Genital Tuberculosis Notes

Genital TB

Genital TB is a type of pelvic inflammatory disease (PID) with a hematogenous route of spread, making it a secondary infection. The primary infection site is usually the lungs, followed by the lymph nodes.

  • Spread: From the lungs or lymph nodes, the infection spreads via blood to the genital tract.

  • Most Common Site: Fallopian tubes.

  • Specific Location in Fallopian Tubes: Most commonly affects the ampulla, least commonly the intramural part.

  • Symptom: The primary symptom is infertility due to tubal blockage.

  • Second Most Common Site: Endometrium.

Routes of Spread

  • Genital TB: Hematogenous spread is the most common route.

  • Endometrial TB: Direct spread from the fallopian tubes is the most common route.

  • Least Common Site: Vagina and vulva are the least common sites for genital TB.

Hysterosalpingography (HSG) and Genital TB

HSG is usually performed to check for tubal blockage in infertile patients after ruling out anovulatory causes. However, HSG is contraindicated in patients with genital TB due to the risk of spreading the infection when the dye exits the fimbrial end of the tube.

Characteristic Appearances on HSG

If HSG is inadvertently performed on a patient with genital TB, certain characteristic appearances may be observed:

  • Beaded Appearance: The tube appears like beads on a string.

  • Lead Pipe Appearance: The tube looks straight, like a lead pipe or pipe stem.

  • Tobacco Pouch Appearance: The distal end of the tube is swollen and blocked, resembling a tobacco pouch.

  • Golf Stick Appearance: The tube resembles a golf stick.

  • Moth-Eaten Appearance: The tube appears nibbled.

  • Bilateral Cornual Block: Blockage at both cornual ends of the fallopian tubes.

    • Most Common Cause: Physiological spasm of the tube due to pain during the procedure.

    • Most Common Pathological Cause: Genital TB.

Endometrial TB

In endometrial TB, the infection typically spreads from the fallopian tubes to the endometrium. Infertility is a common symptom of overall genital TB, but endometrial TB can specifically manifest as:

Asherman Syndrome

  • Characteristics:

    • Intrauterine adhesions.

    • Thin and defective endometrium.

  • Cause: Vigorous curettage, especially in the postpartum period (e.g., after retained placenta removal), genital TB, or schistosomiasis.

  • Most Common Presentation: Menstrual irregularities (hypomenorrhea - less bleeding due to thin endometrium, or secondary amenorrhea).
    * If presented with options including a group of menstrual problems the answer should be menstrual irregularities

  • Most Common Single Problem: Infertility is the most common single presentation.
    * If presented with specific problems like oligomenorrhea, hypomenorrhea, amenorrhea, and infertility, the answer should be infertility.

  • Investigation of Choice: Hysteroscopy (both diagnostic and therapeutic).

    • HSG may show characteristic appearances, but hysteroscopy is preferred.

  • Treatment:

    • Hysteroscopic adhesiolysis (cutting the adhesions).

    • Insertion of a pediatric Foley's catheter to prevent adhesion reformation.

    • Estrogen and progesterone to thicken the endometrium and prevent endometrial cancer (estrogen alone is contraindicated in females with a uterus).

Hysteroscopy Findings in Asherman Syndrome

  • White scarred tissue.

  • Visible intrauterine adhesions.

Hints of Asherman Syndrome on HSG and Ultrasound

  • HSG: Multiple filling defects with irregular lining due to scarred tissue preventing dye flow.

  • Ultrasound: Visible adhesions inside the uterine cavity.

Pyometra

  • Pyometra: Pus inside the uterus.

    • Most Common Cause: Senile endometritis.

    • Most Common Cancer Causing Pyometra: Cancer cervix, followed by cancer endometrium.

Hematometra

  • Hematometra: Blood inside the uterine cavity.

    • Most Common Cause: Imperforate hymen.

Diagnosis of Genital TB

  • Endometrial Biopsy:

    • TB tubercles are typically present in the deep layer of the endometrium and come to the superficial layer near menstruation.

    • Perform endometrial biopsy one or two days before menstruation for optimal detection.

    • Alternatively, menstrual blood can be used for endometrial biopsy if the patient presents during menstruation.

Management of Genital TB

  • Treatment of TB: Anti-TB therapy (ATT) for six months.

  • Treatment of Infertility: In vitro fertilization (IVF) is necessary due to tubal blockage.

Important Points

  • Most Common Menstrual Irregularity: Polymenorrhea (frequent menstruation) due to congestion, followed by secondary amenorrhea due to Asherman syndrome.

  • Most Common Pelvic Finding: Usually, no specific pelvic finding; everything appears normal.

  • Second Most Common Pelvic Finding: Bilateral adnexal tenderness.

  • Most Common Pelvic Finding in Adolescent Girls: Bilateral adnexal mass.

Conclusion

Genital TB, vaginitis, and PID are primarily theoretical topics of lower yield. You may or may not see questions on them in your exams.