Genital TB mostly spreads from the lungs or other organs with transmission being usually by hematogenous or lymphatic route or sometimes direct spread from adjacent organs (bowel or lymph node). It may be sexually-transmitted through infected semen from active genitourinary TB in the male partner.
Frequency of tuberculosis in female genital organs
Endometrium – 50–60%
Ovaries – 20–30%
Cervix – 5–15%
Vulva and vagina – 1%
TUBERCULOSIS OF FALLOPIAN TUBES
Hydrosalpinx and the tubal condition can be graded on laparoscopy and laparotomy as per the type of adhesions, patency of tubes, morphology of tubes and fimbrial stricture for prognostication of fertility.
TUBERCULOSIS OF ENDOMETRIUM
The endometrium is affected in 50-80 per cent (average 70%) patients through haematogenous, lymphatic or contagious route. Initially, there are no obvious lesions, later ulcers are formed and in advanced stages, distortion of the uterus occurs due to synechiae. The lesions can be focal or multiple ulcers, necrosis or haemorrhagic areas. Destruction of the endometrium may occur with Asherman’s syndrome manifesting as secondary amenorrhoea and infertility. On microscopy, typical caseative epithelioid granulomas, epithelioid cells and specialized Langerhans giant cells may not form due to the shedding of the endometrium during menstruation. The presence of a focal collection of lymphocytes on endometrial biopsies may also indicate FGTB.
TUBERCULOSIS OF OVARIES:
Ovaries are affected in 20-30 per cent patients with adhesions, caseation, adnexal cyst or mass formation with defective ovarian function and reserve and sometimes complete destruction of ovary. Sometimes tubo-ovarian cyst can manifest as acute abdomen simulating acute appendicitis and may be diagnosed on laparoscopy or laparotomy.
TUBERCULOSIS OF CERVIX:
The cervix may be involved in about five per cent cases of genital TB usually secondary to tubal or endometrial TB, but may rarely be primary disease transmitted by the partner through infected semen. It manifests as polypoidal growth or ulceration simulating cervical cancer necessitating biopsy and histopathological demonstration of granulomatous inflammation.
TUBERCULOSIS OF VAGINA AND VULVA:
The involvement of vagina and vulva is rare and is usually an extension from endometrium or cervix, or rarely primary due to transmission from an infected semen of the partner. There may be a hypertrophic ulcer or growth on the vulva or vagina requiring biopsy and histopathological demonstration of granuloma and to rule out cancer and other diseases such as syphilis and lymphogranuloma venereum.Rarely, a giant vulval tumour may be formed in FGTB. Even vesicovaginal and rectovaginal fistulas can rarely occur in FGTB.
IMAGING TECHNIQUES:
The two imaging techniques useful in the diagnosis of FGTB are hysterosalpingography (HSG) and ultrasonography (USG). HSG evaluates the internal structure of the female genital tract and tubal patency whereas USG allows simultaneous evaluation of ovarian, uterine and extrapelvic involvement.
HYSTEROSALPINGOGRAPHY (HSG)
Genital TB is associated with characteristic structural changes in the organs involved, and HSG is a useful tool in visualizing the abnormalities. In HSG, presentation of tubal TB varies from non-specific changes such as tubal dilatation, tubal occlusion, irregular contour, diverticular outpouching (salpingitis isthmica nodosa), hydrosalpinx to specific pattern such as ‘cotton wool plug’, ‘pipestem tube’, ‘golf club tube’, ‘cobblestone tube’, ‘beaded tube’, ‘leopard skin tube’, tubal occlusion and adhesions in the peritubal region which may present as straight spill, corkscrew appearance and peritubal halo. TB should be strongly suspected in the presence of synechiae, tubal obstruction in the transition zone between the isthmus and ampulla, multiple constrictions, calcified lymph nodes, irregular linear or nodular calcifications in the adnexal area.
The uterine changes due to TB may be seen as specific features such as ‘collarstud abscess’, ‘T-shaped’ uterus and ‘pseudounicornuate’ uterus or non-specific features such as synechiae formation, uterine contour distortion, obliteration of the uterine cavity, venous and lymphatic intravasations. Chronic infection may lead to extensive destruction of the endometrium and myometrium resulting in complete narrowing of the uterine cavity called Netter syndrome. It appears in the HSG as a gloved finger consisting of cervical canal and small part of the uterus. Cervical TB is rare as the stratified epithelium of the ectocervix is naturally resistant to bacterial penetration; hence, cervical TB is mostly secondary to TB of the fallopian tubes and endometrium. Cervical involvement is visualized in HSG as irregularity in contours and diverticular outpouching with a feathery appearance, cervical distortion and serrated endocervical canal. As TB of the cervix will most frequently be misdiagnosed as cervical cancer, the need for ruling out the later immediately is critical in the management.
USG (PELVIS):
The fallopian tubes may appear dilated, thickened and may be filled with clear fluid called hydrosalpinx or thick caseous material called pyosalpinx. The endometrium is affected in 60-90 per cent of cases with genital TB, and the uterine enlargement may be due to filling by caseous material. The endometrium may appear heterogeneous with hyperechoic areas representing foci of calcification or fibrosis, intrauterine adhesions and a distorted uterine cavity. Findings may vary from a normal scan to abnormalities such as thin or thickened endometrium, cornual obliteration, alteration in the endometrial vascularity during midcycle in stimulated menstrual cycles, calcification of the sub endometrium, variation in the uterine artery flow during midcycle, tubal fluid, free and loculated peritoneal fluid, heterogeneous enlargement of ovaries and adnexal fixation. Some findings with greater specificity are oligemic myometrial cysts, follicles with echogenic rims and presence of endometrial fluid along with a hydrosalpinx. Computed tomography and magnetic resonance imaging are employed in FGTB in the presence of an abdominal or pelvic mass.
TREATMENT:
Treatment of FGTB is similar to pulmonary TB. The regimen recommendation for many forms of EPTB is mostly not based on evidence from vigorous studies as those for PTB and the duration of treatment for six months though debatable is considered adequate. In patients with organisms sensitive to first-line drugs, sixmonth regimen is highly effective. The WHO treatment guidelines for TB (2010) recommend that patients newly diagnosed with TB should receive a regimen containing rifampicin for six months: intensive phase with isoniazid, ethambutol and pyrazinamide for a duration of two months followed by continuation phase with HR for four months. Alternative to the daily regimen is that TB patients may receive a daily intensive phase followed by thrice weekly continuation phase [2HRZE/4(HR)3] or thrice weekly dosing throughout therapy [2(HRZE)3/4(HR)3] provided that each dose is directly observed. Retreatment TB patients who default or relapse from their first treatment course may receive 2HRZES/1HRZE/5HRE. According to Standards for TB Care Guidelines for new TB patients, the initial phase should consist of two months of HREZ followed by HR for four months. Studies have reported the usage of ATT for duration of six months consisting of H, R, E, Z for two months, followed by H and R for the subsequent four months for the management of patients with genital TB. There is very limited literature available regarding randomized clinical trials which have investigated the optimal drugs and the duration of treatment for genital TB. Patients should be monitored for adverse drug reactions during the course of treatment. Since all the four drugs can cause hepatitis, monitoring of liver function is absolutely necessary. Good adherence to first-line drugs is essential as irregular drug intake can lead to the development of treatment failure, development of multidrug resistant TB as well as TB recurrence and subsequent complications. The bacteriological confirmation of response to treatment is often not possible due to the difficulty in obtaining follow up samples and lack of follow up guidelines for these patients.
