Genital tuberculosis

lecture on genital TB

1. Genital Tuberculosis Dr. chandrima karki Obs /gyn Lecturer kmcth

2. objective

3. Introduction

4. Major health problem in many developing countries. TB affects almost 50% of the population in Third World countries. An estimated 30 million persons have active TB, and 7–10 million people die each year of TB.

5. Incidence 11% of patients are asymptomatic and the disease is discovered incidentally. 5- 10 % in infertile cases

6. Pathogenesis Mycobacterium tuberculo sis is the infective organism Always secondary to primary extra – genital infection (50% from lungs) Invariably fallopian tubes are involved first.

7. Mode of Spread

8. Pathology Fallopian tube: These are involved first. Both tubes are affected simultaneously. Sub- mucosal layer of ampullary part of tube is the initial site of infection  muscular layer of the tube  fibrosis . Walls become thick, calcified and ossified. Involves mucosa – swollen - destroyed Fimbriae are everted, abdominal ostium usually remains patent

9. Tubes- elongated, distorted, sometime segmented. Tubal block is due to adhesion. Pouring of caseous materials from brust tubercle, leads to pyosalpinx Tubercles are seen on the surface of the tubes Tubes will be red, edematous and swollen (50% tubes are normal looking) Infection sometime spreads outwards and causes perisalphingitis with exudation resulting dense adhesions with surrounding organs – tubercular tubo - ovarian mass

10. Pathology…. Uterus: Cornual ends are affected mostly Tubercles are situated in basal layer and comes to surface premenstrually and sheds in menstruation Reinfection occurs from basal layer Endometrial ulceration leads to adhesion or synechiae formation, if caseation occur it leads to pyometra in postmenopousal female

11. Pathology…. Cervix: Less common, rarely due to sexual contact ulcerative lesion, nodular which bleeds on touch (confused with carcinoma) Vagina and Vulva: Rare lesion is shallow, superficial and ulcerative with undermined edges

12. Pathology cont.. Ovary: Involve in 30% of cases Lesions are surface tubercles, thickened capsule or caseating surface abscess and adhesion Fistula and Sinuses: It involves abdominal wall, tubes, uterus, vagina, bladder and bowel which forms spontaneously

13. Peritoneum: Pelvic peritoneum involves in 30- 40% cases and 2 types a. Dry variety (adhesive type) b. wet variety (exudative type) Microscopically it consists of granuloma with ch. Inflammatory cells and multinuceated gaint cells ( Langhans Cell) with or without caseation necrosis

14. Clinical features 80% to 90% of cases diagnosed in patients 20–40 years old, often during workup for subfertility. Although in many developing countries, genital TB is more common among younger women, in developed countries most patients are older than 40 years.

15. Symptoms

16. Symptoms

17. Clinical Features

18. Signs Most series suggest physical examination can be normal in up to 50% of cases of female genital TB.  Normal   Abdominal mass   Pelvic mass   Adnexal mass   Abdominal tenderness   Pelvic/adnexal tenderness   Ascites   Excessive vaginal discharge   Ulcer in the vulva, vagina, and cervix   Enlarged uterus with pyometra   Fistula

19. Diagnosis Blood- TC, DC, ESR Mantoux Test- Negative test excludes the tuberculosis Chest x-ray Endometrial biopsy (premenstrual) – Tissue is send for culture (Lowenstein- jensen media) , Histopathological examination of the ch . Inflammatory cells and foreign body Giant cell reaction ; bacilli can be identify by Ziehl - Neelsens stain First day menstrual blood culture for TB bacilli ( Guineapig inoculation) – negative result cannot exclude disease

20. Diagnosis f) TB PCR of Endometrial tissue- Sensitive but not specific, it will give positive result with dead bacilli or with other Mycobacterial infection g) Ultrasound Scan- reveal only TO mass h) Laparoscopy – Reveal peritoneal tubercles, TO mass, nodular tubes and can take biopsy Sputum AFB to rule out pulmonary TB j) Lymph node biopsy if Lymph nodes are enlarged

21. Treatment

22. Chemotherapy

23. DRUG Daily oral dose Nature Toxicity Comments Isoniazid 5mg/kg Max-300mg Bactericidal Hepatitis,peripheral neuropathy Check LFT, Combine pyridoxine 50mg daily Rifampicin 10mg/kg Max-600mg Bactericidal Hepatic dysfunction, Orange discolouration urine,febrile reaction avoid- ocp Monitor liver enzymes Pyrizinamide 20-25mg/kg Max-2gm Bactericidal Hepatitis,huperuricaemia,GI upset,arthralgia LFT, Active against intracellular dividing forms Ethambutol 15-20mg/kg Max-2.5gm Bacteriostatic Visual disturbances,optic neuritis,loss of visual activity Ophthalmoscopic prior to therapy

24. SURGERY

25. PROGNOSIS 90%-cured Only 10%-fertility restored Of these who conceived 50% -tubal pregnancy 20-30%-abort Only 2%-live births

26. THANK YOU