Genital tuberculosis is an infection of the female genital organs caused by Mycobacterium tuberculosis. Genital tuberculosis is manifested by menstrual dysfunction, infertility, subfebrility, intoxication, chronic pelvic pain. Diagnosis is based on anamnesis data, the results of tuberculin tests, endometrial smear and scraping studies, ultrasound, laparoscopy, hysterosalpingography. Treatment includes specific drug therapy, physiotherapy, and, according to indications, surgical treatment.
A18.1 Tuberculosis of the genitourinary organs
Genital tuberculosis is most often a secondary lesion caused by the introduction of infection from the primary foci of the lesion (with pulmonary tuberculosis or intestinal tuberculosis). Tuberculosis lesion of the genitourinary system occupies the first place in the frequency of occurrence among extrapulmonary tuberculosis and is 6.5% among these forms. In the structure of disease, the defeat of the fallopian tubes comes to the fore (in 90-100% of patients), followed by the defeat of the endometrium (in 25-30% of women). In rare cases, such forms of genital lesions as tuberculosis of the ovaries, cervix, vagina and vulva are diagnosed.
A decrease in immunological resistance due to chronic infections, stress, malnutrition, and other factors leads to hematogenic or lymphogenic drift or contact entry of mycobacteria from the primary focus into the organs of the reproductive system. Infection during sexual contact with a partner suffering from this disease is possible only theoretically, because the multilayer epithelium lining the vulva, vagina and the vaginal part of the cervix is resistant to mycobacteria.
Genital tuberculosis is characterized by the development of morphohistological changes typical of infection in the genitals. According to the clinical and morphological characteristics, the following are distinguished:
- chronic form, characterized by productive inflammation, mild symptoms
- subacute form, occurring with the phenomena of exudation and proliferation, pronounced manifestations
- caseous form, accompanied by acute and severe processes
- completed tuberculosis process, encapsulation of calcification foci.
Depending on the affected area, tuberculous salpingitis, salpingoophoritis, endometritis may develop. According to the degree of activity, genital tuberculosis can be active (for 2 years), subsiding (from 2 to 4 years), inactive or characterized as the consequences of the tuberculosis process. With the aggravation of the clinical course in the first 4 years, the condition is regarded as an exacerbation of genital tuberculosis, in later terms – as a relapse. According to the isolation of mycobacteria, disease is classified into MBT (-) and MBT(+).
The manifestation occurs more often at the age of 20-30 years; less often – during puberty and postmenopause. The course is more often erased and variable, which is explained by the variety of morphological changes. Often the leading and even the only symptom is infertility caused by damage to the endometrium and fallopian tubes. In most women, menstrual function changes: oligomenorrhea, amenorrhea, irregular periods, dismenorrhea develop, less often — metrorrhagia and menorrhagia. Menstrual disorders in genital tuberculosis are caused by the involvement of the ovarian parenchyma, endometrium, intoxication.
The course of genital tuberculosis is accompanied by pain in the lower abdomen of a pulling and aching nature due to the development of adhesions in the pelvis, vascular sclerosis, nerve endings. Tuberculosis intoxication is characteristic – subfebrility, sweating at night, weakness, weight loss, loss of appetite. When the peritoneum is involved, disease often manifests from the acute abdominal clinic, in connection with which patients come to the operating table with suspected ovarian apoplexy, ectopic pregnancy, appendicitis.
Tuberculous lesion of the fallopian tubes often leads to their obliteration, the development of pyosalpinx, the formation of tubercles in the muscle layer. With tuberculosis of the appendages, the peritoneum and intestinal loops can be affected, which leads to ascites, adhesions, and the formation of fistulas. Tuberculous endometritis is also characterized by the presence of tubercles, areas of caseous necrosis. With genital tuberculosis, the urinary tract is often affected.
Suspicion of a tuberculous etiology of genital inflammation may occur when a history of pleurisy, pneumonia, bronchoadenitis, pulmonary tuberculosis or other localization is indicated. In young patients who do not live a sexual life, genital tuberculosis may be indicated by adnexitis, combined with amenorrhea and prolonged subfebrility. To confirm genital tuberculosis:
- Tuberculin samples. Subcutaneous administration of tuberculin with assessment of the general and focal reaction. The general response in genital tuberculosis is manifested by a temperature reaction, tachycardia (> 100 beats. in min.), changes in the blood formula. The local reaction in the focus of the tuberculous lesion includes increased abdominal pain, increased tenderness and swelling of the uterine appendages during palpation, an increase in temperature in the cervix.
- Gynecological examination. During vaginal examination, signs of inflammation of the appendages, adhesive processes in the pelvis can be determined. Pelvic ultrasound and ultrasound hysterosalpingoscopy for genital tuberculosis are of auxiliary diagnostic value.
- Laboratory tests. The most accurate methods of diagnosis in gynecology are bacteriological examination of secretions from the genital tract, menstrual blood, aspirate from the uterine cavity, endometrial scrapings, PCR detection of mycobacterium tuberculosis, immunological methods (T-SPOT and quantiferon test).
- Diagnostic operation. During diagnostic laparoscopy, specific changes in the pelvis are detected – tuberculous tubercles on the peritoneum, adhesive processes, caseous foci, inflammation of the appendages. Laparoscopy allows you to take material for histological examination, perform surgical correction of the consequences of genital tuberculosis: lysis of adhesions, restore patency of the fallopian tubes or remove appendages.
- Morphological examination. Histology of tissues obtained as a result of endometrial biopsy or separate diagnostic curettage in genital tuberculosis reveals the presence of perivascular infiltrates, tubercules with the phenomena of caseous decay or fibrosis in the samples. Cytological analysis of aspirate from the uterine cavity, scrapings of the cervix reveals multinucleated Pirogov-Langhans cells.
- GSG. Radiographs obtained with genital tuberculosis during hysterosalpingography indicate a displacement of the uterus due to the adhesive process, the presence of intrauterine synechiae, obliteration and changes in the contours of the tubes, calcifications in the ovaries, tubes, lymph nodes. Suspicion or detection requires the involvement of a specialist phthisiologist.
Therapy is carried out in specialized dispensaries, hospitals, sanatoriums. The basis of medical treatment of genital tuberculosis is chemotherapy with the appointment of at least 3 specific drugs. Rifampicin, streptomycin, isoniazid, ethambutol, pyrazinamide are among the main anti-tuberculosis drugs; kanamycin, amikacin, ofloxacin, etc. are also used. The course of drug therapy for genital tuberculosis lasts 6-24 months.
Patients are shown full nutrition, vitamin therapy, rest, physiotherapy (hydrocortisone ultraphonophoresis, electrophoresis, amplipulstherapy), spa therapy. In some cases, correction of menstrual function disorders is required. In the presence of tubovarial formations, ineffectiveness of antitubercular treatment, formation of fistulas and intrauterine synechiae, pronounced scarring processes in the pelvis, surgical tactics are indicated.
Relapses are observed in 7% of patients. The disease can be complicated by adhesive disease, fistulous forms of genital tuberculosis. Restoration of reproductive function is observed in 5-7% of women. Pregnancy management in patients who have undergone genital tuberculosis is associated with the risks of spontaneous termination of pregnancy, premature birth, and the development of fetal hypoxia. In drug-resistant forms of tuberculosis, treatment is delayed.
Specific prevention of primary tuberculosis includes vaccination of newborns with BCG vaccine, revaccination of children and adolescents, Mantoux reaction, preventive fluorography, isolation of patients with active forms. Measures of nonspecific prevention are general health measures, full rest and nutrition. Prolonged, sluggish and poorly responding to the usual treatment of genital inflammation, combined with menstrual function disorders and infertility, require examination for genital tuberculosis.