Introduction
Pelvic tuberculosis (TB) is a form of extrapulmonary tuberculosis that affects the female genital tract and pelvic organs. Although tuberculosis primarily targets the lungs, it can disseminate to other parts of the body, including the pelvis, causing significant morbidity. Pelvic TB is a major cause of Infertility in women, particularly in regions where tuberculosis is endemic.
Etiology and Pathogenesis
Pelvic tuberculosis is caused by Mycobacterium tuberculosis, the same bacterium responsible for pulmonary TB. The infection usually reaches the pelvic organs via hematogenous spread from a primary focus, often the lungs. Less commonly, it may spread through lymphatic routes or direct extension from adjacent infected structures.
The fallopian tubes are the most commonly affected site in pelvic TB, followed by the endometrium, ovaries, cervix, and rarely the vagina and vulva. The infection leads to chronic granulomatous inflammation, caseation necrosis, and fibrosis, which can cause scarring and adhesions.
Epidemiology
Pelvic tuberculosis is more common in developing countries where tuberculosis remains endemic. It primarily affects women of reproductive age, generally between 20 and 40 years old. The incidence is rising in association with HIV infection and immunosuppression.
Clinical Presentation
Pelvic TB often presents with non-specific symptoms, which may delay diagnosis. Common clinical features include:
- Chronic lower abdominal or pelvic pain
- Menstrual irregularities such as amenorrhea, oligomenorrhea, or menorrhagia
- Infertility or difficulty conceiving
- Abnormal vaginal discharge
- Constitutional symptoms like low-grade fever, night sweats, and weight loss (less common)
- On pelvic examination, findings might include adnexal masses, tenderness, or tubo-ovarian masses.
Diagnosis
Diagnosing pelvic tuberculosis can be challenging due to its nonspecific presentation. A combination of clinical suspicion, laboratory tests, imaging, and histopathology is often necessary.
Investigations:
- Mantoux test (Tuberculin skin test): May support diagnosis but is not definitive.
- Chest X-ray: To identify any pulmonary focus.
- Ultrasound: May reveal adnexal masses or tubo-ovarian abscesses.
- Hysterosalpingography (HSG): Can show characteristic tubal abnormalities such as beading, strictures, or obstruction.
- Endometrial biopsy: Histopathological examination showing granulomas with caseous necrosis confirms diagnosis.
- Microbiological culture and PCR: Detection of Mycobacterium tuberculosis DNA from pelvic tissue or fluid enhances diagnostic accuracy.
- Laparoscopy: Direct visualization of pelvic organs may reveal tubercles, adhesions, or caseous material, allowing for biopsy.
Treatment
Pelvic tuberculosis is treated primarily with anti-tuberculous therapy (ATT), following standard regimens used for pulmonary TB. The usual course involves multiple drugs over 6 to 9 months, including isoniazid, rifampicin, pyrazinamide, and ethambutol.
Surgical intervention is reserved for cases with persistent masses, abscesses, or complications such as bowel obstruction. Surgery can also be diagnostic via laparoscopy or laparotomy.
Complications
If left untreated or diagnosed late, pelvic tuberculosis can lead to serious complications, including:
- Infertility due to tubal damage and pelvic adhesions
- Chronic pelvic pain
- Ectopic pregnancy from damaged fallopian tubes
- Pelvic abscess formation
- Dissemination to other pelvic organs
Prognosis
With timely and appropriate treatment, pelvic tuberculosis has a good prognosis. However, fertility outcomes may be compromised due to irreversible tubal and endometrial damage. Early diagnosis is crucial to prevent long-term sequelae.
Pelvic tuberculosis remains a significant health issue in endemic areas and should be considered in women presenting with chronic pelvic symptoms and infertility. Early recognition, combined with appropriate anti-tuberculous treatment, can prevent complications and improve outcomes. Multidisciplinary management including gynecologists, infectious disease specialists, and radiologists is essential for optimal care.
