According to the World Health Organization, the incidence of tuberculosis has increased in varying degrees in 41.5% of developing countries and 25% of developed countries in the five years from 1986 to 1990 [1]. About one-third of the country’s population has been infected with Mycobacterium tuberculosis, with more than 400 million people infected, and the prevalence of tuberculosis is still quite high (367/100,000), and the prevalence of tuberculosis in Guangdong Province is 352/100,000. The increase in pulmonary tuberculosis implies an increase in extrapulmonary tuberculosis [2], and it can be expected that female genital tuberculosis (FGT) will also be more frequent; and in some Asian countries, more than 25% of infertile patients are found to have FGT [3], and the most common symptom of FGT is infertility, and it is estimated that 85% of FGT cases never become pregnant, and for patients with primary infertility, genital tuberculosis is more common. Chavhan et al [4] conducted a retrospective hysterosalpingography (HSG) study of 492 infertility patients over a 4-year period and found that 37 (7.5%) of them had FGT, and the results of lumpectomy showed that FGT was found in 350 (18.64%) of 1878 primary infertility patients; in FGT was found in 122 (8.58%) of the 1422 patients with secondary infertility[4] . In addition, Dong Mei et al. performed PCR examination of Mycobacterium tuberculosis DNA in the peritoneal fluid of 41 patients with unexplained infertility and found that 19 of them (46.34%) were positive. The above data indicate that FGT is not uncommon among infertility patients in China, especially in primary infertility, so attention should be paid to actively search for evidence of tuberculosis infection in the process of infertility diagnosis and treatment; some tuberculosis patients with pelvic masses and ascites are easily misdiagnosed as ovarian tumors and ovarian cancer.
At present, there are very few studies on FGT at home and abroad, and there are few gaps in the epidemiology of FGT formation in China, including primary prevention and secondary prevention, and only a few reports on the incidence of FGT are mostly statistical data from local areas of hospitals, and there is a lack of large samples and formal epidemiological data on FGT, and there is a lack of exact statistics on the incidence of FGT. The clinical diagnosis of FGT is much more difficult than that of tuberculosis, especially the early diagnosis, which is prone to miss diagnosis or treatment [5], causing great pain and harm to patients and families, and there is no clear laboratory diagnostic index for early diagnosis of FGT. challenging problem is how to detect patients with FGT at an early stage in order to treat them early and achieve the purpose of reducing the infertility rate and reducing misdiagnosis and underdiagnosis, thus the epidemiological study of FGT and early diagnosis and treatment are of great significance.
Reasons for misdiagnosis and underdiagnosis.
1. neglecting the menstrual history and marital history which have important diagnostic value;. Insufficient understanding of multiple clinical manifestations of female genital tuberculosis at the first consultation; pelvic tuberculous mass and ovarian tumor have many similar symptoms and signs, both can have abdominal distension, masses, etc. Both masses can show surface unevenness, adhesions and poor activity, which are not easy to differentiate and increase the difficulty of diagnosis, so a comprehensive analysis of clinical data should be made, combined with ultrasound examination, erythrocyte sedimentation rate, tuberculin test, tuberculosis antibody and Therefore, a comprehensive analysis of clinical data should be conducted, combined with ultrasound examination, erythrocyte sedimentation rate, tuberculosis bacteriocin test, tuberculosis antibody and history of childbirth and menstruation, and a comprehensive analysis of the patient’s past history.
The trend of increasing incidence of tuberculosis is not well recognized, and the occurrence of FGT has clear age and geographic characteristics: it is more common in young women and in women from developing countries where tuberculosis is endemic. The majority of FGT is secondary to pulmonary tuberculosis, and within 1 year of the onset of pulmonary tuberculosis, Mycobacterium tuberculosis can spread hematologically to the female internal reproductive organs (mostly the fallopian tubes); direct spread of primary tuberculosis from adjacent tissues (e.g., urinary tract tuberculosis, peritoneal tuberculosis, and mesenteric lymph node tuberculosis) is another important route of FGT. In addition, there are sporadic reports of primary FGT, which are mostly thought to be sexually transmitted to the female genital tract from the active urogenital tract of the partner.
3. Suspected endometrial tuberculosis such as primary infertility and menstrual disorders is easily diagnosed by diagnostic scraping and pathological examination. The difficult clinical differentiation is between pelvic tuberculosis with pelvic masses combined with ascites and ovarian cancer. The clinical manifestations of both are non-specific, the symptoms are diverse, and some of them are not obvious in general, the tumor markers CEA and CA125 can be increased in pelvic tuberculosis, and the blood sedimentation can be increased in both. Therefore, CT examination is the main imaging method, but it should be combined with clinical and laboratory examinations for diagnosis, and should be distinguished from ovarian cysts, ovarian cancer, ovarian endometriosis cysts and uterine fibroids in female reproductive organs.
4. Insufficient understanding of the complexity of the treatment of extrapulmonary tuberculosis, that short-term experimental treatment with anti-tuberculosis drugs is ineffective to exclude tuberculosis, and that the treatment course of pelvic tuberculosis should generally be extended to 18 months-2 years, generally choosing a combination of 4-5 drugs, and that the diagnosis of tuberculosis should not be easily denied to those whose diagnostic treatment is ineffective.
Measures to reduce the rate of misdiagnosis.
1, must raise the vigilance of tuberculosis, detailed medical history, careful physical examination, perform the necessary auxiliary examination, the results of the auxiliary examination should be combined with clinical symptoms and signs and comprehensive analysis, and dynamic follow-up observation.
2. Patients with infertility, menstrual disorders and amenorrhea should be especially alert to the presence of combined pelvic tuberculosis when gynecological consultation and treatment by general methods are ineffective, and PPD test, chest and abdominal X-ray and laparoscopy can help to diagnose it.
3, pelvic tuberculosis forms irregular pelvic masses with ascites, which are not easily distinguished from ovarian cancer clinically, so laparoscopy can be performed under the guidance of B ultrasound, and smear can be performed to find Mycobacterium tuberculosis and cancer cells, but the positive rate of general smear is extremely low. However, patients with pelvic tuberculosis mostly have extensive pelvic-abdominal adhesions and some have closed pelvic cavity, suggesting that we should pay attention to this problem when using laparoscopic methods to avoid damage to the intestinal canal. Ordinary surgery should take into account wound healing, age and other factors, and pay attention to the length of the surgical incision. If the pelvic and abdominal intestinal adhesions are heavy, accompanied by abscesses and caseous necrosis, the pus and necrotic tissue can be aspirated as much as possible and appropriate intestinal adhesions can be released during open surgery. It relieves the symptoms of tuberculosis toxicity, improves the patient’s general and local condition, and has good effect on further postoperative anti-tuberculosis treatment.
Treatment.
1, drug therapy Anti-tuberculosis treatment is effective for 90% of female genital tuberculosis. The principles of anti-tuberculosis treatment are early, combined, regular, moderate, and full, and in recent years, the combination of rifampin, isoniazid, ethambutol, streptomycin, and pyrazinamide, etc., for a course of 18-24 months, with good efficacy. At present, the short course program is no longer used, and its treatment cannot completely eliminate tuberculosis bacteria, and after stopping the drug It is easy to relapse after stopping the drug.
Surgical treatment should be strictly controlled, and is suitable for those whose pelvic masses have shrunk after drug treatment but cannot completely subside and cannot exclude malignant tumors; those whose treatment is ineffective or recurrent after treatment; those whose endometrial tuberculosis is ineffective after drug treatment should undergo surgery, and surgery should be performed to remove the tuberculosis lesions, and if necessary, bilateral adnexal and total hysterectomy is appropriate, and ovarian function should be preserved as much as possible for young women. In order to avoid the spread of infection and poor healing of the incision during surgery, anti-tuberculosis drugs should be used for 2 months before surgery, and treatment with anti-tuberculosis drugs should be continued according to the activity of tuberculosis and whether the lesions are removed.
Treatment of female genital tuberculosis infertility (FGTI) with fertility assistance: in vitro fertilization-embryo transfer (IVF-ET) is the only option to treat FGT infertility. Anti-tuberculosis treatment and surgery alone do not save the severely impaired reproductive function of the majority of FGTI patients, and IVF-ET can significantly improve the chances of conception, but its prognosis remains unsatisfactory. As early as 10 years ago, Gurgan et al. studied IVF-ET outcomes in patients with FGTI and found significantly lower pregnancy rates than in patients with non-tuberculous infertility (9. 1% vs. 21. 3%) and a higher rate of spontaneous abortion after transplantation (75% vs. 19. 2%) [9]. A recent study by Dam et al. in patients with recurrent IVF failure due to latent TB not only reconfirmed these results, but also showed that combined anti-tuberculosis treatment significantly improved some ovarian reserve function and endometrial tolerability indicators, and increased the rate of egg production, but did not contribute much to transplantation outcome. Therefore, before IVF-ET, patients should be fully informed of the reality that pregnancy success rates are still low, so that they can make a reasonable choice according to their situation. Therefore, there is a need to research and develop new techniques to assist pregnancy in response to the pathogenesis of female genital tuberculosis infertility, such as rational combination and selection of multiple treatment options, aggressive ovarian protection, endometrial transplantation and repair, and tissue engineering of the uterus, in order to achieve increased pregnancy and live birth rates.
Prevention.
1, advocate national fitness exercise, exercise, enhance physical fitness, improve the body’s resistance and resistance to disease.
2, do a good job of BCG vaccination, active prevention and treatment of tuberculosis, lymphatic tuberculosis and intestinal tuberculosis, to avoid causing genital tuberculosis.
3.Regular health checkups, “three early”, that is, early detection, early diagnosis, early treatment.
4. For adolescent and fertile women with low fever, night sweats, weakness, loss of appetite or ascites, pelvic masses; or patients with menstrual disorders, scanty or amenorrhea, pelvic effusion or primary infertility; or chronic pelvic inflammatory disease that has not been cured for a long time; or those who have a history of contact with tuberculosis or who have had tuberculosis themselves, detailed medical history should be taken, comprehensive examination should be conducted, early diagnosis should be confirmed, and the early diagnosis and cure rate should be improved.