The British Journal of Radiology, 77 (2004), 164–169 E 2004 The British Institute of Radiology

DOI: 10.1259/bjr/27379200

Pictorial review
Female genital tuberculosis: hysterosalpingographic
appearances
1
G B CHAVHAN, MD, 1P HIRA, MD, 1K RATHOD, MD, 2T T ZACHARIA, MD, 1A CHAWLA, MBBS,
1
P BADHE, MD and 1H PARMAR, MD
Department of Radiology, 1King Edward Memorial Hospital, Parel, Mumbai-400012 and 2Kasturba Hospital, Manipal, India

Abstract. Genital tuberculosis is an important cause of infertility in developing countries and hysterosalping-
ography (HSG) is the initial procedure performed for the evaluation. Reviewing 37 cases of female genital
tuberculosis, we encountered various appearances on HSG. Of 579 HSGs performed over a period of 4 years,
492 (85%) were performed as part of infertility work up. Genital tuberculosis was found in 6.3% of all the
patients who underwent HSGs and 7.5% of all patients investigated for infertility. The various features of
proven tuberculosis cases are illustrated in this pictorial review. We briefly discuss the pathology and these
appearances along with radiopathological correlation.

Genital tract tuberculosis is an important cause of infer-
tility in the developing countries, where hysterosalpingo-
grams (HSG) remain the initial diagnostic procedure in the
assessment of tubal and peritoneal factors leading to
infertility [1]. It is an invaluable procedure for evaluating
the internal architecture of the female genital tract [1], and
is the most helpful procedure in suggesting the diagnosis of
genital tuberculosis in patients being investigated for
infertility [2].
We retrospectively reviewed 579 hysterosalpingograms
performed over 4 years. 492 (85%) HSGs were performed
as part of infertility work up, of these 37 (6.3% of all
HSGs and 7.5% of infertility patients) were proved to have
genital tuberculosis. The previously reported incidence of
tuberculosis of the female genital tract causing infertility
was 13% in 1979 [3].
This pictorial review aims to illustrate the various
radiographic appearances produced by tuberculosis as seen
on HSG. These cases were proved either by curettage and
biopsy of the endometrium, tubercles and adhesions at
laproscopy or a history of pulmonary tuberculosis and
response to the treatment.
Pathology
Genital tuberculosis is almost always acquired by
haematogenous spread from an extragenital source [2].
The primary focus of genital tuberculosis is the fallopian
tubes, which are almost always affected bilaterally but not
symmetrically [4]. The tubes are thickened and show a
rough external surface with adhesions. Caseous ulceration
of the mucosa produces ragged contours and diverticular
outpouchings of both the isthmus and ampulla [4]. As
tuberculosis heals, the entire tube become encased in heavy
connective scar tissue and the lumen develops a beaded,
rigid pipe stem appearance [5]. The obstruction of the tube
most frequently occurs in the region of transition between
the isthmus and the ampulla [6]. Although hydrosalpinx is
very uncommonly noted in the western literature, it is a
Received 12 July 2002 and in final form 13 October 2003, accepted 20
November 2003.
common finding in India [7]. Tubal tuberculosis spreads to
the endometrium in approximately one half of the cases
[5]. Therefore a negative culture from uterine curetting
does not exclude the diagnosis of genital tuberculosis.
Tubal tuberculosis
Calcifications
Plain films of the pelvis may show calcification of the
fallopian tubes or ovaries. This calcification must be dif-
ferentiated from calcified pelvic nodes, calcified uterine
myomas, pelvic phleboliths and calcification in an ovarian
dermoid [5]. Tubal calcification can take the form of linear
streaks, which lie in the course of the fallopian tube or
appear as faint or dense tiny nodules [7].
In our series only two (5.4%) of 37 patients showed
calcifications (Figure 1).
Tubal outline
Caseous ulceration of the mucosa of the tube produces
an irregular contour of the lumen of the tubes. Diverticular
cavities may surround the ampulla and give it a character-
istic ‘‘tufted’’ appearance. Isthmic diverticula resembling
those seen in Salphingitis isthmica nodosa may be seen [5].
Blind ending sinus tract or occasionally fistula to adjacent
bowel may form [5].
In our series irregularity of the tube was noted in six
(16%) HSGs and ampullary diverticuli (Figure 2) were
seen in three (8%) patients.
Tubal occlusion
Tubal occlusion in tuberculosis occurs most commonly
in the region of isthmus and ampulla. Multiple constrictions
along the course of fallopian tube can form because of
scarring and give rise to ‘‘beaded’’ appearance to the tubes
on HSG. Scarring also leads to a ‘‘rigid pipe stem’’
appearance of the tubes.

164 The British Journal of Radiology, February 2004

Pictorial review: HSG in tuberculosis
Tubal occlusion is the most common HSG finding
encountered in genital tuberculosis. We noticed tubal occlu-
sion in 30 (81%) of our patients. Occlusion with terminal
hydrosalpinx was seen in 12 (32%), a rigid pipe stem appear-
ance in nine (24%) (Figure 3) and beaded appearance was
seen in six (16%) of our patients (Figure 4).
Cornual occlusion is the most common site of tubal
occlusion of any cause followed by obstruction in the
ampullary segment. However, cornual occlusion is not so
common in tuberculosis. Other causes of tubal occlusion
include pelvic inflammatory diseases due to Chlamydia and
gonococci, prior pelvic surgery, Crohn’s disease, ulcerative
colitis, endometriosis, and the use of intrauterine contra-
ceptive device [8].
Tubal dilatation
Tuberculous hydrosalpinx is not uncommon in India [7],
hydrosalpinx is usually moderate or slight with a club like
appearance to the ampulla. Thickened mucosal folds in the
dilated tubes are the commonly seen feature in tuberculosis
[9] (Figures 5 and 6).
Tubal dilatation with or without obstruction was seen in
17 (46%) of our patients. Other causes of tubal dilatation
include other pelvic inflammatory diseases, adhesions and
obstruction of any cause.
Peritubal adhesion
Distal tubal disease usually appears secondary to
peritubal adhesions. These adhesions disrupt the delicate
anatomical relationship between the tube and the ovary,
interfering with normal ovulation [7]. The presence of a
convoluted or corkscrew fallopian tube (Figure 7), peri-
tubal halo, tubal fixation and loculated spillage of contrast
material (Figure 8) is suggestive of peritubal adhesions.
Adhesions were seen in 11 (30%) of our patients.
Other causes of pelvic adhesions include other chronic
pelvic inflammatory conditions, previous surgery and
endometriosis.
Figure 1. 28-year-old woman with genital tuberculosis. (a) Plain film of the pelvis frontal projection shows 1066 mm calcific density
(arrow) on the left side. (b) Hysterosalpingogram frontal projection shows isthmic obstruction of the left fallopian tube just proximal
to the calcification. There is obstruction in the interstitial part of the tube on the right side. The endometrial cavity shows irregularity.
The British Journal of Radiology, February 2004
Endometrial tuberculosis
Endometrial tuberculosis has been reported to have a
non-specific appearance on HSG, commonly characterized
by synechiae, a distorted uterine contour, and venous and
lymphatic intravasation [2].
The synechiae and intrauterine adhesions in tuberculosis
are characteristically irregular, angulated and stellate
shaped with well-demarcated borders [7] (Figures 3 and
9). Six (16%) of our patients showed synechiae. Other
causes of intrauterine adhesions include dilatation and
curettage, trauma, surgery and other infections.
Unilateral scarring may lead to obliteration of the
uterine cavity on one side giving rise to a unicornuate
like appearance called ‘‘pseudounicornuate’’ uterus [7].
Scarring in tuberculosis may result in conversion of
the triangular uterine cavity into a T-shape (Figure 10).
These T-shape uteri are very similar to those seen in
Diethylstilbestrol uteri [7]. An asymmetric small sized
uterine cavity is usually due to tuberculosis (Figures 11
and 12).
Venous and lymphatic intravasation is a good indicator
suggesting endometrial tuberculosis and was seen in 10
(27%) of our patients.
It is not specific for tuberculosis and can be seen in
HSGs done early in the menstrual cycle, shortly after
endometrial instrumentation and in any condition causing
obstruction to the flow of contrast such as intrauterine
adhesions and tubal obstruction of any aetiology [10].
Although the various features described are not specific
for genital tuberculosis, they are highly suggestive of it.
The diagnostic criteria established by Klein et al [6] is very
useful for this purpose:
1) Calcified lymph nodes or smaller, irregular calcifica-
tions in the adnexal area.
2) Obstruction of the fallopian tube in the zone of
transition between the isthmus and the ampulla.
3) Multiple constrictions along the course of the fallopian
tube.
4) Endometrial adhesion and or deformity or obliteration
of the endometrial cavity, in the absence of curettage or
surgical termination of pregnancy.
165
 G B Chavhan, P Hira, K Rathod et al

Figure 2. 30-year-old woman with genital tuberculosis.
Hysterosalpingogram frontal projection shows occlusion of
bilateral tubes in the ampullary region with multiple diverticula
bilaterally (small arrows). The thick arrow indicates terminal
hydrosalpinx.
Figure 3. 25-years-old woman with genital tuberculosis.
Hysterosalpingogram frontal projection shows isthmic obstruc-
tion of both fallopian tubes. The tubes appear rigid ‘‘pipe-
stem’’ and are beaded. There is a lucent filling defect in the
lower uterine segment suggestive of adhesion (arrow).

Figure 4. 27-year-old woman with genital tuberculosis. (a) Hysterosalpingogram shows isthmic obstruction of both the tubes. The
left tube shows ‘‘beaded’’ appearance (small arrows). Also seen are irregularity of the endometrial cavity and intravasation of the
contrast medium. (b) Hysterosalpingogram next film shows multiple diverticula in the isthmic portion of the right tube (arrowheads)
giving salpingitis isthmica nodosa like appearance.

166 The British Journal of Radiology, February 2004

Pictorial review: HSG in tuberculosis

Figure 5. 21-year-old woman with genital tuberculosis.
Hysterosalpingogram oblique projection shows ampullary obstruc-
tion of both the tubes (large arrows). There is dilatation of the
ampullary region with prominent mucosal folds (small arrows)
on the right side. The uterus is anteflexed.
Figure 6. 35-year-old woman with genital tuberculosis.
Hysterosalpingogram shows dilatation of ampullary portion of
the left tube with obstruction. This tube is seen overlapping
the uterine cavity. The contrast pooling at the end of the right
tube could represent loculated spill or a poorly filled hydrosal-
pinx (small arrows). Laproscopy showed pelvic adhesions and
left tube adherent to the anterior surface of the uterus.

Figure 7. 33-year-old woman with genital tuberculosis. (a) Hysterosalpingogram shows bilateral isthmic block. Both the tubes are
vertically oriented and appear fixed. The right tube shows ‘‘cork screw’’ appearance (small arrows). (b) On injecting more contrast
hysterosalpingogram shows intravasation of contrast medium (arrowheads). At laproscopy lots of adhesions were seen in the pelvis
with multiple tubercles on the uterine surface.

The British Journal of Radiology, February 2004 167

 G B Chavhan, P Hira, K Rathod et al

Figure 8. 28-year-old woman with genital tuberculosis.

Hysterosalpingogram shows bilateral tubes convoluted and
fixed. There is a loculated spill (small arrows) on the right side
suggestive of adhesions.

Figure 9. 32-year-old woman with genital tuberculosis. Hysterosalpingogram frontal projection shows two lucent defects (large arrows)
in the lower uterine segment suggestive of intrauterine synechiae. There is contour defect of the left side of the fundus (small arrows).

Figure 10. 40-year-old woman with genital tuberculosis. Hysterosalpingogram shows isthmic obstruction of both the tubes (large
arrows). The uterine cavity is deformed and shows ‘‘T’’ shaped configuration (small arrows). Also note the intravasation of the con-
trast medium. There is fundal impression on the uterine cavity (black arrow).

168 The British Journal of Radiology, February 2004

Pictorial review: HSG in tuberculosis

Figure 11. 27-year-old woman with genital tuberculosis. She had completed 9 months of antitubercular treatment. Hysterosalpingogram
shows isthmic obstruction of bilateral tubes (curved arrows). The calcification (large arrow) is seen in the path of the right tube. The uterine
cavity is deformed with indentation of the fundus (black arrow). There is a lucent area (arrowheads) in the uterine cavity suggestive of
intrauterine adhesion. Also seen is a small diverticulum from the fundus on the right side (small arrows).

Figure 12. 32-year-old woman with genital tuberculosis.
Hysterosalpingogram shows small contracted uterus with irre-
gular outline.
Conclusion
Even though the diagnosis
possible by the demonstration
genital tract, the characteristic
on HSG are reliable indicators
of genital tuberculosis is
of mycobacterium in the
radiographic appearances
of genital tuberculosis.
References
1. Karasick S. Hysterosalpingography. Urol Radiol 1991;13:
67–73.
2. Schwimmer M. Gynecological inflammatory diseases. In:
Pollack HM, editor. Clinical urography (1st edn) Philadelphia:
W.B. Saunders, 1990:985–6.
3. Krishna VR, Sathe AV, Mehta H, Wagle S, Purandare VN.
Tubal factors in sterility. J Obstet Gynecol India 1979;29:663.
4. Nogales-Ortiz F, Tarancon I, Nogales FF. The pathology of
female genital tuberculosis. Obstet Gynecol 1979;53:422–8.
5. Yoder IC. Hysterosalpingography and pelvic ultrasound:
imaging in infertility and gynecology (1st edn). Boston: Little
Brown and Company, 1988:66–9.
6. Klein TA, Richmond JA, Mishell DR. Pelvic tuberculosis.
Obstet Gynecol 1976;48:99–104.
7. Merchant SA. Genital tract tuberculosis. In: Subbarao K,
Banerjee S, editors. Diagnostic radiology and imaging (1st
edn). New Delhi: Jaypee Brothers, 1997:637–46.
8. Winfield AC, Wentz AC. Hysterosalpingography of fallopian
tubes. In: Imaging in infertility (2nd edn). Baltimore: Williams
and Wilkins, 1992:167–91.
9. Whitehouse GH, Wright CH. Imaging in gynaecology. In:
Grainger RG, Allison D, editors. Grainger and Allison’s
diagnostic radiology: a textbook of medical imaging (3rd edn).
New York: Churchill Livingstone, 1997:1963.
10. Winfield AC, Wentz AC. The normal hysterosalpingogram.
In: Imaging in infertility (2nd edn). Baltimore: Williams and
Wilkins, 1992:39–56.

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