Genital Tuberculosis

1
Genital Tuberculosis
2

• Dr Ajit Virkud
• Professor, and Head of Department,
• K.B.B.Hospital, Bandra, Mumbai.
• Consultant,
• Bhatia Hospital, Mumbai

3
Who said this?
THERE IS A DREAD DISEASE.. IN WHICH LIFE AND
DEATH ARE SO STRONGLY BLENDED THAT DEATH TAKES
THE GLOW AND HUE OF LIFE, AND LIFE THE GAUNT AND
GRISLY FORM OF DEATH.

• What was he referring to?

4
Answer

• Charles Dickens referring to Tuberculosis

5
Who discovered the Tubercle Bacillus?
6
Answer

• Robert Koch discovered the tubercle bacilli in
  1882.
• The word tuberculosis was first used in 1834.

7
What was this disease called in ancient Indian
Vedas?
8
Answer

• Tuberculosis was known as Raksyasman - king of
  diseases, in the ancient Indian Vedas

9
Who described the first case of genital TB?

• Who described the first case of TB endometritis?

10
Answer

• First recorded case of genital tuberculosis was
  described by Morgagni in 1744
• First case of tubercular endometritis was
  reported by Kiwsch in 1847.

11
Which country has the highest incidence of TB?
12
Answer

• India has the highest incidence in the world. The
  reported incidence in India is 2-10 (Malkani,
  1975 9.3, Agarwal, 1993 2.4).

13
What is Mycobacterium tuberculosis complex?

• MTB complex?

14
Answer

• It comprises
• M. tuberculosis hominis
• M. bovis
• M. africanum (atypical Mycobacteria spp.)
• Tuberculosis in humans is mainly caused by
  bacteria called M. tuberculosis hominis
  (occasionally mycobacterium bovis or atypical
  tuberculosis organisms are also found).

15
How does TB bacillus differ from other bacteria?

• Why does it not respond to commonly used
  anti-bacterial agents?

16
Answer

• Tuberculosis organism is a non-motile obligate
  aerobe with replicating cycle of 17-24 hours
  (slow growing)
• It does not have a capsule.
• It has a property of being acid-fast due to the
  surface lipids. This property makes it resistant
  to common antibacterial agents and lytic enzymes.

17
How does Tuberculosis spread?

• Is it a sexually transmitted disease?

18
Answer

• Hematogenous spread according to Magnus Hames
  this is the commonest mode of spread seen in 90
  of cases.
• Descending infection (7) direct or lymphatic
  spread from the peritoneum, bowel or mesenteric
  lymph nodes
• Ascending infection rarely (1-2 cases)
  infection occurs from coitus with a male
  suffering from urogenital tuberculosis or by use
  of infected sputum as a lubricant for intercourse
  or in children who sit naked on infected sputum.

19
On PV examination F. Tubs are palpable?

• What is your diagnosis?

20
Answer

• Thickened, palpable fallopian tubes suggests
  tubercular salpingitis.

21
What is frozen pelvis?

• What is its differential diagnosis?

22
Answer

• When all pelvic structures are matted together
  and fixed with the uterus it results in frozen
  pelvis.
• DD of frozen pelvis?
• Florid genital tuberculosis
• Grade III/IV pelvic endometriosis
• Advance invasive carcinoma of cervix
• Following radiotherapy for invasive carcinoma of
  cervix

23
You are doing D C to rule out TB endometritis.

• How do you obtain the endometrium and how do you
  send the sample?

24
Answer

• One must do a thorough curettage, including bothy
  cornual regions (common sites for TB
  endometritis)
• Entire endometrium is collected and divided in
  two parts
• Half in for formalin for histopathological
  examination to look for tuberculous granulomas.
• Other half in saline for smear / culture / guinea
  pig inoculation. Smear Ziehl Neelson stain

25
How do you obtain a sample in adolescent
unmarried girls?

• In virginal adolescent girls with s/s of PID one
  must rule out Genital TB.

26
Answer

• In unmarried adolescent girls menstrual discharge
  collected within 12 hours of onset of menses can
  be used for culture.

27
What are the different culture media used for TB?
28
Answer

• Various culture media used are
• Lowenstein Jensen medium (color malachite green),
  
• Dorset's egg, Petroff's,
• Tween 80, Dubois medium
• Colonies are cream colored, raised, coarsely
  granular dry friable and rough with spreading
  edges suggests virulent forms.
• Culture report takes 3-6 weeks.

29
Is Guinea pig inoculation essential for diagnosis?

• Can you use any other animal for testing?

30
Answer

• Animal inoculation is the only investigation
  accepted as confirmatory evidence of TB Smaller
  lab animals like mice can be used

31
Read this HSG

• What is your diagnosis?

32
Answer

• HSG showing sperm head appearance suggesting TB
  salpingitis.

33
Read this hsg?

• What is your diagnosis?

34
Answer

• Moth eaten appearance suggestive of TB
  endometritis

35
Read this HSG?

• What is your diagnosis?

36
Answer

• Venous Lymphatic Intravasation
• DD
• Genital TB
• False passage
• Hsg done during or just after menses
• Injection of dye in a patient with bilateral
  cornual block

37
Read this HSG?

• What is your diagnosis?

38
Answer

• Tobacco Pouch Appearance seen in genital TB

39
What are the HSG findings suggestive of pelvic
tuberculosis ?
40
Answer In F. Tubes

• Bilateral blocked tubes especially at cornual end
• Beaded appearance
• Irregular shaggy outline of tubes
• Golf club/ sperm head appearance small
  sacculation at the filling end of
  isthmus/ampullary portion of tube
• Maltese cross appearance in fibrotic
  stage-curved or straight pipe-like appearance of
  tubes with lack of normal tortuosity
• Multiple filling defects, diverticuli or
  extravasation in tubal wall

41
Answer In F. Tubes

• Leopard skin appearance the ampulla of the tube
  is partially filled with dye giving a speckled
  appearance
• Rosette the distal end of the tube is filled
  with dye that has a rosette appearance
• Tobacco pouch appearance
• Straight thickened, rigid pipe stem tubes
• Hydrosalpinx/ pyosalpinx
• Calcification in tubes

42
Answer In Uterus

• Moth-eaten appearance irregular outline of
  cavity (TB endometritis)
• Intra-uterine adhesions (synichae)
• Venous/lymphatic intravasation of dye

43
What is Blue Uterus Sign?

• What is the role of laparoscopy in diagnosis of
  genital TB?

44
Answer
Laparoscopy should be done carefully to avoid
injury to adherent bowel loops open laparoscopy
is preferred.

• Blue uterus when chromopertubation test done
  with methylene blue
• Acute salpingitis red, swollen edematous tubes
• Tiny tubercles 1-4 mm on surface of organs
  tubes, uterus
• Hydrosalpinx, pyosalpinx
• Tobacco-pouch appearance
• Violin string adhesions
• Unilateral / bilateral TO masses
• Straw colored thick jelly like exudate in POD
• Fimbrial biopsy, peritoneal fluid may be taken to
  confirm the diagnosis

45
What are the usg findings suggestive of TB?
46
Answer

• Loculated ascites The presence of fine lacy
  strands or particulate matter in fluid is due to
  thin fibrin strands
• Bilateral or unilateral tubo-ovarian mass

47
What is Mitchison Grosset Hypothesis

• What was he referring to?

48
Answer
Group I Fast growing, neutral pH, aerobic
Group II Slow growing, intracellular, acidic
Group III Slow growing, neutral pH, hypoxic
Dormant bacilli
THE BATTLE AGAINST TUBERCULOSIS CANNOT BE WON
UNTIL DRUGS THAT CAN EFFECTIVELY KILL THESE
DORMANT TUBERCULOUS BACILLI ARE FOUND.
49
Which drugs are used in the 4 drug short course
treatment?

• Why are these drugs used?

50
Answer
Drug Bactericidal activity
Isoniazide Bactericidal in-vivo and in-vitro
Rifampicin Bactericidal in-vivo and in-vitro
Pyrazinamide Selectively bactericidal
Streptomycin Selectively bactericidal
51
What are the doses of these 4 drugs?

• Can you give these drugs twice weekly? On what
  basis?

52
Answer
Drug Dose (lt50 Kg) Dose (gt50 Kg) Twice wkly dose
Isoniazid (Z) 300 mg 450mg (8-12mg / Kg 600-900 mg
Rifampicin (R) 450 mg 600 mg Tab. 600 mg
Pyrazinamide (Z) 1500 mg 2000 mg 3000 mg
Ethambutol (E) 1200 mg 1500 mg 2400 mg
THE REASON WHY ANTI-TUBERCULOUS DRUGS CAN BE
EFFECTIVELY GIVEN IN TWICE WEEKLY DOSES ALSO IS
BECAUSE M. TUBERCULOSIS IS A SLOW GROWING
ORGANISM (REPLICATING CYCLE OF 17-24 HOURS).
53
What is DOTS?
54
Answer

• WHO declared tuberculosis a global emergency in
  1993. World health assembly (WHA) set two
  targets for TB control to be reached by 2000
• Detection of 70 of all new sputum-smear positive
  cases arising each year
• Treat 85 of these cases successfully
• To achieve this WHO promoted a new effective TB
  control program based on five essential elements
  called the Directly Observed Treatment Short
  course (DOTS) strategy

55
Answer The five elements are

• Continued political commitment from governments
• Case detection through quality-assured
  bacteriology
• Standardized short-course chemotherapy (mentioned
  in detail below) for 6-8 months involving
  directly observing the patient
• An effective drug supply and management system
• Monitoring and evaluation system for overall
  assessment of program performance.

56
Answer

• It is defined as supervised intake of drugs five
  times a week for 8 weeks (in India, the patient
  is observed to take the drug daily in the
  intensive phase) and then three times a week for
  4 months.
• The patients are given fixed drug combipack.
• The observer should be accessible, acceptable and
  accountable.

57
What is DOTS plus strategy?
58
Answer

• Patients who have a relapse or failure are
  categorized into WHO category II.
• In the initial phase they are given intramuscular
  injections of streptomycin thrice weekly for two
  months along with four drugs of category I (RHZE)
  under direct supervision. This is followed by
  four drugs (RHZE) thrice a week for another
  month. In the continuation phase they are given
  three drugs (RHE) thrice a week for 5 more months
  under direct observation.

59
What is MDR XDR TB?
60
Answer

• Resistance to one drug e.g. rifampicin or
  isoniazid is called drug resistant tuberculosis.
  Resistance to both main anti-tuberculous drugs is
  called multi-drug resistance (MDR) whereas
  resistance to many drugs namely isoniazid,
  rifampicin, injectable amino-glycosides and
  fluroquinolones is called extreme drug
  resistance (XDR).
• Drug resistant tuberculosis is treated as
  category IV with a DOTS Plus strategy

61
Answer

• Drug resistant tuberculosis is treated as
  category IV with a DOTS Plus strategy comprising
  six second line drugs daily for six months
  followed by four drugs for the next 18 months in
  the continuation phase.

62
What are the reserve line of drugs used in
treatment of TB?
63
Answer
Drug lt50 Kg gt50 Kg
Thiacetazone 150 mg 150 mg
Ethionamide 500 mg 750 mg
Cyclocerine 750 mg 1000 mg
Inj. Kanamycin 750 mg 1000 mg
Inj. Capreomycin 750 mg 1000 mg
Inj. Viomycin 750 mg 1000 mg
64
What are the newer drugs used in the treatment of
drug resistant TB?
65
Answer

• Fluoroquinolones Ciprofloxacin (1500 mg/day),
  and Ofloxacin (400-600 mg/day) for 6 months
• Anti-leprosy drugs Clofazine (100-200 mg/day)
• Beta-lactam antibiotics amoxicillin clavulanic
  acid (Augmentin)
• Macrolides azithromycin, roxithromycin, and
  clarithromycin

66
Management of Infertility in Genital Tuberculosis?
67
Answer

• Tubal reconstructive surgery is contraindicated
  because there is usually irreparable damage of
  tubes (cilia are destroyed)
• May result in reactivation and dissemination
• Those with infertility must be treated with
  medical treatment and if this does not help
  artificial reproductive techniques may be
  considered. However one must remember that in the
  presence of TB endometritis, the results of
  embryo transfer are disappointing.

68
What is the role of surgery in treatment of
genital TB?
69
Answer

• Only surgical treatment possible is extirpative
  surgery with bilateral salpingo-oophorectomy
• Anti-TB chemotherpy started 2 weeks prior and
  continued for 6 months post-operatively.
• Indications for TAH with BSO are
• Failure of medical line of treatment progression
  or persistence of active tuberculosis
• Large T-O masses, pyosalpinx, pyometra or ovarian
  abscess in a symptomatic patient of
  perimenopausal age group.

70
Answer

• Contraindications to surgery
• Active tuberculosis elsewhere in body
• Plastic peritonitis or dense adhesions around
  pelvic organs.
• During surgery do not use non-absorbable sutures
  because of risk of fistula / sinus
• Vulvectomy may be required in cases of
  hypertrophic vulvar involvement.

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What is the prognosis in genital TB cases as
regards fertility?
72
Answer

• Prognosis for child-bearing is very poor almost
  nil if endometrium is destroyed.
• Only 2-5 patients will conceive
• 20-30 will have spontaneous abortion
• 40-50 ectopic pregnancy
• Only 20 will go to full term
• Even after ART, the prognosis is poor especially
  if endometrium is destroyed

73
If mankind is to win the war against tuberculous
organism, it is imperative that world bodies like
WHO, Stop TB Organization and TB Alliance should
work together to develop new and effective
anti-tuberculous drugs and vaccines.

• Tuberculosis Minded

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• Thank You!