Sexually Transmitted Diseases - I. I. Mavrov 2005

Genital Tuberculosis
Genital Tuberculosis in Women

A distinction is made between lower genital tuberculosis (affecting the vulva, Vagina, and cervix) and upper metroadnexal tuberculosis (metroadnexitis, tuberculous endometritis, and involvement of the uterine appendages).

Tuberculosis of the lower segment of the Reproductive System is relatively straightforward to diagnose. Because lesions in this area are accessible to visual inspection, their Diagnosis and Treatment present little difficulty. Both primary localization—an inoculation chancre (which is rare)—and secondary forms are recognized.

The primary chancre exhibits specific Clinical Features. The incubation period lasts 1 to 2 weeks, with a maximum of 8 weeks. The ulcer may be small and oval, with smooth edges and a base covered in purulent debris. It is non-indurated and causes pain only upon Palpation. Regional lymphadenitis develops concurrently.

The inflamed Lymph node is small, occasionally the size of a hazelnut, and the condition can progress to polylymphadenitis with fistulae. The patient's general condition remains unaffected, although low-grade fever may be present. Concurrently with the appearance of the chancre, the tuberculin Skin test becomes positive.

Vulvar tuberculosis. This accounts for no more than 1–2% of all cases of Female Genital Tuberculosis. The ulcers may be single or multiple, soft, with serpiginous margins, a reddish base, and gray granulations covered with yellowish pus. When multiple ulcers are present, they tend to coalesce. The condition is occasionally accompanied by inguinal lymphadenitis. The ulcers are typically located on the inner surface of the Labia Majora and minora, as well as around the urethral meatus.

Infection occurs via hands or toiletries contaminated with mycobacteria, or through feces in cases of intestinal tuberculosis. Sexual transmission is also possible. Isolated vulvar tuberculosis has a protracted course and is frequently associated with other clinical forms.

Tuberculosis of Bartholin's gland. This is a very rare form of tuberculosis. Infection occurs hematogenously or via a downward spread from an affected endometrium or fallopian tubes. It is hypothesized that infection of the gland can also occur via the hands of patients suffering from Pulmonary Tuberculosis.

Tuberculous bartholinitis is painless, mimicking chronic inflammation. It typically leads to suppuration, and following spontaneous or surgical drainage, a fistula forms. Secondary infection can result in an acute clinical course.

Vaginal tuberculosis. Cases of vaginal tuberculosis have been documented in women whose sexual partners suffered from tuberculous epididymitis. This localization is generally considered to be a hematogenous metastasis.

The onset of the disease is insidious and the course is slow. The mucosa exhibits yellowish nodules or ulcers that are initially solitary, later multiplying and fusing to form larger ulcerations. Diagnosis is established through laboratory testing. The Differential diagnosis must rule out Chancroid, Syphilis, ulcerated neoplasms, vaginal diphtheria, and other conditions. Tuberculous vaginitis is notoriously resistant to treatment.

Cervical tuberculosis. This occurs more frequently than other Clinical forms of lower segment tuberculosis. In the majority of cases, cervical involvement presents as a hematogenous metastasis, although reports of primary cervical tuberculosis do exist.

It is frequently associated with involvement of the Uterus and fallopian tubes. The ulcerative form is the most common, though vegetative and miliary forms are also observed.

The ulcer is typically non-specific in appearance. In the vegetative form, the cervix is covered with reddish-purple, friable, and easily bleeding vegetative growths. In the miliary form, the cervix is invariably enlarged and hypertrophied, with visible follicles On the surface. Biopsy is the definitive diagnostic method, particularly in cases refractory to non-specific treatments, most notably electrocoagulation.

Tuberculous endometritis. This is observed in 56% of patients with genital tuberculosis and generally has a favorable clinical course. Isolated uterine involvement is exceedingly rare. Tuberculous endometritis is much more likely to cause menorrhagia or hypomenorrhea than Amenorrhea, which occurs only in the presence of marked endometrial sclerosis. If endometrial biopsy results are non-diagnostic for a specific infection, the diagnosis must rely on indirect evidence, including medical history, chest radiography, and hysterosalpingography. A positive finding on the latter may indicate specific salpingitis.

The fallopian tubes may be stenotic, atrophic, slightly thickened, and filled with turbid fluid, often exhibiting tortuosity. Nodules frequently form in the isthmic portion or at the uterotubal junction. Typically, delicate adhesions tether the tube to the Ovary, broad ligaments, and adjacent Organs. The fallopian tubes are affected in all cases of genital tuberculosis, whereas the Ovaries are involved in an estimated 15–30% of cases. Ovarian lesions typically affect the cortical layer and the walls of the corpus luteum.

Tuberculous lesions of the uterus and its appendages lead to varying degrees of functional impairment. Typically, multiple reproductive Functions are disrupted: morphogenesis (uterine hypoplasia, cylindrical or globular uterus with increased density); the Menstrual cycle (amenorrhea, hypomenorrhea, hypermenorrhea, etc.); conception (Infertility, Ectopic Pregnancy, Spontaneous Abortion); and neuroendocrine functions (ovarian insufficiency, neurovascular endocrine disorders such as hot flashes, headaches, and decreased libido). Patients may also experience lower abdominal pain, dysmenorrhea, and intermenstrual crises.

Other systemic symptoms of tuberculosis—such as generalized weakness, anorexia, low-grade fever, night sweats, and weight loss—are primarily associated with active tuberculous processes and are observed in only 1–2% of patients with genital tuberculosis.

Infertility is one of the primary reasons patients with genital tuberculosis seek medical care. The incidence of primary infertility in women with genital tuberculosis is as high as 98%. The underlying cause is typically tubal occlusion or mucosal destruction of the fallopian tubes. Endometrial and ovarian involvement play a lesser role in the Pathogenesis of infertility.

The prevalence of female genital tuberculosis among infertile populations varies depending on geographic Location and the general socioeconomic level: 0.7% in Austria, 1% in the USA, 5% in Italy, and 17.4% in India.

The tuberculous process may involve the fallopian tubes and the uterus, while the ovaries are affected less frequently. Vulvovaginal tuberculous lesions are extremely rare and present as ulcers with regular margins. These ulcers tend to coalesce, have an uneven base, and occasionally contain caseous necrotic debris. In severe cases, rectovaginal or vesicovaginal fistulae may develop. Also rare are infiltrative forms with palpable tumor-like masses in the adnexa, as well as forms accompanied by peritoneal or intestinal involvement. Clinically ambiguous cases of genital tuberculosis are occasionally encountered.

Diagnosis

The DIAGNOSIS OF GENITAL tuberculosis is conducted in several stages: establishing a clinical diagnosis in patients with suspected genital tuberculosis, followed by confirmation through pathogen detection, radiological and morphological evaluations, as well as immunological, molecular-genetic, and molecular-biological studies.

A clinical diagnosis is of paramount practical importance as it helps identify patients with suspected tuberculosis who require laboratory and radiological investigations to precisely characterize the disease. It is based on a meticulous analysis of personal and familial medical history. Of particular interest is a history of pleuroperitoneal localization, as well as manifestations in the Lungs, Urinary Tract, Lymph Nodes, intestines (e.g., appendicitis), or the osteoarticular system. A SYSTEMATIC REVIEW OF all urogenital functions and The Nature of any changes is essential.

When an insidious, painless inflammatory process is present—characterized by an Epididymis that is nodular and firm like Cartilage, alongside similar nodules in the prostate or Seminal Vesicles—the diagnosis of Urogenital tuberculosis is often unquestionable. An insidious onset, slow progression without fever, absence of prior urethral discharge, minimal or absent local pain, and a history of tuberculosis all strongly point toward a tuberculous Etiology.

Particularly conclusive diagnostic signs include scrotal skin fistulae originating from the epididymis (corresponding to its anatomical location), fluctuating abscesses in these regions, or involvement of the vas deferens.

Attention should be paid to the nature of vaginal and cervical secretions, as well as menstruation (onset, cycle regularity, duration, amount of discharge, and periods of amenorrhea). It is important to be aware of potential conception disorders resulting from infertility, ectopic pregnancies, and miscarriages. Metroadnexa infection occurring after an abortion is an important diagnostic sign when the diagnosis is established late and in the absence of clinical manifestations.

It is also necessary to take into account sensory disorders, such as pain in the Urethra, Perineum, lower abdomen, and pain during menstruation, urination, ejaculation, etc. Painful sensations are reported in 8-10% of patients with urogenital tuberculosis. They are more persistent in men, whereas women are characterized by recurrent attacks interspersed with prolonged latent periods.

Today, urogenital tuberculosis proceeds in most cases with blurred symptoms; numerous forms of this disease with micro-lesions are observed. Therefore, clinical diagnosis must be active, mobilizing all available resources to examine individuals suspected of having genital tuberculosis.

Confirmation of the diagnosis. Despite the progress achieved in diagnosing genital tuberculosis based on its clinical manifestations, morphological, and radiological data, the detection of Mycobacterium tuberculosis is of vital, and sometimes decisive, importance.

Microbiological Methods help establish the tuberculous Nature of the process in its early stages. Laboratory studies utilize: urethral and cervical discharges, fistular pus, prostate secretion, ejaculate, epididymal aspirate, prostate biopsy, epididymal biopsy, resected segments of the fallopian tube, ovary, etc., obtained after surgery; menstrual Blood; and fluid obtained by uterine cavity lavage.

Methods for detecting Mycobacterium tuberculosis. 1) Direct examination method. Due to the fact that tubercle bacilli are usually present in small quantities in urethral and cervical discharges and menstrual blood, the following are applied: auramine staining, concentration methods via homogenization of the test material (specifically using Electrophoresis), and fluorescent Cell/15.html">Microscopy. The latter method has undeniable advantages: firstly, simplicity of the staining technique; secondly, rapid results (in 1-3 min). 2) Direct slide culture. This method is suitable for poorly equipped laboratories. 7-14 days after inoculating the test material, slides stained by the Ziehl-Neelsen method are examined under a Microscope to detect mycobacteria. 3) Cultures on special media. Advantages of the method: cultures allow the Determination of the type of tubercle bacillus and its resistance to antituberculous drugs, providing epidemiologically valuable information. However, the method cannot be considered universal: it requires a well-equipped laboratory and a long time to obtain results—averaging 3 months. With consistently negative culture results, 11% of patients still have certain urogenital lesions, and 40% have an active process in the prostate, appendages, or fallopian tubes. 4) Guinea pig inoculation. This is the most specific and sensitive, albeit quite expensive and complex, method for diagnosing tuberculosis. 5) Intracerebral mouse inoculation. On the 8th day after administration of the test material, the animals are sacrificed, smears are prepared, and morphological studies of their Brain, Liver, Spleen, and lungs are performed. Considering that results are obtained in 8 days (rather than 2 months as in guinea pig inoculation) and that control studies can confirm the accuracy of initial findings, this is a valuable bacteriological diagnostic method. 6) Morphological study with Ziehl-Neelsen staining. This is how surgical material obtained via biopsy and other Materials suitable for morphological examination are studied. For instance, positive results from morphological studies of endometrial scrapings serve as a criterion for the tuberculous etiology of the process. The method has no advantages over others. Morphological diagnosis (anatomopathological studies of the urethral mucosa, cervical canal, endometrium, etc.; Cytological examination of endometrial, cervical, urethral, and vaginal smears) not only detects mycobacteria but also determines the nature of lymphoid clusters, epithelioid clear Cells, and even giant multinucleated cells. 7) Radiological examination. Urethrography, vesiculography, and salpingography are important methods that Complement bacteriological and morphological findings. Radiological methods play a leading role in detecting internal genital tuberculosis in patients with advanced forms of the disease, but they are uninformative in patients with early lesions. They are also used to examine infertile patients, especially women with a history of tuberculosis, to detect potential tubal infertility. 8) Diagnosis via immunological tests. Enzyme-linked immunosorbent assay (ELISA) and other serological methods are used to detect not the pathogen itself, but its Antigens and Antibodies against them. These methods allow the diagnosis of tuberculosis in the Cytology/cytology/16.html">Early stages of the disease. 9) Other Research Methods: determination of general and focal reactions to tuberculin (50 TU of tuberculin administered subcutaneously once), and blood parameters—ESR, formed elements (red blood cell count slightly reduced, minor leukopenia, increased lymphocyte count and decreased monocyte count, and in some cases, a decreased eosinophil count). The hemogram provides relative information and plays an auxiliary role.

A negative tuberculin skin test indicates the absence of the tubercle bacillus and, therefore, rules out the presence of tuberculosis. Following primary infection, the tuberculin test becomes positive, and the degree of its expression depends on the nature of immunological reactions. An intense tuberculin reaction indicates a recently developed or active tuberculous process.

Molecular-genetic and molecular-biological methods are used to establish the diagnosis of genital tuberculosis. In particular, Polymerase Chain Reaction (PCR), DNA fingerprinting, and mutation Analysis of the Mycobacterium tuberculosis genome, which determine the pathogen's resistance to antituberculosis drugs.

When diagnosing genital tuberculosis, the clinician must take into account data on the diagnostic sensitivity and Specificity of Laboratory tests in order to correctly and most beneficially prescribe a particular spectrum of analyses for each specific case (e.g., skin test (sensitivity - 65%, specificity - 80%); Ziehl-Neelsen staining (sensitivity - 50%, specificity - 80-85%); bacterial culture (sensitivity - 80-85%, specificity - 100%); serum antibody levels (sensitivity - 80%); PCR (sensitivity > 95%, specificity - 95%)).

Treatment

The management of patients with genital tuberculosis is based on the principles of adequate etiopathogenetic treatment. Methodologies for repeated surgical interventions have been developed for widespread and complicated forms of the disease. Pathogenetic treatment methods have been proposed, including enzyme therapy and therapies accounting for microcirculation disorders. Comprehensive treatment is aimed, on the one hand, against the pathogenic agent, and on the other hand, amounts to adjunctive treatment to strengthen the body's defense mechanisms.

Specific antituberculosis therapy includes: general and local treatment with tuberculostatics; Surgical treatment consisting of the excision of tuberculous foci resistant to conservative management.

Non-specific Treatment of the disease involves: additional neurohormonal therapy and pathogenetic Chemotherapy (Hormones, mediators, biostimulants, infiltration anesthesia, etc.); adjunctive treatment utilizing environmental factors (physiochemotherapy, climatophysiotherapy).

In cases of minor anatomical and functional Changes in the genital organs, generally accepted standardized antibacterial therapy regimens proposed by the WHO are typically applied. Two main antibacterial drugs are used, with the mandatory inclusion of isonicotinic acid hydrazide - INH (syn. isoniazid, tubazid) or its derivatives (ftivazide, saluzid, metazide). Simultaneously, biostimulants, electrophoresis with zinc sulfate or sodium hyposulfite, and phonophoresis with hydrocortisone are prescribed. The duration of the main course of therapy is 8-10 months.

In cases of pronounced anatomical and functional changes in the genital organs During the first 4-6 months, three antibacterial drugs are prescribed, with the mandatory inclusion of rifampicin or streptomycin. Only after the resolution of inflammation in the lesion site does treatment transition to two tuberculostatic drugs with the sequential addition of physical Procedures, including physioenzyme therapy with terrilitin, which increases the bacteriostatic activity of Tissues and the concentration of specific drugs in tuberculous foci. This drug also improves microcirculation, prevents excessive fibrous tissue formation in the affected organ, liquefies caseous masses, and simultaneously increases the effectiveness of etiopathogenetic treatment.

In the presence of a Tuberculoma, for example in the uterine appendages, antibacterial therapy is considered preoperative preparation lasting no longer than 1-3 months. Physiotherapy and biostimulants are not indicated for such patients. Subsequently, antibacterial therapy is supplemented by surgical correction. Indications for the latter include infertility, pain syndrome, and persistent menstrual dysfunction.

Adjunctive treatment plays a supporting role by enhancing local resistance and microcirculation, favorably altering the neurotrophic state of genital tissues, and thereby amplifying the efficacy of Antibiotics.

Hormonal treatment is of great importance in compensating for functional disorders resulting from endocrine insufficiency or disorders during the course of the disease. Patients are prescribed thyroid hormone medications, corticosteroid hormones, etc.

Among adjunctive treatment methods, special attention deserves: blood and blood substitute transfusions; phonophoresis with hyaluronidase; rectal administration of isoniazid and rifampicin in combination with dimethyl sulfoxide (DMSO); heparin (locally in the form of compresses); electrophoresis; and in the presence of immunodeficiency—thymalin or levamisole to activate The Immune System; climate-sanatorium treatment (heliotherapy, climatotherapy, air baths, hydrotherapy, therapeutic physical exercises, etc.).

Restoration of reproductive function in patients with urogenital tuberculosis is difficult. The prognosis for childbearing is unfavorable in A number of cases, even with minor tuberculous involvement of the genital organs. If symptoms or morphological changes persist after appropriate antituberculosis therapy, radical surgical treatment consisting of Hysterectomy and bilateral salpingectomy is indicated.

Prevention

A patient with genital tuberculosis serves as a focus of infection and spread within the family and domestic environment. Therefore, preventive work regarding this disease is aimed at preventing infection of the genital organs; activation of tuberculous foci in the genital organs; and specific infection originating from tuberculous foci in the genital organs.

A decrease in the incidence of tuberculosis of various localizations in an endemic focus leads to a reduction in the number of individuals (men and women) affected by genital tuberculosis. It is also evident that preventive measures against the spread of tuberculosis among the population are indirectly prophylactic for genital tuberculosis, as the latter frequently results from infection of various localizations. To prevent infection with genital tuberculosis, women should avoid sexual intercourse with men suffering from Various Forms of urogenital tuberculosis, and even with men suffering from active extragenital lesions, because direct infection of the female genital organs is possible under such circumstances. Conversely, men should be wary of genital tuberculosis infection in women and initiate appropriate measures if necessary.

According to clinical observations, the risk of infection is low; however, to prevent the spread of infection, a number of rules must be observed. Young girls should not be allowed to play on the floor of a room inhabited by a patient with an infectious form of tuberculosis. Family members are prohibited from using toilet articles, especially bidés, douching equipment, etc., belonging to a person with genital or urogenital tuberculosis. Daily compliance with hygiene and sanitation requirements is necessary (disinfection of hands and toiletries, as well as treatment of dressings and pads soiled with urethral, vaginal, or menstrual discharge using bleaching powder, 2% caustic soda, or a 5-10% chloramine solution before disposal).

During hospitalization or in specialized sanatoriums, patients must also observe hygienic standards. Special attention must be paid to rooms designated for hygienic procedures. The aforementioned precautionary measures must also be strictly observed by medical personnel and staff of facilities housing patients with urogenital tuberculosis.

During menstruation, the risk of infection increases, so sexual intercourse should be avoided. In cases of vulvovaginal tuberculosis and profuse cervical discharge, sexual intercourse is strictly prohibited.

Both women and men diagnosed with genital tuberculosis must undergo a mandatory course of treatment. Prior to marriage, individuals should maintain a healthy lifestyle and adhere to proper sexual hygiene.

Female patients suffering from genital tuberculosis may transmit the infection to the fetus hematogenously during pregnancy, or during childbirth As a result of bronchopulmonary aspiration of Amniotic Fluid or cervicovaginal secretions, particularly in prolonged and difficult labors.

A child born to a mother suffering from genital tuberculosis who has received inadequate treatment or has disseminated tuberculosis must be isolated, closely monitored, and treated if necessary. If the child's general condition and weight curve are below normal parameters, while radiological changes are absent and the tuberculin skin test is negative, intrauterine infection should be suspected and prophylactic treatment with tuberculostatic drugs prescribed.

Genital tuberculosis often manifests clear clinical symptoms shortly after marriage. It has been proven that marriage acts as a trigger activating latent genital tuberculosis. According to clinical observations, marriage led to The Emergence of overt Clinical symptoms of genital tuberculosis within 2 to 6 months in approximately 7.5% of women.

The family environment is also of great importance regarding the infection of children. Studies show that the risk of infection is significantly higher in children whose parents have tuberculosis. Traumatic, inflammatory, and chemical lesions of the mucous membranes of the vagina, uterus, and urethra facilitate the spread of infection in general, including tuberculosis, and contribute to the emergence of associated Sexually Transmitted Infections.

In a number of cases, on terrain "prepared" by tuberculosis, secondary infections lead to lesions with The formation of large pelvic abscesses that show a distinct tendency to invade adjacent reproductive organs. Pelvic tuberculosis complicated by a secondary sexually transmitted infection frequently requires surgical intervention.

Sexual intercourse in patients with concomitant venereal infection, especially when excessive, can not only activate latent tuberculous lesions but also cause ascending genital tuberculosis infection and exacerbate flare-ups of latent tuberculosis processes.

Women and men suffering from genital tuberculosis must be barred from working in public catering establishments, maternity hospitals, childcare facilities, and juvenile correctional institutions until their treatment is fully completed. In agricultural production, affected individuals must not be assigned to tasks involving the care and milking of cows, as this poses a risk of milk contamination.