1. Female Genital Tuberculosis by Dr. Narayan M. Patel M.D.,D.G.O.FICS 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

2. Genital Tuberculosis History First recorded case tuberculosis of female genital organ was described by Morgagni in year 1961, at autopsy First recorded case tuberculosis of female genital organ was described by Morgagni in year 1961, at autopsy

3. Genital Tuberculosis Genital tuberculosis Genital tuberculosis is always secondary to tuberculosis else where in body, usually in lungs, peritoneum, lymph glands, bones etc.

4. Genital Tuberculosis Incidence in different countries in case of Infertility CountryAuthorYear Incidence IndiaNair hosp.198914.7% IndiaMukerjee196714.5% Saudi Arabia19851 to 7% SpainBotella l196710.6% JapanShinjawa19605.5% EnglandHainas19584.0% U.S.A.Foss19580.6% AustraliaTownsend19550.7% Incidence of genital tuberculosis in U.S.A. is increasing due to increase in immigrant population increasing due to increase in immigrant population

5. Genital Tuberculosis Historical aspect. Kardos removed the tubes following medical treatment for tuberculosis for 10 months. Kardos removed the tubes following medical treatment for tuberculosis for 10 months. Tuberculosis was active in 3.5% of cases Tuberculosis was active in 3.5% of cases

6. Genital Tuberculosis Value of endometrial biopsy Absence of signs of tuberculous endometritis in any one biopsy, is not a proof of absence of the disease. 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. 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 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

7. Genital Tuberculosis Types of Tuberculosis Schefer has differentiated two types of genital 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

8. Genital Tuberculosis Involvement of organs---Norries Involvement of organs---Norries (1) Fallopian tubes------85 to 90% (1) Fallopian tubes------85 to 90% (2) Endometrium--------35 to 50% (2) Endometrium--------35 to 50% (3) Ovaries---------------- 5 to 6% (3) Ovaries---------------- 5 to 6% (4) cervix—-----------------3 % (4) cervix—-----------------3 % (5) Vagina & vulva -------2 % (5) Vagina & vulva -------2 % Genital Tuberculosis

9. Involment of tubes. The involvement of Fallopian Tubes in case of Tuberculosis, is mostly bilateral

10. Genital Tuberculosis Tuberculous pyosalpingx Tuberculous pyosalpingx is due to early closure of the ostium and accumulation of cheesy exudate within the lumen. Tuberculous pyosalpingx is due to early closure of the ostium and accumulation of cheesy exudate within the lumen.

11. Green berg has described the characteristic Green berg has described the characteristic Tobacco-pouch or mail pouch mail pouch appearance of the fimbriated extremity. H.S.G. appearance

12. One should always differentiate between Female genital toberculosis (F.G.T.) and 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 F.G.T. & Pelvic tuberculosis

13. Genital Tuberculosis 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

14. Genital Tuberculosis In F.G.T. there is involvement of mucosa of fallopian tubes, with or without spread to the uterus. 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 F.G.T.

15. Genital Tuberculosis In a report by Serum Institute of India :- (1) There are 2.2 million new cases of Tuberculosis in India, each year. (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. Incidence

16. Genital Tuberculosis Hysterosalpingography, if properly performed and interpreted, can be of great value in the diagnosis of genital tuberculosis. Hysterosalpingography

17. The great value of H.S.G. lies in its revelation of the characteristic radiographic changes, that are pathognomonic The great value of H.S.G. lies in its revelation of the characteristic radiographic changes, that are pathognomonic Genital Tuberculosis

18. As per Mishell’s textbook of infertility As per Mishell’s 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. Genital Tuberculosis

19. The appearance of Koch’s tubes is similar to bilateral tubal ligation. The appearance of Koch’s tubes is similar to bilateral tubal ligation. John Richmond Terminal ends of tubes have similar look like that of sperm head Narayan Patel Genital Tuberculosis

20. 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. 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. Genital Tuberculosis

21. At histology the typical tubercle follicle is composed of central zone of epitheloid cells surrounded by, lymphocytes and plasma cells. 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. Giant cells may be present. A central zone of caseation is present sometimes A central zone of caseation is present sometimes Genital Tuberculosis

22. Fallopian tubes are involved in almost all cases of endometrial tuberculosis Fallopian tubes are involved in almost all cases of endometrial tuberculosis Genital Tuberculosis

23. Culture of menstrual blood containing mucous and endometrial shreds, is recommended. Culture of menstrual blood containing mucous and endometrial shreds, is recommended. Culture media recommended is Loewenstein’s or Petragnani’s Culture media recommended is Loewenstein’s or Petragnani’s 6 to 8 consecutive negative culture is necessary in order to exclude genital tuberculosis. 6 to 8 consecutive negative culture is necessary in order to exclude genital tuberculosis. Genital Tuberculosis

24. The infection may spread via blood stream or lymphatic or direct extension of the neighbouring organs The infection may spread via blood stream or lymphatic or direct extension of the neighbouring organs In 80% it is haematogenous spread. In 80% it is haematogenous spread. Genital Tuberculosis

25. Differential Diagnosis Differential Diagnosis (1) Pelvic inflammation. (2) Endometriosis (3) Ovarian tumours. (4) Cervical cancer---in case of Cx (5) Elephantiasis------in case of vulva (6) Lymphoganuloma--- ” Genital Tuberculosis

26. Tuberculous infection, in most of the cases is by human type of tuberculous bacilli (80%) and about 20% by bovine type 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. Genital Tuberculosis

27. Menstrual irregularity in cases of Genital Tuberculous Menstrual irregularity in cases of Genital Tuberculous (1) Normal------------11.8% (1) Normal------------11.8% (2) Oligomenorrhoea—36% (2) Oligomenorrhoea—36% (3)Menorrhagia-----------10% (3)Menorrhagia-----------10% (4)Amenrrhoea------------41% (4)Amenrrhoea------------41%Dr.Malkani Genital Tuberculosis

28. Endometrial curettage still remains an important diagnostic investigation in India, where tuberculosis is endemic. Endometrial curettage still remains an important diagnostic investigation in India, where tuberculosis is endemic. Genital Tuberculosis

29. 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. 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. Genital Tuberculosis

30. Reconstructive surgery has no place in cases of tuberculosis of tubes. As per one of the report :- 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 Genital Tuberculosis

31. When the endometrial tuberculosis is extensive, the endometrium is destroyed and replaced by hyalanised connective tissue, thereby obliterating the cavity. 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 Genital Tuberculosis

32. Genital tuberculosis 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.

33. Genital Tuberculosis Amenorrhoea Amenorrhoea is the eventual result of the endometrial damage Amenorrhoea is the eventual result of the endometrial damage

34. Genital tuberculosis Surgery is reserved for those patients who has failed to respond to adequate trial of medical treatment.

35. Genital tuberculosis Halberchart reported 20% of all patients treated medically for tuberculosis, sooner or latter, had ectopic pregnancy.

36. Genital tuberculosis If a virgin girl suffer from a pelvic inflammatory mass, it is almost always Tuberculous in origin

37. Genital Tuberculosis