[Overview].
Tuberculosis is still one of the common diseases in China. Female genital tuberculosis is not rare in pelvic inflammatory disease, and the course of the disease is slow and insidious, and its tuberculosis bacteria can be excreted with menstrual blood, which is a source of infection to the surrounding environment. In order to significantly reduce the epidemic of tuberculosis in China, we should pay attention to the prevention and treatment of genital tuberculosis.
[Diagnosis].
In order to further improve the diagnosis rate, suspicious signs must not be let go easily, such as infertile patients with scanty menstruation or amenorrhea, unmarried patients with low fever and wasting, chronic pelvic inflammatory disease that has not been cured for a long time, and those who have a history of contact with tuberculosis or have a history of tuberculosis themselves should first consider the possibility of genital tuberculosis. About 20% of patients with genital tuberculosis have a family history of tuberculosis; more than 50% have had tuberculosis outside the pelvic organs at an early stage, commonly pulmonary tuberculosis, pleurisy, followed by tuberculous peritonitis, erythema nodosum and renal and bone tuberculosis. If such a history is found, one should be particularly alert to the possibility of this disease. Infertility is often the main or only symptom of the disease. Therefore, a history of tuberculosis and a chest x-ray should be carefully investigated in these patients. If genital tuberculosis is suspected and there are no clear signs, the diagnosis should be clarified by endometrial pathology or bacteriological examination, hysterosalpingography, and other ancillary diagnostic methods.
Some patients with genital tuberculosis have a long history of chronic wasting, poor appetite, wasting, easy fatigue, persistent afternoon fever or menstrual fever, irregular menstruation, and chronic lower abdominal pain. The diagnosis of adnexal tuberculosis is almost always made in young girls with an inflammatory adnexal mass. For no obvious history of infection, the course of the disease is slow, the general treatment effect is not good adnexitis mass should be considered as tuberculous.
Pathogenesis
A. Pathogenic bacteria Mycobacterium tuberculosis is a class of elongated bacilli, with a tendency to branch growth, belonging to the genus Mycobacterium, extended staining time to color, once the color can resist the decolorization of hydrochloric acid alcohol, so also known as acid-resistant bacilli. There are many species of this genus, and the human type and bovine type are generally pathogenic to humans. The former infects the lungs first, and the latter infects the gastrointestinal tract first, and then spreads to other organs, including reproductive organs, through various pathways respectively. In recent years, many countries have attached importance to the infection of humans by atypical mycobacteria, among which there are tuberculosis-like mycobacteria that cause tuberculosis-like lesions in humans. The incidence of atypical mycobacterial pulmonary infections in China accounts for about 4.3% of mycobacterial pulmonary infections.
Mitchison (1980) classified the groups of Mycobacterium tuberculosis in tuberculosis lesions, according to the metabolic growth characteristics of Mycobacterium tuberculosis, into four groups: group A: actively growing Mycobacterium tuberculosis, present in large numbers outside the cells in early active lesions; group B: growing in macrophages in an acidic environment as the disease progresses, in small amounts; group C: in neutral cheese lesions, multiplying slowly or intermittently, in small amounts; group D Group D: dormant, not reproducing at all. The above four groups of tuberculosis bacteria show different responses to anti-tuberculosis drugs, such as group D. No anti-tuberculosis drugs work on them, and they are only cleared by the body’s immune function or the bacteria themselves die out.
Pathogenic Mycobacterium tuberculosis requires oxygen, but in the absence of oxygen can not reproduce, but still survive for a long time. Nutrition requirements are high, under good conditions, growth is slow, about 18 to 24 hours to reproduce a generation (general bacteria on average 20 minutes to reproduce a generation), bringing greater difficulties to culture, generally need to be animal inoculation. However, clinical use of this slow growth feature, intermittent dosing regimen proposed, can achieve the same effect as continuous dosing.
Mycobacterium tuberculosis often mutates spontaneously, so there are strains of tuberculosis that are primary resistant to certain anti-tuberculosis drugs, and very few strains that are primary resistant to both drugs. A single drug can easily eliminate sensitive strains from the flora while drug-resistant strains gain reproductive advantage, but there are almost no drug-resistant strains when three drugs are used in combination.
The infection is mainly secondary, mainly from pulmonary and peritoneal tuberculosis. There are several possible routes of transmission.
(i) Blood-borne transmission: This is the main route of transmission. Tuberculosis bacteria first invade the respiratory tract. Animal experiments have shown that the injection of two to six tuberculosis bacteria can produce lesions and spread rapidly, forming foci in the lungs, pleura or nearby lymph nodes, and then spreading to the internal reproductive organs via the blood circulation, starting with the fallopian tubes and gradually spreading to the endometrium and ovaries. Cervical, vaginal, and vulvar infections are rare.
There is evidence that primary pulmonary infections are much more likely to involve the genital tract through hematogenous dissemination (i.e., pre-sensitization bacteraemia) if they are close to the onset of menstruation, when the tissue response is unremarkable and clinically asymptomatic. The circulating tubercle bacilli can be cleared by the reticuloendothelial system, but in the fallopian tube they can form latent metastatic foci, which can be in a quiescent phase for 1-10 years or even longer, until local immunity is depressed by certain factors, the latent foci are reactivated and the infection recurs. Because of this slow asymptomatic process often the primary lesion in the lung is completely absorbed without leaving radiographically diagnosable traces, which is almost universal in the definitive diagnosis of genital tract tuberculosis.
(b) Direct intraperitoneal spread: In cases of tuberculous peritonitis, ruptured caseous lesions of mesenteric lymph node tuberculosis, or extensive adhesions of intestinal or bladder tuberculosis to internal genital organs, Mycobacterium tuberculosis may spread directly to the surface of genital organs. Tuberculosis of the fallopian tubes often coexists with peritoneal tuberculosis and may be preceded by tuberculosis of the fallopian tubes and then spread to the peritoneum or vice versa. It may also be the result of hematogenous dissemination from both sides.
(iii) Lymphatic dissemination: The bacilli are transmitted retrogradely from intra-abdominal organ tuberculosis lesions, such as intestinal tuberculosis, to the internal genital organs through the lymphatic vessels, which is rare because retrograde dissemination is required.
(iv) Primary infection: The possibility of direct infection of the female genital organs with tuberculosis, forming a primary lesion, is still debated. In men with genitourinary tuberculosis (e.g., epididymal tuberculosis), direct transmission to their sexual partners through sexual intercourse, resulting in primary vulvar or cervical tuberculosis, has been reported in the literature, but Mycobacterium tuberculosis is infrequently found in semen, and the presence of early asymptomatic primary lesions in the lungs or elsewhere cannot be ruled out in these cases. Sutherland (1982) found active genitourinary tract tuberculosis in 5 (3.9%) of 128 female patients with genital tract tuberculosis, however, in 3 of these 5 cases, the partner also had extragenital tract tuberculosis.
[Pathological changes
When Mycobacterium tuberculosis infects a susceptible host, the local tissue first appears as an inflammatory exudate of polymorphonuclear leukocytes, which is replaced by monocytes within 48 hours and becomes the initial site for intracellular multiplication and replication of Mycobacterium tuberculosis. When cellular immunity is present, Mycobacterium tuberculosis is eliminated and caseous necrosis of the tissue occurs. Later, if the foci of infection are reactivated, they cause proliferative granulomatous lesions – tuberculosis nodules. The typical histologic picture shows a central caseous necrotic tissue surrounded by concentric layers of epithelioid cells and multinucleated giant cells, with lymphocytes, monocytes, and fibroblasts infiltrating the periphery.
The fallopian tubes are the most affected part of female genital tuberculosis, accounting for 90-100% of cases, mostly bilaterally. The uterus is involved in 50-60% of cases, almost all of which are in the endometrium and rarely invade the myometrium. Ovarian tuberculosis often spreads directly from the infected fallopian tubes. Because of the tough white membrane surrounding the ovaries, the infection rate is lower than that of the endometrium, accounting for 20-30% of cases, and at least half of them are bilateral. Cervical tuberculosis originates from the downstream infection of endometrial tuberculosis, which is not uncommon if serial cervical sections are made and can account for 5-15%. Vaginal and vulvar tuberculosis is occasionally seen, accounting for about 1%.
I. Tuberculosis of the fallopian tubes There are roughly 3 types of tuberculous tuberculosis in the early stages of tuberculosis due to different routes of infection.
(a) Tuberculous perituberculosis: The plasma membrane surface of the fallopian tubes is covered with small grayish white corn-like nodules, which do not begin to affect deep muscle and mucosal tissues, and are often a subset of diffuse tuberculous peritonitis or pelvic peritonitis, with many scattered grayish white, caseinized nodules of varying sizes on the plasma membrane surface of the entire pelvic organs, intestinal canal, mesentery, peritoneum, and uterine surface, ranging from several mm to 1 cm in diameter, with the entire The entire plasma membrane surface is congested and swollen, and a small amount of ascites may be present.
(b) Interstitial tuberculosis tuberculosis: initially, small scattered nodules appear in the submucosa or muscular layer. This type of tuberculosis is apparently due to hematogenous dissemination.
(iii) Tuberculous endometritis: the endometrium of the fallopian tube is first involved, often at the distal end of the fallopian tube. The mucosa at the umbilical end is swollen, the lumen gradually becomes larger, and the mucosal folds adhere to each other due to necrosis and surface epithelial peeling. However, the umbilicus is not necessarily occluded and can be ectopic and remain open. This type of infection is mostly hematogenous and secondary to tuberculous peritonitis (invasion of Mycobacterium tuberculosis from the umbilical part of the fallopian tube) is less common. According to statistics, only 13.5% of patients with tuberculous peritonitis have genital tuberculosis, whereas 32.8% have genital tuberculosis with peritoneal tuberculosis, indicating that in the case of an open fallopian tube, Mycobacterium tuberculosis can spread directly from the fallopian tube to the peritoneum.
As the virulence of the bacteria and the immunity of the body vary, the lesions continue to develop and there are two general types.
1. Hyperplastic adhesion type: more common, 80% belong to this category, the lesions progress slowly and the clinical manifestations are vague and insignificant. The wall of the fallopian tube is thickened and appears thick and rigid. Although the mouth of the tube may be open, narrowing or obstruction can occur anywhere in the lumen. Caseous nodular lesions may be found in the mucosa and muscle wall on section, and calcification may occur in chronic cases. Sometimes proliferative lesions occur in the mucosa, and the proliferating mucosal folds resemble adenocarcinoma. When the lesion extends to the plasma membrane layer or when the tube is completely destroyed, there may be caseous exudate, which later invades through granulation tissue, resulting in close adhesion of the tube to adjacent organs. Sometimes it adheres to the intestinal canal, mesentery, bladder and rectum, forming an inflammatory mass that cannot be easily separated; in severe cases, the abdominal cavity cannot be accessed during surgery. However, ascites is not significant and, if present, often forms an encapsulated effusion. Due to dense adhesions, intestinal obstruction can be complicated.
2. Exudative type: It is an acute or subacute course with significant swelling of the fallopian tube, more dramatic destruction of the mucosa, filling of the lumen with caseous material and thickening of the wall, forming tuberculous tubal effusion. It is often closely adherent to the surrounding adjacent intestines, omentum, mural peritoneum, ovaries and uterus, but some may be non-adherent to the surrounding area and misdiagnosed as ovarian cysts due to high mobility. There may be a few nodules on the surface of the plasma layer, which are usually unremarkable and not easily noticeable. Larger tubal abscesses often spread to the ovaries and form tuberculous tubo-ovarian abscesses, and sometimes there is also accumulation of blood or fluid in the fallopian tubes.
The pus of tuberculous tubo-ovarian abscess is usually free of bacteria, but it is highly susceptible to secondary infection by general septic bacteria, which can cause severe lower abdominal pain, fever, leukocytosis and other inflammatory symptoms, and a rapidly enlarging painful mass can be found on one side. These abscesses are prone to penetrate into the adjacent area and form chronic fistulas. If incorrect incision and drainage is performed during the acute phase, fistulae are more likely to occur, and even intestinal obstruction may occur.
Tuberculosis of the uterus may be normal in size and shape. Most of the tuberculous lesions are confined to the endometrium, mainly at the base of the uterus and in the two corners of the uterus, and most of them are downstream and expanding from the tubal lumen. The endometrial changes in early stage patients are difficult to distinguish from endometritis, and sometimes the endometrium and glands are basically normal except for a few scattered nodules. The endometrium around the nodules has a low glucose content and continues in a proliferative state, while those further peripheral to the nodules have typical secretory phase changes, so menstruation is mostly unchanged. Due to the cyclic shedding of the endothelium, there is not enough time for the formation of extensive and severe foci of endothelial nodules, and caseification, fibrosis, and calcification are rare. In a few severe cases, the endometrium may be partially or completely destroyed, replaced by case-like tissue or ulcers, and eventually the uterus becomes pus-filled, resulting in complete loss of endometrial function and amenorrhea. There is also a rare type of hyperplastic endometrial tuberculosis, in which the uterine cavity is filled with case-like granuloma-like tissue, and a large amount of plasmacytic foul-smelling leucorrhea is discharged, and the uterus is spherically enlarged, which is easily confused with uterine cancer.
Ovarian tuberculosis is often bilaterally invaded, and there are two types of tuberculosis: periovarian and ovarian. The former is a direct spread of tuberculosis from the fallopian tube, with tuberculous granulation tissue on the surface of the ovary, which adheres to the fallopian tube to form a tubo-ovarian mass, and often adheres to the intestinal canal or omentum. Ovarian inflammation is caused by hematogenous spread, with lesions in the deep interstitial layers of the ovary, forming nodules or caseous abscesses, while the cortex is often normal. This type is less common.
Peritoneal tuberculosis Diffuse cornular peritoneal tuberculosis may have many scattered grayish-white, cheese-like nodules of various sizes throughout the peritoneal wall layer and the plasma membrane layer of organs in the abdominal and pelvic cavities, and the entire peritoneal surface is congested and swollen. In the case of acute cornual tuberculosis, ascites may appear, the nodules gradually fibrosis, ascites is gradually absorbed, the tuberculous lesions temporarily improve or adhere, forming an encapsulated effusion. Sometimes the caseating nodules break down, necrosis and ulceration or intermingled with septic infection, resulting in repeated inflammation of the pelvic and abdominal cavities and finally forming extensive adhesions and irregular masses, or even a “frozen pelvis.”
V. Cervical tuberculosis Cervical tuberculosis is less common than the tuberculous lesions in the above mentioned areas. The lesions can be divided into 4 types, which are easily confused with cervicitis or cervical cancer and must be differentiated by biopsy and pathological examination.
(i) Ulcerated type: The ulcer is irregular in shape, superficial, with hard edges and obvious boundaries, and the base is uneven and grayish-yellow in color.
(b) Papillary type: It is rare, papillary or nodular, gray-red, brittle, and resembles cauliflower, rather like cauliflower-type cervical cancer.
(c) Interstitial type: It is a kind of cornified lesion that comes from hematogenous dissemination and involves all fibromuscular tissues of the cervix, making the cervix swollen and enlarged, which is the rarest.
(d) Mucosal type of the uterine cervix: confined to the mucosa of the cervical canal, directly spread by endometrial tuberculosis, with mucosal hyperplasia, superficial ulcers and caseous nodules on the surface, and obvious blood on palpation, sometimes blocking the cervical canal and causing pus accumulation in the uterine cavity.
Both are rare and are mostly secondary foci of infection caused by tuberculous lesions in the internal genital tract. The lesions may start as small nodules in the labia or vestibular mucosa, which immediately break down and become irregularly shaped superficial ulcers with irregular bases and a slow and persistent course. It may involve deeper tissues and form sinus tracts with caseous or pus discharge. Vaginal tuberculosis lesions look very similar to cancer and can be diagnosed by biopsy.
Clinical manifestations
The clinical manifestation of female genital tuberculosis varies greatly with the severity and duration of the disease because of the slow course and the insidious nature of the lesions, and some cases may have no symptoms and signs except for infertility, while more severe cases have systemic symptoms in addition to the typical tuberculous changes of the genital organs.
Infertility is the main symptom of genital tuberculosis, with infertility as the only complaint, and 40 to 50% of patients with reproductive tract tuberculosis are diagnosed after examination. As the fallopian tubes are the first to be involved, the lesions often cause obstruction or narrowing of the umbilical end or other segments, or interstitial inflammation, causing abnormal peristalsis or destruction of mucosal cilia, affecting the transport of sperm or fertilized eggs and resulting in infertility. Endometrial tuberculosis prevents the fertilized egg from being laid and causes infertility or miscarriage.
Lower abdominal pain is the second most common complaint of patients, accounting for about 25-50% of the complaints. It is usually a long-term lower abdominal pain, which is aggravated before menstruation.
Irregular uterine bleeding Generally, menstruation is not affected, but various menstrual changes may occur when stasis of blood in the pelvic organs or inflammatory changes in the endometrium are caused.
Increased leucorrhea can occur due to pelvic or endometrial tuberculosis. Especially in the case of cervical tuberculosis, the discharge is purulent or pus-blooded, and sometimes there is even contact bleeding or foul-smelling pus-blood.
V. Combination of tuberculosis in other organs Patients with genital tuberculosis often have a combination of tuberculosis in other organs, such as careful history taking and careful whole body examination (including silk examination), at least 80% of them have had extra-genital tuberculosis lesions. The coexistence with active tuberculosis lesions in other organs accounts for about 10%, the most common being pulmonary, pleural and peritoneal tuberculosis, followed by renal and bone tuberculosis.
Patients with genital tuberculosis may have common symptoms of tuberculosis: fatigue, weakness, loss of appetite, weight loss, mildly elevated body temperature in the evening, night sweats and other symptoms of chronic wasting, but most patients lack conscious symptoms, which are often found during systematic physical examination, and the actual number of patients with real fever is double that of those with conscious fever, which is more obvious during menstruation.
Physical examination results vary greatly depending on the severity of the disease. Asymptomatic patients may not have any abnormal findings on physical examination. If there are pelvic or peritoneal tuberculosis lesions, abdominal examination may reveal: slight tension of the abdominal wall, pressure pain, tenderness and ascites signs.
In patients with genital tuberculosis, uterine mobility may be normal or limited by adhesions. In severe cases, inflammatory masses of varying sizes may be palpated in the adnexa, which are fixed and painful to the touch; as they continue to develop, the lesions become necrotic, caseous, and fibrotic, mingling with each other and forming a huge, hard, brittle, uneven, uneven, immobile mass that fills the pelvic cavity and even becomes fixed in a slab-like fashion, as in advanced cancerous lesions. However, it is not fixed in the pelvic wall and sacrum, the main ligament is not hard, and there is no hard nodule.
Auxiliary examination
Routine laboratory tests are not very helpful for diagnosis. In chronic mild internal genital tuberculosis, the acceleration of erythrocyte sedimentation rate is not as obvious as that in septic or gonorrheal pelvic inflammatory disease, but it often indicates that the lesion is still active and can be used as a reference for diagnosis and treatment, so the blood sedimentation test should be included as a routine test.
Chest X-ray The majority of patients with this disease have secondary lung infection, so chest radiography should be included as a routine examination, focusing on the presence of old tuberculosis foci or pleural tuberculosis signs, and positive findings have some reference value for diagnosing suspicious patients, but negative findings should not be used to deny the possibility of this disease.
Third, tuberculin test The standard technique is to inject 0.1 ml of tuberculin (pure protein derivative – PPD tuberculin, equal to 5 times tuberculin units) intradermally and detect the size of skin hardness and redness within 48 to 72 hours. A positive skin test indicates a previous infection and does not indicate that active TB lesions are still present at the time of the test. The reference value is to raise the index of suspicion, especially in strongly positive patients or adolescent girls, to identify the need for more specific tests. It is important to note that negative results sometimes do not completely exclude tuberculosis, such as subjects infected with severe tuberculosis, the use of adrenocorticotropic hormones, the elderly, malnutrition, etc.
Fourth, serological diagnosis In recent years, there is the application of Mycobacterium tuberculosis purified protein antigen enzyme-linked immunosorbent assay to detect specific antibodies IgG and IgA against pure protein derivatives (PPD) in serum, which has also been used for clinical diagnosis of active tuberculosis in China. In addition, indirect immunofluorescence tests to detect specific antibodies in patient sera using appropriate monoclonal antibody techniques have the potential to increase the sensitivity and specificity for identification of M. tuberculosis. The advent and widespread use of these techniques provides a rapid and sensitive means of diagnosis of genital tuberculosis.
V. Special tests More than half of the genital tuberculosis involves the endometrium, and endometrial tissue is readily available. Therefore, pathological examination of the endometrium as well as bacterial culture of uterine secretions and animal inoculation are methods to confirm the diagnosis of genital tuberculosis. However, when Mycobacterium tuberculosis reaches the uterine cavity from the fallopian tube and has not yet caused significant endometrial lesions, pathological histological examination is impossible to identify, but bacterial culture or animal inoculation can yield positive results, and drug sensitivity tests can be used to understand the drug resistance of the strain and serve as a reference for the selection of drugs in clinical treatment. Therefore, bacteriological examination is more important. However, the culture results are affected by the sensitivity of the medium, the time and nature of the material, and the difficulty of the culture, which takes a long time (6-8 weeks to get the results) so that the clinical value of bacteriological examination is somewhat limited. At present, the above three kinds of tests are generally used at the same time, the positive diagnostic rate has significantly improved.
(a) Diagnostic scraping: It is most appropriate to perform within 2-3 days before menstruation or within 12 hours of menstrual flow. Endometrial tuberculosis is mostly found in the area adjacent to the uterine horn, so special attention should be paid to obtaining material there, and because early endometrial tuberculosis lesions are small and scattered, all the endometrium should be scraped to obtain sufficient material, and the endocervical lining and cervical biopsy should be scraped at the same time and sent for examination in groups so as not to overlook the presence of cervical tuberculosis. The endocervical specimens should be divided into two groups, one in 10% formalin solution for pathological examination and one in dry tubes for immediate bacterial culture and animal inoculation. The pathological specimens should be sliced consecutively in order to prevent leakage. Patients with long amenorrhea may not be able to scrape the endometrium, so blood from the uterine cavity can be collected for bacterial culture and animal inoculation. The scraping procedure can activate pelvic tuberculosis foci, and to prevent the spread of tuberculosis, intramuscular injection of streptomycin 1 g daily should be started 3 days before the procedure, and the treatment should be continued for 4 days after the procedure.
Negative pathological findings do not yet exclude the possibility of tuberculosis. Those who are clinically suspicious should repeat the scraping at an interval of 2 to 3 months. If all 3 examinations are negative, the endometrial tuberculosis can be considered to be absent or cured.
(B) Bacterial culture and animal inoculation: Since the number of endometrial tuberculosis bacilli is small, direct smear staining microscopy with endometrial or uterine secretions has too low a positive rate to be of clinical utility. Generally, half of the scraped specimens were retained for bacterial culture and animal inoculation. Endometrial fragments are finely ground in sterile vessels and planted on appropriate media, and cultures are examined once a week until 2 months or until they appear positive. Alternatively, the finely ground endometrial suspension was injected subcutaneously into the abdominal wall of guinea pigs. After 6-8 weeks, the experimental animals were executed and their regional lymph nodes, lumbar lymph nodes and spleen were taken as smear specimens, stained and examined directly by microscopy, or then cultured for bacterial inoculation.
In order to avoid the risk of tuberculosis dissemination due to scraping, the collection of menstrual blood for culture has been advocated. The method is to collect menstrual blood for culture with a cervical cap in the patient’s cervical coat during menstruation, or to take menstrual blood for culture under direct visualization with a speculum on the first two days of menstruation, but the positive rate is lower than that of endometrial bacteriological examination. The culture of intermenstrual cervical secretions is not limited by time and can be repeated, but the positivity rate is even lower.
Although the above-mentioned bacterial cultures and animal inoculations can confirm the diagnosis, sometimes it is necessary to repeat them before a positive reaction of Mycobacterium tuberculosis is obtained, so it is usually set at least 3 times negative to exclude tuberculosis.
(iii) Iodine contrast imaging of the uterine tubes: Iodine contrast imaging of the uterine tubes in genital tuberculosis lesions can reveal certain features that, when combined with a high clinical suspicion of tuberculosis, can basically lead to a diagnosis of genital tuberculosis.
Iodine contrast agents are iodine oil and water-soluble iodine. Because iodine water is less irritating than iodine oil, absorbs quickly, does not cause granuloma and oil embolism, and can reveal subtle tubal fistulas, iodine water is mostly used as a contrast agent at present, but its disadvantage is that the iodine disappears within a short time if the film is not taken in time.
The best time for imaging is within 2 to 3 days after menstruation. Inflammatory masses in the adnexa and patients with fever are contraindicated. To prevent the spread of lesion activation, streptomycin can be administered intramuscularly for several days before and after the procedure.
Liu Bo-ning et al. divided the features of genital tuberculosis on the radiographs of hysterosalpingography into two categories according to their diagnostic value.
(1) More reliable signs: Anyone with clinical suspicion of tuberculosis and any of the following features can basically be diagnosed as genital tuberculosis.
(1) Most calcified spots in the pelvis: There are few cases in the gynecological field that lead to pathological calcification of the pelvis. A majority of calcified spots in the equivalent of the fallopian tube is very unlikely to be anything other than genital tuberculosis.
(2) Obstruction of the middle part of the fallopian tube with a perfusion defect of ulceration or fistula formation in the interstitium of the fallopian tube with iodine oil.
(3) Multiple strictures in the fallopian tubes with a rosacea pattern.
(4) Severe stenosis or malformation of the uterine lumen.
(5) Intraluminal perfusion with iodine oil (i.e., iodine oil enters the lymphatic vessels, blood vessels, or interstitial tissue. With narrowing or deformation of the uterine cavity.
2. Possible signs: If there is clinical suspicion of tuberculosis and any 2 or more of the following signs, the diagnosis of genital tuberculosis is basically made.
(1) Isolated calcified spots on pelvic plain film.
(2) Stiff, straight tube with distal obstruction of the fallopian tube.
(3) Irregularly shaped and obstructed fallopian tubes.
(4) One side of the fallopian tube is not visualized and the middle part of the tube is obstructed with interstitial iodine perfusion.
(5) Distal atresia of the fallopian tubes with perfusion defects in the lumen.
(6) Bilateral obstruction of the isthmus of the fallopian tubes.
(7) Irregular and jagged margins of the uterine cavity.
(8) Iodine oil perfusion in the uterine interstitium, lymphatic vessels or veins.
(4) Laparoscopy: the lesion can be directly observed and biopsies can be taken for pathological examination under the microscope, ascites for direct smear, anti-acid staining, microscopy, or sent for bacterial culture with highly increased sensitivity. It is especially valuable for the differentiation of endometriosis or ovarian cancer. Many difficult cases that cannot be diagnosed by ultrasound scan and CT examination are diagnosed by laparoscopy. However, in cases with severe lesions, dense adhesions can often damage the intestinal canal and are contraindicated, and it is safer to make a small incision to take the specimen in such cases.
Differential diagnosis
The following common gynecologic diseases are very similar to internal genital tuberculosis in terms of signs and symptoms and often need to be differentiated clinically.
Patients with chronic non-specific adnexitis and chronic pelvic inflammatory disease are often infertile, and the pelvic signs are very similar to those of internal genital tuberculosis, but the former have a history of childbirth, abortion and acute pelvic inflammatory disease; menstrual flow is usually high, and amenorrhea is rarely present; when chronic adnexitis remains untreated, hysterosalpingography or scraping can be done to exclude genital tuberculosis.
Endometriosis of the ovaries has more similarities with the clinical manifestations of genital tuberculosis. For example, infertility, low-grade fever, abnormal menstruation, lower abdominal cramps, and the formation of painful pressure and solid masses in the pelvis. However, patients with endometriosis often have progressive dysmenorrhea, and one to two or more small hard nodules are often palpable in the rectal fossa, uterosacral ligament, or posterior wall of the cervix. In the absence of the above two clinical manifestations, laparoscopic examination can be performed to clarify the diagnosis when there is difficulty in diagnosis.
Ovarian tumors Tuberculous encapsulated effusion can sometimes be misdiagnosed as ovarian cystic species or ovarian cystic adenoma. It can be easily identified by medical history, clinical symptoms, and physical signs such as nodular adnexal mass with unsmooth surface, inactivity and surrounding fibrous adhesion thickening.
Patients with advanced ovarian cancer often have cachexia, fever, accelerated blood sedimentation, and metastatic lesions in the pelvic floor in addition to adnexal masses, which are not easily distinguished from pelvic tuberculosis combined with tuberculous masses of fallopian tubes and ovaries. Fine needle aspiration can be performed under B-ultrasound guidance to find antacid bacteria and cancer cells. If it is out of reach, laparoscopy or dissection should be performed according to the situation, so that the diagnosis can be clarified early and appropriate treatment can be sought to save the patient’s life.