GENITAL TUBERCULOSIS

DEFINITION & INTRODUCTION

EPIDEMIOLOGY

• Comprises ~4% of all EPTB cases in India (may be underestimated).
• Female genital TB (FGTB): Incidence ranges from <1% (USA, Sweden) to ~10% in infertile Indian women; up to 26.7% in tertiary centres, 48.5% in tubal factor infertility, and even higher in repeated IVF failures.
• Predominantly affects women aged 20–30 years in India (68–89% of cases); older age groups (40–50 yr) in western countries.
• Male genital TB (MGTB): Incidence in men is twice that in women; mean age ~40 years.
• Less common in postmenopausal women (atrophic endometrium is a poor milieu for bacilli).

PATHOGENESIS

1. Route of spread: Haematogenous > lymphatic > direct contiguous spread from peritoneal organs.
2. Primary focus: Usually pulmonary TB; rarely extrapulmonary (kidney, GIT, bone/joint).
3. In miliary TB, genitalia may be part of multiorgan involvement.
4. In FGTB: Fallopian tube is the initial site → then spreads to endometrium, ovary, cervix, vagina/vulva.
5. In MGTB: Epididymis (especially globus minor) is the most common site (up to 78% of cases) via haematogenous spread. Retrograde spread from bladder through ejaculatory ducts → vas deferens → seminal vesicles → prostate → epididymis → testis.
6. Primary genital TB: via infected semen from male partner with genitourinary TB.

PATHOLOGY

Female Genital TB

Male Genital TB

• Epididymis: Most common site; globus minor (tail) preferred; may present as acute epididymitis, chronic epididymitis, scrotal abscess/sinus, or bilateral infertility; "beaded" epididymis.
• Testis: Always secondary to epididymis; rarely primary orchitis.
• Vas deferens: "Beaded" vas on palpation; results in infertility.
• Prostate: Rare; diagnosed on biopsy/prostatectomy specimen; chronic granulomatous inflammation → caseation → fibrosis → "autoprostatectomy"; haemospermia; ejaculatory duct obstruction.
• Seminal vesicles: CT-detectable lesions; obstruction causes azoospermia.
• Penis: Very rare; ulcer of glans penis mimicking malignancy; confirmed by biopsy.

CLINICAL PRESENTATION

Female Genital TB

1. Infertility (primary or secondary) — most common presenting symptom (40–81% of reported series); FGTB is a leading cause of infertility in North India.
2. Menstrual disturbances: Amenorrhoea (most common type), oligomenorrhoea, menorrhagia, postmenopausal bleeding.
3. Chronic lower abdominal/pelvic pain — second most common; dull aching; may flare acutely.
4. Vaginal discharge — especially in cervical/endocervical TB.
5. Unusual presentations: Vulval lesions, Bartholin gland swelling, vesicovaginal fistula, pelvic masses, uterocutaneous fistula, ascites, elevated CA-125 (mimicking ovarian cancer).

• Often no physical sign (high index of suspicion essential).
• Systemic: fever, lymphadenopathy, weight loss.
• Abdominal: ascites, doughy feel, vague/definite lump.
• Vaginal: adnexal mass/tenderness, tubo-ovarian mass, fullness in pouch of Douglas, pyometra.
• Unusual: Ulcerative/hypertrophic lesions of vulva/cervix (mimicking cancer), fistulae, Bartholin swelling.

Male Genital TB

• Scrotal pain, swelling, sinus.
• Beaded vas deferens.
• Haemospermia.
• Infertility (obstructive azoospermia).
• Prostatic nodule or firm prostate.

DIFFERENTIAL DIAGNOSIS

DIAGNOSIS

Diagnostic Modalities for FGTB

• Best performed premenstrually (granulomas close to surface).
• Histopathology positive in 50–76% of genital TB cases.
• Microscopy: granulomas with Langhans' giant cells, epithelioid cells, caseation, lymphocytic infiltration.
• A negative biopsy does not rule out FGTB (sampling error; disease may be confined to tubes/ovaries).

• Of endometrial biopsy, menstrual blood, cervical secretions, tubal biopsy, peritoneal fluid.
• Culture positivity lower than histopathology in most series (Table 26.6).
• L-J medium culture remains gold standard for confirmation + DST.

• Contraindicated in acute stage (risk of dissemination/exacerbation).
• HSG findings (Rozin's signs):
  • Golf club appearance: rigid stovepipe isthmus with only proximal ampulla filled.
  • Beaded appearance: alternate areas of filling.
  • Maltese cross: completely filled rigid tube with irregular outline.
  • Rosette appearance: distal end filled with dye.
  • Leopard skin: speckled appearance of ampulla.
  • Stem pipe tube: straight, rigid lumen.
  • Calcified tubes/ovaries/pelvic lymph nodes — most significant finding.
  • Cornual block, hydrosalpinx, venous/lymphatic intravasation of dye, distorted uterine cavity.

• Reveals abnormalities in ~60% despite normal physical examination.
• Subacute stage: Miliary yellow-white granulations, hyperaemia, flimsy adhesions, congested pelvic organs.
• Chronic stage:
  • Nodular salpingitis (yellow nodes on tube).
  • Patchy salpingitis (short swollen tubes, agglutinated fimbriae).
  • Hydrosalpinx ("retort-shaped" bilateral tubes).
  • Caseosalpinx (ovoid whitish-yellow dilatation of ampulla).
  • Dense pelvic adhesions.
  • Tobacco pouch appearance.
  • "Python sign" (Sharma's sign): tubes distend like a blue python with alternate constriction/dilatation on methylene blue injection.
  • "Sharma's hanging gallbladder sign": change in gallbladder position in abdominopelvic TB.
  • Fitz-Hugh-Curtis syndrome (perihepatic adhesions) — very high prevalence.
• Caution: Laparoscopy in FGTB has increased complication rates (31% vs 4%) — bleeding, inability to visualise pelvis, peritonitis.

• Pale endometrium, obliterated/partially obliterated cavity, intrauterine adhesions (Asherman's syndrome — FGTB is an important cause in India).
• Grades 1–4 adhesions, often involving ostia.
• Should be performed by experienced operator, preferably under laparoscopic guidance.

• Non-invasive; bilateral solid adnexal masses with small calcifications highly suggestive.
• Free fluid in pelvis, pelvic masses, encysted ascites.

• CT: Hypodense masses, adenopathy, pelvic lesions, hepatic/adrenal/splenic lesions (may mimic malignancy).
• MRI: Hypodense masses with rim enhancement abutting pelvic walls; bilateral tubo-ovarian masses, hydrosalpinx, TB deposits; superior for soft tissue characterization.

• Demonstrates active disease via increased FDG uptake; useful for monitoring activity of tubo-ovarian masses.

• PCR: Supportive test; false positivity (especially in-house PCR) is high — do not start ATT on PCR alone without other evidence.
• Xpert MTB/RIF: Useful in MDR-TB diagnosis in FGTB with tubo-ovarian masses not responding to first-line treatment; sensitivity varies widely in gynaecological specimens.

• Laparoscopic appearance typical for FGTB.
• Any gynaecological specimen AFB-positive on microscopy or Mtb-positive on culture.
• Any gynaecological specimen with histopathological findings consistent with FGTB.

Diagnostic Modalities for MGTB

• Scrotal ultrasound; FNAC of epididymal mass (AFB smear + culture + cytology) — risk of damaging epididymis.
• Biopsy if FNAC inconclusive or malignancy suspected.
• Evaluate co-existent urinary TB (early morning urine × 3–5, US KUB, renal function).
• IVU/CT urography for urinary tract involvement.

TREATMENT

Medical Treatment

• Standard first-line ATT: 2RHZE / 4RHE (6 months total) is the recommended regimen (INDEX-TB guidelines).
• FGTB patients in India receive DOTS under RNTCP/National TB Elimination Programme.
• Modern short-course chemotherapy is highly effective; significantly reduces need for surgery.

Minimal FGTB

• Diagnosed on endometrial histology/culture; standard ATT × 6 months.
• D&C at completion; follow up annually (exacerbations reported up to 10 years before modern therapy).

Advanced FGTB (palpable tubo-ovarian masses)

• ATT × 6 months; monthly monitoring.
• If masses persist after 6 months → surgical intervention (TAH + BSO).
• Conservative approach preferred in young infertile women.

Surgical Indications in FGTB (Table 26.8)

1. Persistence/increase of pelvic masses after 6-month ATT.
2. Recurrence of positive endometrial culture/histology after 6 months ATT.
3. Persistence/recurrence of pain or bleeding after 6 months ATT.
4. Postmenopausal patient with recurrent pyometra due to TB.
5. Limited surgery: drainage of residual large pelvic/tubo-ovarian abscesses or pyosalpinx.

⚠️ Surgery in FGTB is associated with high complication rates (no surgical planes, vascular adhesions, risk of bowel injury, excessive haemorrhage). In suspected pelvic TB found at laparotomy, obtain representative biopsies, close abdomen, and await biopsy reports before definitive surgical clearance.

Surgical Treatment in MGTB

• Not routinely required.
• Epididymectomy: for caseating abscess persisting after completed ATT.
• Orchiectomy, excision of fistula, de-roofing of prostatic abscess as indicated.
• Endoscopic resection of ejaculatory duct obstruction in select cases.
• Vasoepididymostomy for vasal obstruction (possible only in minority due to multifocal disease).

FERTILITY OUTCOMES

FGTB and Infertility

• FGTB is the leading cause of infertility (tubal factor) in North India.
• Full-term pregnancy is uncommon after treatment of histologically proven FGTB.
• Post-treatment pregnancy often results in ectopic pregnancy or abortion.
• Live birth rate is low (7%); conception rate ~19.2%.
• IVF-ET is the treatment of choice for infertile women with FGTB:
  • Pregnancy rate: 16.6% per transfer (Parikh et al).
  • Recommended if tubes are damaged but endometrium is receptive.
  • If Asherman's syndrome with severely damaged endometrium → gestational surrogacy or adoption.
• Repeated ATT courses in women remaining infertile after completed ATT are not necessary.
• Repeated IVF failure in young women with unexplained infertility — consider latent FGTB.

MGTB and Infertility

• Infertility is a possible long-term complication; does not indicate treatment failure.
• Bilateral epididymal involvement → azoospermia.
• Prostatic/vasal/seminal vesicle involvement → obstructive azoospermia.

SPECIAL FEATURES / IMPORTANT POINTS FOR EXAM