary infection of d contents may occur.
f) it may be confused with PID.
g) sometimes it may reveal hyperplastic edematous pattern resembling endometrial carcinoma.
h) it may show granulomatous lesion with chronic inflammatory infiltration.

2. Tuberculous exosalpingitis.
a) it is actually in instance of tuberculous pelvic peritonitis.
b) peritoneal surface is studded with miliary tubercles.
c) ampullary portion is dilated with fimbrial end open & pouting.
It is called TOBACCO POUCH APPEARANCE.
d) Tubercles may not be prominent on peritoneal surface. It is called FROZEN PELVIS.
e) Attempt to separate adhesion may lead to fistula and trauma.

3. Interstitial tuberculous salpingitis.
a) tube is thickened.
b) diagnosis based only on histology

DIAGNOSIS-

1. In advanced lesion., typical giant cells with caseation.
2. In early cases several section have to be studied.
3.  Culture of tissue or inoculation in guinea pig may be needed to confirm diagnosis.

A] Ovaries.
Infected in 30% cases. May consist of tubercles or adhesion with tube.

B] Uterus.
Involved in 70% cases, the infection descending from tube. Endometrium shows giant cells. In more advanced cases caseating material collects in uterine cavity to form a pyometra.
Adhesions withhn uterine cavity lead to formation of synechiae & to Asherman syndrome when pt complains of amenorrhea.
Abscess in myometrium may occur.

C] Cervix
tb is of descending type. Lesion may appear as an ulcer or as red papillary erosion which bleeds easily on touch. Biopsy needed for confirmation.

D] Vulva & vagina
appears in form of shallow ulcer with undermined edges. Heals with scarring. Very painful. Sometimes can be hypertrophic

SYMPTOMS-

1. 10% are asymptomatic.
2. Infertility.
It is most common presentation. There is history of tb contact.
3. Menstrual disorders.
Majority present as menorrhagia. Some complain of amenorrhea being sign of extensive disease.
If pelvic examination reveals an adnexal mass likelihood of tb must be considered.
It should also be included in cause of postmenopausal bleeding.
Also tb should be assumed if therapy with hormones fail.
4. Pain
uncommon unless secondary inf sets in with development of tuberculous peritonitis or tubo-ovarian abscess.
Secondary inf of salpingitis is characterized by pain, nausea, vomiting & fever. A fixed tender mass felt in pelvis.
Recurrent subacute PID should be suspected in tb.
If virgin girl suffers from PID it is almost always due to tb.
5. Vaginal discharge
It includes blood stained discharge, postcoital bleeding, leucorrhea and painful ulcer.
6. Abdominal mass
it is immobile. Associated menstrual disorder suggests tb.
A doughy feel indicates tuberculos peritonitis.
Dysmenorrhea, dyspareunia & repeated PID are seen.
7. Fistula formation
persistant fistula following surgery for abscess.

SIGNS
1. General condition is good. No signs of primary focus.
2. Doughy feel in tuberculous peritonitis.
3. Tuberculous encysted cyst is immobile & tympanic on percussion bcoz of intestinal adhesion.
4. Tuberculous ascitis is straw colored.
5. Pelvic adnexal mass present. Non tender, small & fixed.
6. Hysterosalpingogram shows following:
rigid nonperistaltic pipe like tube called lead pipe appearance.
Beading & variation in filling density.
Calcification of tube.
Cornual block.
Jagged fluffiness of tubal outline.
Vascular or lymphatic intravasation of dye.
Tobacco pouch & dilated distal end of tubes due to pyosalpinx.
However in a proven case of tb the procedure is contraindicated due to fear of spread.
7. PID not responding to therapy & its recurrence not accompanied by polymorphonuclear leukocytosis.
8. Finding of an active but more often healed extragenital lesion in a woman suffering from infertility menstrual disorder or pelvic mass suggests tb.
9. Postmenopausal woman with pyometra or bleeding may have tb.
10. Cervical ulcer or growth may be seen.

INVESTIGATIONS.
1. D & C.
The material is used for histopathological examination & tissue culture.
2. Suction lavage during premenstrual phase for endometrial samples.
3. Hysterosalpingography not done until pelvic tb is excluded.
4. Diagnostic Laproscopy.
Biopsy & pcr done on tissue obtained.
5. Transvaginal tricut biopsy.
6. USG
7. FNAC from tubal mass.
8. Mantoux test & ESR.
9. Chest x-ray
10. Sputum & urine culture for acid fast bacilli.
11. ELISA
12. Bactec
13. Gas chromatography for tuberculous proteins
14. Soluble antigen fluorescence antibody test.
15. Semen culture.
16. Indirect hemagglutination reaction, precipitation reaction & agar gel diffusion test.
17. Hiv testing.

DIFFERENTIAL DIAGNOSIS
1. Ovarian cyst
2. PID
3. Ectopic pregnancy
4. Ca cervix
5. Elephantiasis vulva
6. Puberty menorrhagia
7. Fungal & sarcoid disease

TREATMENT.
A] Chemotherapy
treatment given as per dots.
First line drugs
1. Isoniazid 5 to 10 mg/kg o.d. Daily
 side effect- hepatotoxic, peripheral neuritis, hypersensitivity.
2. Rifampicin 10 mg/kg o.d. Daily
side effect - hepatotoxic, fever, rash, orange urine
3. Pyrazinamide 25 to 30 mg/kg o.d. Daily
side effect -hepatitis, hyperuricemia
4. Ethambutol 15 mg/kg o.d. Daily
side effect - optic neuritis, rash
1, 2, 3 are bactericidal. 4 is bacterostatic.

Note.
Contraceptives should not be combined with rifampin.
Pyridoxine 10mg daily prevents peripheral neuritis.
Optic examination mandatory before using ethambutol.

Newer drugs include.
1. Capreomycin
2. Kanamycin
3. Ethionamide
4. Para amino salycylic acid
5. Cycloserine

B] Surgery
done in following
1. Progression of disease
2. Persistant active lesion
3. Persistance of large inflammatory masses
4. Persistant symptoms.

Contraindications include active lesion anywhere else and plastic adhesion of bowels.

Types.
1. Total hysterectomy with removal of ovaries & tubes.
2. Vulvectomy in hypertrophy.

PROGNOSIS
1. 90% cure with drugs.
2. Fertility restored in only 10%.
3. 50% have tubal pregnancy.
4. 2% will have live births.
5. Pt. can be offered in vitro fertilization