Inflammatory disease of the female genitalia caused by Mycobacterium tuberculosis is called genital tuberculosis, also known as tuberculous pelvic inflammatory disease. It is mostly found in women between 20 and 40 years of age, but can also be seen in older women after menopause. Tuberculosis of the fallopian tubes is the most common, accounting for about 85% to 95% of female genital tuberculosis, followed by endometrial tuberculosis, with few other types of incidence. The vast majority of genital tuberculosis is secondary to infection. Primary female genital tuberculosis is rare.
Clinical presentation.
The clinical manifestations of genital tuberculosis are very inconsistent, and many patients can be asymptomatic, while others are more symptomatic.
1. menstrual disorders.
2. lower abdominal cramps.
3. systemic symptoms.
4, infertility.
Many patients are found to have endometrial tuberculosis only after diagnostic scraping for infertility, without obvious signs and other conscious symptoms.
The disease is described as female genital inflammation caused by Mycobacterium tuberculosis, also known as tuberculous pelvic inflammatory disease. It is most commonly seen in women in their 40s and also in older postmenopausal women.
Symptoms and signs The clinical manifestations of genital tuberculosis are very inconsistent, and many patients can be asymptomatic, while others are more symptomatic.
Infertility is often caused by mucosal destruction and adhesions of the fallopian tubes, which often block the lumen of the tubes; or by adhesions around the fallopian tubes, which sometimes remain partially open, but the mucosal cilia are destroyed and the tubes become stiff and restricted in peristalsis and lose their transport function; the endometrium of the uterus is also damaged by the tuberculosis lesions, which can cause infertility, so most patients are infertile. Genital tuberculosis is often one of the main causes of primary infertility.
2. Menstrual disorders In the early stage, there may be excessive menstrual flow due to endometrial congestion and ulceration. Most of the patients have been suffering from the disease for a long time and the endometrium has been damaged to varying degrees by the time they are seen, and they show scanty menstruation or amenorrhea.
Lower abdominal cramps Due to pelvic inflammation and adhesions, there may be different degrees of lower abdominal cramps, which are aggravated during menstruation.
4.Systemic symptoms If it is active, there may be general symptoms of tuberculosis, such as fever, night sweats, weakness, loss of appetite, weight loss, etc. In mild cases, the systemic symptoms are not obvious, and sometimes there is only menstrual fever, but in heavy cases, there may be systemic toxic symptoms such as high fever.
More patients are found to have pelvic tuberculosis only after diagnostic scraping, hysterosalpingography and laparoscopy due to infertility, without obvious physical signs and other conscious symptoms. In more severe cases with peritoneal tuberculosis, there is tenderness or ascites sign in the abdomen during examination, and in case of encapsulated fluid, a cystic mass can be palpated with unclear and inactive borders, and the surface is hollow on percussion because of intestinal adhesions. The uterus is generally poorly developed and often has limited activity due to surrounding adhesions. If the adnexa are involved, a mass of variable size and irregular shape, hard, uneven, nodular or papillary, or calcified nodules may be palpated on both sides of the uterus.
Genital tuberculosis is a manifestation of systemic tuberculosis, often secondary to tuberculosis in other parts of the body, such as pulmonary tuberculosis, intestinal tuberculosis, peritoneal tuberculosis, tuberculous lesions in the mesenteric lymph nodes, and also secondary to lymphatic tuberculosis, bone tuberculosis, or urological tuberculosis, and about 10% of patients with pulmonary tuberculosis have genital tuberculosis.
Pathophysiology
1. Blood-borne transmission is the most important route of transmission. In adolescence, when the genitalia are developing and the blood supply is abundant, the tuberculosis bacilli are easily transmitted by blood. The tuberculosis bacilli can infect the internal genitalia within about one year after the tuberculosis bacillus infects the lungs. Since the mucous membrane of the fallopian tubes is conducive to the latent infection of tuberculosis bacilli, the tuberculosis bacilli first invade the fallopian tubes and then spread to the endometrium and ovaries in turn, and less invade the cervix, vagina and vulva.
2. Direct transmission Peritoneal tuberculosis and intestinal tuberculosis can spread directly to the internal genitalia.
3.Lymphatic transmission is less common. Gastrointestinal tuberculosis can infect the internal genitalia through lymphatic transmission.
4. Sexual transmission is extremely rare. Men with urinary tuberculosis are infected upstream through sexual intercourse. The incubation period of genital TB is long, up to 1-10 years, and most patients have healed their primary lesions by the time genital TB is detected later.
Most patients lack obvious symptoms and have few positive signs, so the diagnosis is easily overlooked. To improve the diagnosis rate, a detailed history should be taken, especially when the patient has primary infertility, scanty menstruation or amenorrhea; when an unmarried young woman has low fever, night sweats, pelvic inflammatory disease or ascites; when chronic pelvic inflammatory disease has been untreated for a long time; and when there is a history of previous contact with tuberculosis or when the patient has had pulmonary tuberculosis, pleurisy or intestinal tuberculosis, the possibility of genital tuberculosis should be considered. Endometrial pathological examination is the most reliable basis for the diagnosis of endometrial tuberculosis. Since the endometrium is thicker before menstruation, the positive rate is high if tuberculosis bacilli are present, so scraping should be done 1 week before menstruation or within 6 hours of menstruation. Daily intramuscular injection of streptomycin 0.75g and oral isoniazid should be given 3 days before and 4 days after the operation to prevent the spread of tuberculosis foci caused by scraping. Since endometrial tuberculosis mostly spreads from the fallopian tubes, care should be taken to scrape the endometrium at the horn of the uterus and send the scrapings for pathological examination, and if a typical tuberculosis nodule is found on the pathological section, the diagnosis is tuberculosis infection. These laboratory tests are not specific and can only be used as a reference for diagnosis.
Treatment plan
1.Supportive therapy Acute patients need bed rest, at least 3 months, chronic patients can engage in some light work, but pay attention to the combination of work and rest, strengthen nutrition, appropriate participation in physical exercise to enhance physical fitness.
2.Anti-tuberculosis drug treatment Anti-tuberculosis drug treatment is effective for more than 90% of female genital tuberculosis. The principles of drug treatment should be early, combined, regular, moderate and full. The combination of anti-tuberculosis drugs such as rifampin, isoniazid, ethambutol, streptomycin and pyrazinamide is used for a period of 18-24 months to achieve good results.
The commonly used anti-tuberculosis drugs are as follows.
(1) Rifampin: It has obvious bactericidal effect on Mycobacterium tuberculosis. Its effect is similar to isoniazid, stronger than streptomycin and ethambutol, no cross-resistance with other anti-tuberculosis drugs, often used in combination with isoniazid and ethambutol, can strengthen the effect and delay the development of drug resistance. It is absorbed orally up to 90-95%, with orange color in urine, half-life up to 2-5 hours, and effective serum concentration maintained for 6 hours. The dosing method is 450-600mg per day, taken in a single dose before breakfast to facilitate absorption. The side effects are mild, mainly on liver damage, transient liver function impairment and elevated transaminases, which mostly occur in patients with pre-existing liver disease. Rifampin has the potential to cause fetal malformation to pregnant women, so it is contraindicated for early pregnancy. Rifampin is similar to rifampicin in terms of its effects and side effects. The dose is 150-200mg daily, taken before breakfast, and has cross-resistance with rifampicin. It is the new semi-synthetic rifamycin antibiotic decay preferred for clinical application in China. It is also used with caution in pregnant women.
(2) Isoniazid: It is a widely used anti-tuberculosis drug because of its strong bactericidal power against Mycobacterium tuberculosis, small dosage, low oral side effects and low cost. Combination with other anti-tuberculosis drugs can reduce the emergence of drug resistance and have a synergistic effect to improve the efficacy. 300mg per day, administered in a single dose.
(3) Streptomycin: intramuscular injection, 0.75g, once daily. Streptomycin alone can easily produce drug resistance, so it is mostly used in combination with other anti-tuberculosis drugs. Long-term use of the drug must pay attention to its side effects (dizziness, mouth numbness, numbness of the limbs, tinnitus, serious cases may lead to deafness), elderly women use with caution.
(4) Ethambutol: It has a strong inhibitory effect on Mycobacterium tuberculosis, no cross-resistance with other anti-tuberculosis drugs, and the combination can enhance the efficacy well delay the emergence of drug resistance, and is absorbed about 80% after oral administration. The main side effect is retrobulbar optic neuritis, the incidence is 0.8%, easy to occur at high doses, early discontinuation of the drug can be recovered.
(5) Pyrazinamide: The dose is 1.5g per day, divided into 3 oral doses. Side effects are common with liver damage, but also hyperuricemia, arthralgia and gastrointestinal reactions. Toxic, easy to develop drug resistance, the inhibition effect is not as good as streptomycin. However, it is effective for slow-growing intracellular tuberculosis bacilli and can be combined with other anti-tuberculosis drugs to shorten the course of treatment. Treatment plan: At present, a short course of drug therapy is implemented, with intensive therapy available for the first 2-3 months and intermittent therapy available for the next 4-6 months.
3.Surgical treatment The pelvic mass shrinks after drug treatment but does not completely subside, especially those who cannot exclude malignant tumor; those who have ineffective treatment or recurrence after treatment; those who have ineffective drug treatment for endometrial tuberculosis should undergo surgery. In order to avoid the spread of infection during surgery and to reduce adhesions to the advantage of surgery, anti-tuberculosis drugs should be used for 1-2 months before surgery and continue to be treated with anti-tuberculosis drugs after surgery to achieve complete cure. Total hysterectomy and bilateral adnexal resection are preferred, and ovarian function should be preserved as much as possible in young women. Since the adhesions caused by genital tuberculosis are often extensive and tight, oral intestinal disinfectant drugs and clean enemas should be given before surgery, and attention should be paid to the anatomical relationships during surgery to avoid injury.
Prevention enhances physical fitness, good BCG vaccination, and active prevention and treatment of tuberculosis, lymphatic tuberculosis and intestinal tuberculosis.
Related drugs.
Rifampicin Isoniazid Ethambutol Streptomycin Pyrazinamide