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What is Genital Tuberculosis?
Genital tuberculosis is a chronic infectious disease in which reproductive organs become infected by tubercular bacteria. Genital tuberculosis is one of the major etiologic factors of female tubal infertility, especially on the Indian subcontinent. In one of the study done by Parikh FR, one hundred seventeen women with a tubal factor were found to have tuberculosis as the cause of tubal blockage. On laparoscopy, 49.5% were found to have simple tubal blockage, 15.3% showed tubo-ovarian masses, and 23.9% had a frozen pelvis.
What is Frozen Pelvis?
A 'frozen pelvis' usually refers to the situation where there has been marked inflammation and loss of normal architecture of adenexal structure within the pelvic tissues, the most common culprit being tuberculosis and endometriosis.
Who gets the frozen pelvis in female?
Endometriosis is a gynaecological condition, which can cause widespread problems in female of reproductive age group because of its nature. Endometriosis is caused by really small particles of menstrual tissue which pass from the uterus to the fallopian tubes and then to the cavity from the pelvis. These 'endometriotic seeds' are very irritable towards the lining of the pelvis and cause anything that they touch being very sticky. This means that pieces of bowel can get stuck to the genital organ or bowel to bladder or other tissue. This can cause problems as short portions of bowel can get trapped in between sticky strands known as 'adhesions' and this can lead to a temporary or permanent blockage, or obstruction of the fallopian tube.
In case of frozen pelvis the bladder could be prevented from emptying fully, with recurrent bladder infections (UTIs). There may also be significant fertility problems in affected female. Because the precise problems felt by an individual will vary from person to person, it is impossible to be definitive about the risks involved in surgery for a frozen pelvis. These would best be discussed with the consultant gynaecologist responsible for a person's case. Where there is a significant part of the bowel involved, often a bowel surgeon may also be consulted and may also be present in the operating theatre to assist the gynaecologist. Genital tuberculosis is another cause of frozen pelvis. Genital tuberculosis in female damages the fallopian tubes irreparably, it also damages the endometrium. In most women, if the diagnosis is made quickly and the infection treated promptly, the uterus heals well, partly because the old uterine lining is shed every month in the menstrual period, and a new one regenerates. However, in severe cases, the TB endometritis does not heal, and leads to scarring and severe fibrosis and adhesions and ultimately frozen pelvis.
Is Genital Tuberculosis a cause of infertility ?
TB cause infertility only when it infects the genital tract (Genital TB). Sometimes latent bacilli that is left over from infections that the body successfully fights off can get reactivated in reproductive age group female, and then spread through the blood stream. Female genital tuberculosis is an important cause of secondary amenorrhea and infertility in developing countries where tuberculosis is endemic. Genital tuberculosis is typically asymptomatic and it is usually diagnosed incidentally during infertility investigations and diagnostic laparoscopy. Symptomatic disease usually presents with infertility, pelvic pain, and/or menstrual irregularities. Infertility is usually brought on by pathology in the endometrium and fallopian tubes and a blockage of ovum transport, and dysfunction of menstruation in young woman is largely attributed to endometrial caseation.
It is proved that antigonadotrophic effect of Mycobacterium tuberculosis might be responsible for the menstrual irregularities that take place in cases of active pulmonary tuberculosis without genital tract lesions. Diagnosis of genital tuberculosis is very tough, even if grounds for suspicion exist. In 2007, the WHO stated that in 92% of cases, diagnosis of genital tuberculosis is secondary to lesions found in the lungs, lymph nodes, urinary system, bones, or joints. The differential proper diagnosis of female genital tuberculosis includes chronic pelvic inflammation, mycotic infection, enterobiasis, lipid salpingitis, and carcinoma. The endometrium is involved in approximately 50-60% of ladies with genital tuberculosis. Hysteroscopy provides direct information about endometrial trophicity, and could reveal a scarred atrophic endometrial layer with adhesions varying from mild to severe, leading to Asherman’s syndrome and secondary amenorrhea.
How is the genital tuberculosis diagnosed ?
Patients with genital tuberculosis might have no documented good reputation for tuberculosis or might have evidence of tubercular lesions elsewhere in the body. In many patients abdominal and vaginal examinations might be normal. In some female high erythrocyte sedimentation (ESR) rate along with a positive Mantoux test are nonspecific, and therefore cannot provide an accurate diagnosis of genital tuberculosis.
Chest X-rays are common first line investigation done generally; however, pelvic ultrasound and hysterosalpingography examinations may assisted in the diagnosis of genital tuberculosis. Histopathological evidence from biopsies of premenstrual endometrial tissue or even the demonstration of tubercle bacilli in cultures of menstrual blood or endometrial curetting is necessary to provide a conclusive proper diagnosis of the genital tuberculosis.
Newer techniques, for example polymerase chain reaction (PCR), can detect genital tuberculosis from clinical samples earlier and are less invasive. However, most of these techniques are too expensive and complex to be of any practical help to most tuberculosis patients residing in developing countries. One of the other popular tests for detecting "silent TB" uses 'reproductive molecular immunology' techniques for PAMP ( pathogen-associated molecular pattern ) for immunopathological evaluation.
Can Men become infected with Genital Tuberculosis?
Tuberculosis latent bacilli can get deposited in any part of the body, causing a TB infection of that part in both male and female. It is only when it lodges and infects the genital tract, that TB can cause infertility in both the sex. In the man it causes tuberculous epididymo-orchitis, blocking the passage, as a result of which the man becomes azoospermic (no sperm enter the semen because the tract is blocked). In the woman, it cause tuberculous endomteritis and salpingitis which is infection of the tubes. This infection can often be silent, and may not cause any symptoms or signs at all !
Is there any role of laparoscopy in diagnosis of frozen pelvis and genital tuberculosis ?
Diagnostic laparoscopy is an important tool in case of female infertility and may times frozen pelvis can be diagnosed during diagnostic laparoscopy. Endometrial TB-PCR had high specificity to diagnose genital tuberculosis, as did laparoscopy. Laparoscopy may therefore be avoided in TB-PCR-positive patients for diagnosis but may still be required to rule out genital tuberculosis in PCR-negative cases. There's a strong association between genital tuberculosis and secondary amenorrhea; therefore, genital tuberculosis could be more frequently diagnosed if the possibility was considered in the evaluation of each and every patient presenting with secondary amenorrhea in places that tuberculosis is endemic. Tuberculosis is a chronic infectious disease in developing country. Genital tract tuberculosis continues to be recognized and treated in excess of hundreds of years, even though actual incidence of pelvic tuberculosis in developing continues to be unknown. It is believed that the incidence of pelvic tuberculosis might well be as high in India and other sub-Saharan African countries; therefore, clinicians in India as well as developing countries must consider genital tuberculosis as an important reason in your woman for tubal blockage and secondary amenorrhea that leads to infertility.
What is the treatment of Genital Tuberculosis?
Modern short-course anti-tuberculous drug regimens are effective of any type of tuberculosis. patients with Genital Tuberculosis. In clinical practice, pyrazinamide should be avoided in those cases not only due to the likelihood of primary resistance but also due to the induction of hyperuricaemia, and hyperuricuria, which, may be detrimental in patients with Genital Tuberculosis. Patients with Genital Tuberculosis caused by M. tuberculosis who are treated with pyrazinamide within the intensive treatment phase should get a xanthinoxydase-inhibitor in addition. A 6-month short span of anti-tuberculous drug regimen is also effective in uncomplicated case. Special considerations apply to treating tuberculosis in patients with impaired renal function. Rifampicin, isoniazid, pyrazinamide, prothionamide, and ethionamide may be succumbed normal dosage. Care is required in using streptomycin, other aminoglycosides, and ethambutol. They are wholly excreted via kidney. Ethambutol causes optic neuritis, which can be irreversible, and reduced dose ought to be given according to the glomerulum fitration rate (GFR). Streptomycin and other aminoglycosides are ototoxic and nephrotoxic, and should not be given to patients with renal failure and particularly after renal transplantation because cyclosporine involves additionally a high risk of nephrotoxity. Encephalopathy is definitely an uncommon complication of isoniazide and may be prevented by pyridoxine (25 to 50 mg daily). Rifampicin boosts the rate of metabolism of corticosteroids, cyclosporine, and lacrolimus. Regular measurement from the concentration of cyclosporine and lacrolimus within the blood of these patients (mostly patients after transplantation) is recommended. In HIV-patients, the antiretroviral therapy interacts adversely with rifampicin. When rifabutin is offered rather than rifampicin the treatment should be extended to 9 to 12 months.
