Female genital tuberculosis: Revisited

Abstract

Female genital tuberculosis (FGTB) is caused by Mycobacterium tuberculosis (rarely Mycobacterium bovis and/or atypical mycobacteria) being usually secondary to TB of the lungs or other organs with infection reaching through haematogenous, lymphatic route or direct spread from abdominal TB. In FGTB, fallopian tubes are affected in 90 per cent women, whereas uterine endometrium is affected in 70 per cent and ovaries in about 25 per cent women. It causes menstrual dysfunction and infertility through the damage of genital organs. Some cases may be asymptomatic. Diagnosis is often made from proper history taking, meticulous clinical examination and judicious use of investigations, especially endometrial aspirate (or biopsy) and endoscopy. Treatment is through multi-drug antitubercular treatment for adequate time period (rifampicin, isoniazid, pyrazinamide, ethambutol daily for 60 days followed by rifampicin, isoniazid, ethambutol daily for 120 days). Treatment is given for 18-24 months using the second-line drugs for drug-resistant (DR) cases. With the advent of increased access to rapid diagnostics and newer drugs, the management protocol is moving towards achieving universal drug sensitivity testing and treatment with injection-free regimens containing newer drugs, especially for new and previously treated DR cases.

Keywords: Fallopian tubes; GeneXpert; Mycobacterium tuberculosis; female genital tuberculosis; infertility.

Fig. 1

Computed tomography with unilateral tubo-ovarianmass in female genital tuberculosis.

Fig. 2

Positron emission tomography and computed tomography scan showing unilateral increased FDG uptake in tubo-ovarian masses (arrow).

Fig. 3

Hysterosalpingography showing bilateral tubal block (arrows).

Fig. 4

Hysterosalpingography showing left hydrosalpinx with fimbrial block (arrow).

Fig. 5

Hysteroscopy showing grade II adhesions in female genital tuberculosis being resected.

Fig. 6

Laparoscopy showing omental adhesions.

Fig. 7

Laparoscopy showing tubercles on uterus, fallopian tubes and ovaries (arrows).

Fig. 8

Laparoscopy showing bilateral hydrosalpinxs, tubo-ovarian masses, adhesions and frozen pelvis (arrows).

Fig. 9

Laparoscopy showing caseous nodules in uterovesical pouch (single arrow) and on anterior abdominal wall (double arrow).

Fig. 10

Laparoscopy showing Fitz-Hugh-Curtis syndrome (single arrow) and hanging gall bladder sign (double arrow).

Fig. 11

Treatment regimens for female genital tuberculosis (FGTB). ^*Moxifloxacin to be given, if resistance to levofloxacin. Recently, 4 drug fixed dose combination (FDC) HRZE (75, 150, 400, 275) has been introduced. HRZE, isoniazid, rifampicin, pyrazinamide and ethambutol; INH, isoniazid; MDR, multi-drug resistant resistant; IM, intramuscular; O, oral. Source: Refs .