Sexually Transmitted Diseases - I. I. Mavrov 2005

Genital Tuberculosis

Over the past few years, the issue of tuberculosis has gained particular urgency. It comes as no surprise that the WHO has declared this disease a global emergency.

Genital tuberculosis, until recently considered a rare condition and viewed solely as a cause of Infertility, is emerging as a critical clinical challenge as accumulated laboratory and clinical data reveal a wide array of manifestations and significant difficulties in Differential Diagnosis when compared with other Reproductive System disorders.

Etiology. The CAUSATIVE AGENT OF the disease is Mycobacterium tuberculosis. Genital tuberculosis lesions are primarily caused by human-type mycobacteria and, in rare instances, by bovine-type tubercle bacilli. Mycobacteria are characterized by acid-fastness: 95% alcohol containing 3% Hydrochloric acid decolorizes all Bacteria except mycobacteria. This acid-fastness is attributed to The Structure of The Cell wall, which is rich in Lipids, Polysaccharides, and Proteins.

There is a growing spread of multidrug-resistant strains of the tuberculosis pathogen, which significantly complicates patient Treatment.

Upon invading Tissues, tubercle bacteria reside predominantly intracellularly—within monocytes, reticuloendothelial Cells, and giant cells. This intracellular localization is one of the key factors that hinders effective Chemotherapy, enabling the microbes to maintain viability.

Routes of Transmission. From the primary focus, tubercle bacilli can spread via hematogenous or lymphatic pathways, as well as directly through the reproductive Organs via intimate contact with infected secretions from a sexual partner. Ascending spread of the primary infection along the female reproductive tract occurs As a result of contamination during sexual intercourse. In Male genital tuberculosis, the presence of tubercle bacilli is typically detected in urine, semen, and epididymal aspirates.

Primary infection of the reproductive tract most frequently occurs during Puberty and adolescence and may remain latent for many years before any clinical symptoms manifest.

Epidemiology. The prevalence of genital tuberculosis is closely linked to overall tuberculosis morbidity rates. In regions with a high incidence of Pulmonary Tuberculosis, the frequency of genital tuberculosis is correspondingly high. Key risk factors for urogenital tuberculosis of any localization include: a history of tuberculosis (observed in two-thirds of patients with extrapulmonary involvement); residual pulmonary lesions indicating a prior infection in newly diagnosed patients; and debilitating comorbidities (such as Diabetes Mellitus, PEPTIC ULCER DISEASE, a history of gastric surgery, etc.).

According to recent studies, the proportion of patients with genital tuberculosis has sharply increased against the backdrop of a steady decline in overall tuberculosis incidence rates. Observations by E.P. Chenskikh and S.A. Mazhenova (1986) indicate that among patients with Extrapulmonary tuberculosis, the largest share (49.3%) presenting with active disease are those with urogenital tuberculosis.

Literature data show that in approximately half of all cases, male genital tuberculosis is associated with Urinary Tract tuberculosis. Other commonly affected sites include the Prostate Gland, Seminal Vesicles, and Epididymis, while involvement of the Penis, Urethra, and other organs is less frequent.

In female genital tuberculosis, the active inflammatory process most often involves the fallopian tubes and Ovaries (adnexa), followed by the endometrium (39.7% of patients), the cervix, Vagina, and vulva (12%). Genital forms of tuberculosis predominantly affect women of reproductive age (20–40 years). It is rarely diagnosed before puberty. Often, many years elapse between the initial infection and the establishment of a definitive diagnosis. Frequently, infertility turns out to be the sole manifestation of genital tuberculosis.

Genital Tuberculosis in men is statistically reported twice as frequently as in women. Some authors attribute this discrepancy solely to the diagnostic challenges of detecting the disease in women. Others believe it reflects a higher overall incidence of tuberculosis among men (W. Christiansen, 1974; H. Simon et al., 1977, etc.). The number of women suffering from genital tuberculosis exceeds the number of affected men only within the 25–35 age bracket—a period that coincides with peak female reproductive function.

Current diagnostic criteria for genital tuberculosis suggest that the actual incidence of this disease in women approaches the prevalence rates observed in men.

The high percentage of genital tuberculosis among individuals over the age of 20 is attributed not only to increased estrogen levels but also to the onset of active sexual activity. From an epidemiological perspective, this fact is of particular interest and warrants further investigation.

An analysis of literature data indicates that genital tuberculosis is not as rare a condition as classical texts suggest. Furthermore, an incomplete understanding of the true incidence of genital tuberculosis leads to an underestimation of its clinical and epidemiological significance. In everyday clinical practice, insufficient attention is paid to the pathways of reproductive tract infection, micro-form tuberculosis lesions, and preventive measures.

In many countries today, numerous cases of genital tuberculosis are still reported without distinguishing between urinary and genital involvement. Because genital tuberculosis represents an open, infectious form of the disease, critical epidemiological responsibilities lie not only with phthisiologists, gynecologists, and epidemiologists, but also with venereologists.

According to I. Vanrell et al. (1980), in 20% of cases, a thorough medical history reveals a family history of tuberculosis or direct contact with tuberculosis patients. In roughly half of these instances, the condition involves pulmonary tuberculosis, lymphadenitis, or abdominal forms of the disease. One-third of patients recall having been treated for pulmonary forms of the disease in the past.

In 10–40% of cases, even after a DIAGNOSIS OF GENITAL tuberculosis has been confirmed, information regarding the localization of the primary site of infection remains absent (G. Magnin et al., 1981). It has been established that the majority of patients, prior to the detection of genital tuberculosis, were typically under the care of gynecologists and urologists.