Tuberculosis

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Tuberculosis (TB) is a leading cause of death among adults worldwide. Initially, pulmonary infection is the most common site of primary disease. Extrapulmonary TB may spread by hematogenous, lymphatic, or local routes. Genital TB arises primarily from hematogenous spread after primary infection. Genital TB is nearly always pelvic disease rather than vulvar or vaginal.

Primary TB is transmitted by infected airborne particles and usually results in mild pneumonic illness that frequently is unnoticed. Following initial infection, a latent phase ensues. By the time genital disease arises, the primary infection site has healed. Rarely, primary infection by sexual transmission or contact may occur. The fallopian tubes are infected in almost 100% of genital tract cases. This is followed by the endometrium in approximately 50% of cases, the ovaries in about 20% of cases, the cervix in 5% of cases, and the vulva and vagina in less than 1% of cases (27). Clinically, patients with genital disease present with infertility, pelvic pain, or abnormal uterine bleeding. Menstrual irregularities occur secondary to direct effects on the endometrium as well as an antagonistic effect on gonadotrophic function. Generally, both fallopian tubes are severely affected. In the endometrium, significant scarring disease may mimic Asherman's syndrome. On the vulva, TB manifests as a chronic painful ulcer that spreads slowly, leaving behind scar tissue. Cutaneous TB is most often manifested by scrofuloderma (64.9%) or lupus vulgaris (21.5%) (28). Adenopathy is often present. In advanced disease, vulvar edema from scarred lymphatics or genital fistulas may present.

Diseases that could be confused with vulvar TB include hidradenitis suppura-tiva, late granuloma inguinale, chancroid, or Crohn's disease. Useful diagnostic tests for genital disease include hysterosalpingogram, pelvic ultrasound, laparoscopy, and hysteroscopy. Isolation of Mycobacterium tuberculosis from endometrial tissue, peritoneal fluid, menstrual fluid, or ulcer exudate provides definitive diagnosis but is difficult to observe because of low bacterial counts in these samples. Acid-fast staining shows red-stained bacilli. Tissue biopsies classically show granulomatous changes, central caseation, surrounding epithelioid cells, and Langerhans giant cells. Culture growth takes four to eight weeks. The tuberculin skin test (Mantoux test) is neither sensitive nor specific for genital TB.

Patients should undergo drug treatment prior to any surgical interventions. Despite treatment, pregnancy outcomes after active genital TB are poor and include increased infertility, ectopic pregnancies, and spontaneous abortions. In vitro fertilization may be promising for infertile couples in specific cases (Table 9).

Table 9 Genital Tuberculosis

Diagnosis

Symptoms

Clinical appearance

Differential diagnosis

Therapy

Genital tuberculosis

Infertility, pelvic pain, abnormal uterine bleeding, painful vulvar ulcers, and adenopathy

Chronic painful ulcers and adenopathy, occlusion of fallopian tubes, pelvic and endometrial scarring

Tubo-ovarian abscess, pelvic endometriosis, ovarian cyst, pelvic inflammatory disease, mycotic infection, enterobiasis, carcinoma

Rifampin, isoniazid hydrochloride (INH), pyrizinamide, and ethambutol or streptomycin for 2 mo followed by two drugs, i.e., INH and rifampin for 4mos

Abbreviation: INH, isoniazid hydrochloride.

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