Genital tuberulosisGenital tuberulosisvulvovaginal lupus vulgaris vulvovaginal lupus vulgaris

Pudendal TB is manifested by chronic, minimally Pudendal TB is manifested by chronic, minimally painfull, exudative sores that are tender, reddish, painfull, exudative sores that are tender, reddish, raised moderately firm,and nodular, with central raised moderately firm,and nodular, with central (apple-jelly ) like content.(apple-jelly ) like content.

Ulcerative, necrotic discharge lesions develop laterUlcerative, necrotic discharge lesions develop laterThere is some tendency towards healing with heavy There is some tendency towards healing with heavy

scaring.scaring.Induration& sinus formation are common in the Induration& sinus formation are common in the

scrofulous type of infection.scrofulous type of infection.Cancer & sexually transmitted diseases must be Cancer & sexually transmitted diseases must be

ruled out &evaluation for TB at other sites carried ruled out &evaluation for TB at other sites carried outout

Treatment : Wet compresses of alumnium Treatment : Wet compresses of alumnium acetate solution(Burow`s solution) are helpful.acetate solution(Burow`s solution) are helpful.

Systemic antituberculosis therapy should be Systemic antituberculosis therapy should be given.given.

Cervical TBCervical TBGenitourinary TB is almost always secondary to Genitourinary TB is almost always secondary to

infection elsewhere in the body, usually infection elsewhere in the body, usually pulmonary TB, but active pulmonary disease pulmonary TB, but active pulmonary disease can be documented in only one third of patients can be documented in only one third of patients

* Vascular dissemination is responsible for * Vascular dissemination is responsible for infection of fallopian tubes in almost all patient infection of fallopian tubes in almost all patient with genitalTB, & involvement of endometrium with genitalTB, & involvement of endometrium follows in 90% follows in 90%

Cervical TB is though to be secondary to Cervical TB is though to be secondary to involvement of endometrial, is rare, occurring in involvement of endometrial, is rare, occurring in only 1% of cases.only 1% of cases.

in the past , genital TB has accounted for only in the past , genital TB has accounted for only 1%of patients with pelvic inflammatory diseases 1%of patients with pelvic inflammatory diseases ,however in European & Asian countries the ,however in European & Asian countries the occurrence ranges from 2-10%occurrence ranges from 2-10%

*with increasing numbers of immigrants to US & *with increasing numbers of immigrants to US & with rise in the incidence of AIDS in American with rise in the incidence of AIDS in American women, an increase in the incidence of pelvic women, an increase in the incidence of pelvic TB can be expected.TB can be expected.

Clinical features of cervical TBClinical features of cervical TB foul- smelling discharge & contact bleeding.foul- smelling discharge & contact bleeding. *the cervix may be hypertrophied & nodular*the cervix may be hypertrophied & nodular *speculum examination may demonstrate either an *speculum examination may demonstrate either an

ulcerative or papillary lesionulcerative or papillary lesion DiagnosisDiagnosis Biopsy, histologically the disease is characterized by Biopsy, histologically the disease is characterized by

tubercules undergoing central caseation tubercules undergoing central caseation Demonstrate acid- fast bacillus by culture &acid fast Demonstrate acid- fast bacillus by culture &acid fast

staining.staining.

Management Management

Most patients are cured by medical Most patients are cured by medical management alone , patients who respond management alone , patients who respond poorly or who have other problems( e.g poorly or who have other problems( e.g tumer or fistula) may require total tumer or fistula) may require total hysterectomy & BSO after a trial of hysterectomy & BSO after a trial of chemotherapy.chemotherapy.

Pelvic TBPelvic TB

It usually represents secondary invasion from a primary It usually represents secondary invasion from a primary lung infection via the lymphohaematogenous routelung infection via the lymphohaematogenous route

The overall incidence of pelvic TB in patients with The overall incidence of pelvic TB in patients with pulmonary TB is approximately 5%pulmonary TB is approximately 5%

Prepubertal TB rarely result in genital tract infectionPrepubertal TB rarely result in genital tract infectionAfter the pelvic organs become affected, direct extension to After the pelvic organs become affected, direct extension to

adjacent organs may occur .adjacent organs may occur .Recent studies indicates that endometrial involvement Recent studies indicates that endometrial involvement

occur in about 90% while oviduct involvement occur in occur in about 90% while oviduct involvement occur in about 5% . about 5% .

Clinical findingsClinical findings

Sign& symptomsSign& symptoms InfertilityInfertility *dysmenorrhea ,pelvic pain & evidence of pelvic *dysmenorrhea ,pelvic pain & evidence of pelvic

peritonitisperitonitis *endometrial involvement may present with *endometrial involvement may present with

amenorrhea & menstrual cycle irregularityamenorrhea & menstrual cycle irregularity *abdominal or pelvic pain is commonly *abdominal or pelvic pain is commonly

associated with low grade fever asthenia associated with low grade fever asthenia &weight loss . &weight loss .

diagnosisdiagnosis

1- history1- history2-physical examination2-physical examination3- CXR & lung scan3- CXR & lung scan4- tuberculin test (Mantoux test)4- tuberculin test (Mantoux test)5- sputum smear & sputum culture5- sputum smear & sputum culture6- gross ascites with fluid containing more 6- gross ascites with fluid containing more

than 3 gm protein per 100 ml of preitoneal than 3 gm protein per 100 ml of preitoneal fluid is characteristic of tuberculus fluid is characteristic of tuberculus peritonitisperitonitis

Pelvic TB is usually encountered in the course of a Pelvic TB is usually encountered in the course of a gynecological operation done for other reasons, gynecological operation done for other reasons, distinguish features are distinguish features are

1- extremely dense adhesions without planes of 1- extremely dense adhesions without planes of cleavagecleavage

2-segmental dilatation of the tubes & lack of 2-segmental dilatation of the tubes & lack of occlusion of the tubes at the ostiaocclusion of the tubes at the ostia

3- if the internal genitalia are involved, with 3- if the internal genitalia are involved, with disseminated granulamatous disease of the disseminated granulamatous disease of the serosal surfaces ,ascites usually is presentserosal surfaces ,ascites usually is present

Clinical diagnosis is difficult.Clinical diagnosis is difficult.

Laboratory findingLaboratory finding The best direct method of diagnosis in suspected genital The best direct method of diagnosis in suspected genital

TB is detection of acid fast bacteria by means of Ziehl-TB is detection of acid fast bacteria by means of Ziehl-Neelsen stain followed by culture on Lowenstein-Jensen Neelsen stain followed by culture on Lowenstein-Jensen mediummedium

SpecimenSpecimen1- menstrual discharge1- menstrual discharge2-curettage or biopsy2-curettage or biopsy3-peritoneal biopsy3-peritoneal biopsy

-rapid sedimentation rate-rapid sedimentation rate - peripheral blood eosinophilia - peripheral blood eosinophilia - strong Mantoux test- strong Mantoux test

- CXR- CXR - hysterosalpingography- hysterosalpingographya- the tubal lining may be irregular & area of a- the tubal lining may be irregular & area of

dilatation may be presentdilatation may be presentB-sacular diverticula extending from the ampulla B-sacular diverticula extending from the ampulla

& giving the impression of a cluster of currents & giving the impression of a cluster of currents are characteristic of glaucomatous salpingitisare characteristic of glaucomatous salpingitis

C- calcification of periaortic or iliac lymph nods.C- calcification of periaortic or iliac lymph nods.

Specific examinationSpecific examinationVisual inspection (laparoscopy)& aspiration of Visual inspection (laparoscopy)& aspiration of

peritoneal fluid for culture & biopsy.peritoneal fluid for culture & biopsy.

Differential diagnosisDifferential diagnosis1- schistosomiasis 1- schistosomiasis 2- enterobiasis2- enterobiasis3-lipoid salpingitis3-lipoid salpingitis4-carcinoma4-carcinoma5-chronic pelvic infection5-chronic pelvic infection6-Mycotic infections6-Mycotic infections

ComplicationsComplications*sterility*sterility*tuberculous peritonitis*tuberculous peritonitis

treatmenttreatment

A- medical measures A- medical measures The initial therapy should include four drugsThe initial therapy should include four drugsThe drug regimen for the 1The drug regimen for the 1stst two months of two months of

treatment should include isoniazid, treatment should include isoniazid, rifampin, pyrazinamide & streptomycin or rifampin, pyrazinamide & streptomycin or ethambutolethambutol

Treatment should be continued for 24-36 Treatment should be continued for 24-36 months, since extra pulmonary TB is more months, since extra pulmonary TB is more difficult to eradicatedifficult to eradicate

Surgical measuresSurgical measures

The primary mode for pelvic TB is medical The primary mode for pelvic TB is medical therapy, however, surgical intervention may therapy, however, surgical intervention may be necessary. medical therapy should be be necessary. medical therapy should be attempted 12-18 months prior to evaluation attempted 12-18 months prior to evaluation for surgeryfor surgery

Indication for surgery includeIndication for surgery include

1-masses not resolving with medical therapy.1-masses not resolving with medical therapy.

2-resistant or reactivated disease2-resistant or reactivated disease

3-persistant menstrual irregularities3-persistant menstrual irregularities

4- fistula formation4- fistula formation

prognosisprognosis

The prognosis for life & health is excellent if The prognosis for life & health is excellent if chemotherapy is instituted promptly, chemotherapy is instituted promptly, although the prognosis for fertility is poor.although the prognosis for fertility is poor.