Female Genital Tuberculosis-Patel

Female Genital Tuberculosis by
Dr. Narayan M. Patel

M.D.,D.G.O.FICS
Prof.Emeritus ob./ gyn. Mun. medical college Postal address :-Mahalaxmi institute of medical teaching, Shantiniketan park, Nr. S.P. Colony,
Ahmedabad -380014 (Gujarat State.) INDIA

Phone;-(079) 27682572 Cell 98252 95530 E mail : narayanpatel1932@yahoo.com
History
First recorded case tuberculosis of female genital organ was described by Morgagni in year 1961, at autopsy
Genital Tuberculosis
Genital tuberculosis
Genital tuberculosis is always secondary to tuberculosis else where in body, usually in lungs, peritoneum, lymph glands, bones etc.
Incidence in different countries in case of Infertility

Country Author Year Incidence India Nair hosp. 1989 14.7% India Mukerjee 1967 14.5% Saudi Arabia 1985 1 to 7% Spain Botella l 1967 10.6% Japan Shinjawa 1960 5.5% England Hainas 1958 4.0% U.S.A. Foss 1958 0.6% Australia Townsend 1955 0.7% Incidence of genital tuberculosis in U.S.A. is increasing due to increase in immigrant population
Historical aspect. Kardos removed the tubes following medical treatment for tuberculosis for 10 months. Tuberculosis was active in 3.5% of cases
Value of endometrial biopsy

Absence of signs of tuberculous endometritis in any one biopsy, is not a proof of absence of the disease. Positive results follows one or more negative results. Kistner used progestron drugs to create a pseudo pregnancy, for 2 to 3 months and than did E.B. with good results for tuberculous endometritis
Types of Tuberculosis
Schefer has differentiated two types of genital tuberculosis Minimal :-symptom-less, except sterility Advance:- genital T.B. with palpable masses. Cases of latent pelvic tuberculosis, far exceed those, showing definite clinical signs
Involvement of organs---Norries (1) Fallopian tubes------85 to 90% (2) Endometrium--------35 to 50% (3) Ovaries---------------- 5 to 6% (4) cervix-----------------3 % (5) Vagina & vulva -------2 %
Involment of tubes.
The involvement of Fallopian Tubes in case of Tuberculosis, is mostly bilateral
Tuberculous pyosalpingx
Tuberculous pyosalpingx is due to early closure of the ostium and accumulation of cheesy exudate within the lumen.
H.S.G. appearance
Green berg has described the characteristic
Tobacco-pouch or mail pouch

appearance of the fimbriated extremity.
F.G.T. & Pelvic tuberculosis
One should always differentiate between Female genital toberculosis (F.G.T.) and pelvic tuberculosis. Involvement of the serosa of the tube does not necessarily mean involvement of the tubal mucosal
Dr.GeorgeSchaefer
Peritonial Tuberculosis In the peritoneal tuberculosis there is millary spread of tubercles in omentum, on serosal surface of intestine and on pelvic viscera. Peritoneal tuberculosis does not involve the mucosa of pelvic organs and may not impair reproduction
Dr.George Schaefer
F.G.T.
In F.G.T. there is involvement of mucosa of fallopian tubes, with or without spread to the uterus. It is always secondary to tuberculosis else where in the body, usually the lungs.
Dr.George Schaefer
Incidence
In a report by Serum Institute of India :-
(1) There are 2.2 million new cases of Tuberculosis in India, each year. (2) About 5,00,000 people die of tuberculosis each year in India.
Hysterosalpingography
Hysterosalpingography, if properly performed and interpreted, can be of great value in the diagnosis of genital tuberculosis.
The great value of H.S.G. lies in its revelation of the
characteristic
radiographic changes, that are pathognomonic
Genital Tuberculosis As per Mishells textbook of infertility The most valuable diagnostic study is hysterosalpingography.
The path gnomonic changes, often present on H.S.G. are:(1) Rigid pipe stem tubes (2) Ragged tubal counter (3) Small terminal tubal dilatation, (4) Calcifies lymph nodes. (5) Partial or complete obliteration of endometrial cavity.
The appearance of Kochs tubes is similar to bilateral tubal ligation.

John Richmond
Terminal ends of tubes have similar look like that of sperm head
Narayan Patel
T.B. of cervix is rare and estimated incidence is 3 to 8 %. The cervix may show frank papillary or ulcerative lesion, which may stimulate carcinoma cervix, on gross examination.
At histology the typical tubercle follicle is composed of central zone of epitheloid cells surrounded by, lymphocytes and plasma cells. Giant cells may be present. A central zone of caseation is present sometimes
Fallopian tubes are involved in almost all cases of endometrial tuberculosis
Culture of menstrual blood containing mucous and endometrial shreds, is recommended . Culture media recommended is
Loewensteins or Petragnanis 6 to 8 consecutive negative culture is necessary in order to exclude genital tuberculosis.
The infection may spread via blood stream or lymphatic or direct extension of the neighbouring organs In 80% it is haematogenous spread .
(1) (2) (3) (4) (5)
Differential Diagnosis
Pelvic inflammation. Endometriosis Ovarian tumours. Cervical cancer---in case of Cx Elephantiasis------in case of vulva Lymphoganuloma---
(6)
Tuberculous infection, in most of the cases is by human type of tuberculous bacilli (80%) and about 20% by bovine type Most common age for infection is between 20 to 40 years. It is vary rare before puberty.
Menstrual irregularity in cases of Genital Tuberculous (1) Normal------------11.8% (2) Oligomenorrhoea36% (3)Menorrhagia-----------10% (4)Amenrrhoea------------41%
Dr.Malkani
Endometrial curettage still remains an important diagnostic investigation in India, where tuberculosis is endemic.
In the series reported by Dr.Shadhana Desai, in only 2 cases endometrial culture shows mycobacterium tuberculosis and in one case, Guinea pig inoculation, grew tuberculous bacilli.
Reconstructive surgery has no place in cases of tuberculosis of tubes. As per one of the report :In 39 cases, who have undergone reconstructive surgery all 39 failed to conceive.
Reconstructive surgery is of no avail and should not be done
When the endometrial tuberculosis is extensive, the endometrium is destroyed and replaced by hyalanised connective tissue, thereby obliterating the cavity. Most of these patients are ammenorric
Negative E.B. is however not an indication for discontinuing treatment of A.K.T. particularly as histological examination of endometrium does not necessarily, reflect the state of the fallopian tubes.
Amenorrhoea
Amenorrhoea is the eventual result of the endometrial damage

Genital tuberculosis Surgery is reserved for those patients who has failed to respond to adequate trial of medical treatment.
Halberchart reported 20% of all patients treated medically for tuberculosis, sooner or latter, had ectopic pregnancy.
Genital tuberculosis If a virgin girl suffer from a pelvic inflammatory mass, it is almost always Tuberculous in origin

Female Genital Tuberculosis-Patel

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Female Genital Tuberculosis-Patel

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Female Genital Tuberculosis by

Dr. Narayan M. Patel

Ahmedabad -380014 (Gujarat State.) INDIA

Incidence in different countries in case of Infertility

Value of endometrial biopsy

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

Green berg has described the characteristic

Tobacco-pouch or mail pouch

F.G.T. & Pelvic tuberculosis

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

The appearance of Kochs tubes is similar to bilateral tubal ligation.

Fallopian tubes are involved in almost all cases of endometrial tuberculosis

Reconstructive surgery is of no avail and should not be done

Amenorrhoea is the eventual result of the endometrial damage

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