Recent Advances in Diagnosis and Management of Female Genital Tuberculosis

Abstract

Female genital tuberculosis (FGTB) is an important cause of significant morbidity and infertility. Gold-standard diagnosis by demonstration of acid fast bacilli on microscopy or culture or detection of epithelioid granuloma on histopathology of endometrial or peritoneal biopsy is positive in only small percentage of cases due to its paucibacillary nature. Use of gene Xpert on endometrial or peritoneal biopsy has improved sensitivity of diagnosis. Composite reference standard (CRS) is a significant landmark in its diagnosis in which combination of factors like AFB on microscopy or culture, positive gene Xpert, epithelioid granuloma on endometrial or peritoneal biopsy, demonstration of definite or probable findings of FGTB on laparoscopy or hysteroscopy. There have been many advances and changes in management of FGTB recently. The program is now called National Tuberculosis Elimination Program (NTEP), and categorization of TB has been stopped. Now, patients are divided into drug-sensitive FGTB for which rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) are given orally daily for 2 months followed by three drugs (rifampicin, isoniazid and ethambutol (RHE) orally daily for next 4 months. Multi-drug-resistant FGTB is treated with shorter MDR TB regimen of 9-11 months or longer MDR TB regimen of 18-20 months with reserved drugs. In vitro fertilization and embryo transfer have good results for blocked tubes and receptive endometrium, while surrogacy or adoption is advised for severe grades of Asherman's syndrome.

Keywords: Composite reference standard; Drug-resistant TB; Drug-sensitive tuberculosis; Female genital tuberculosis; Hysteroscopy; Laparoscopy.

Fig. 1

Laparoscopy showing perihepatic adhesions (Fitz–Hugh–Curtis syndrome) (single arrow) with Sharma’s hanging gall bladder sign (double arrow) in a case of FGTB

Fig. 2

Laparoscopy showing Sharma’s blue python sign with distended hydrosalpinx in the left fallopian tube (single arrow) and tubercles (double arrow) on the right fallopian tube and ovary in a case of FGTB

Fig. 3

Hysteroscopy showing pale endometrium and intrauterine adhesions in a case of FGTB

Fig. 4

Use of composite reference standard (CRS) and diagnostic algorithm for FGTB