ABDOMINOPELVIC TUBERCULOSIS:

DIAGNOSIS !& MANAGEMENT

!

!


Mary Judith Q. Clemente, MD
!
 
!
 INTRODUCTION

References
 TUBERCULOSIS

q TB  is  still  a  global  public  health  problem.  

q The   Philippines   belongs   to   the   high   TB   and   high   MDR   TB  

countries  globally.  

q Most  common  TB  infection  is  still  pulmonary.    

 

References
 World  Health  Organization  Global  TB  Report,  2016  
 WHO GLOBAL TB REPORT 2016

References
World  Health  Organization  Global  TB  Report,  2016!
 Resurgence of TB

q Increase in HIV cases

q Emergence of MDR TB

q Migration

References
 Abdominopelvic TB

q General  term  encompassing  TB  involving  any  abdominal  or  

pelvic  organ  (ex.,  GI,  hepatic,  peritoneal,  endometrial,  tubal,  
etc.)  

q   Female  genital  TB  (FGTB)  involves  the  vulva,  vagina,  cervix,  
endometrium,  tubes  and  ovaries  

References
 Female Genital TB

q First  case  of  reported  FGTB  was  in  

1744  by  Morgagni.  

q Postmortem  examination  of  a  20  year  

old  female  showing  caseous  material  
within  the  uterus  

References
 Epidemiology

q Prevalence  of    FGTB  is  difOicult  to  estimate  due  to  varied  
clinical  presentations.  

q Many  can  be  asymptomatic.  

References
 Estimated Incidences of FGTB in
Various Countries

References
2Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  

 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  

 
 PGH Data

q From  January  2010  to  December  2014:  176  cases  of  AP  TB  referred

References
PGH  Department  of  OB-­‐GYN  Section  of  OB  IDS  Statistics    
 PATHOGENESIS

References
 Pathogenesis

q Primary  genital  TB  is  rare.  

q Hematogenous,  Lymphatic,  Direct  spread  

q Sources:  Pulmonary,  GI,  Renal  

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 Pathogenesis- Hematogenous Spread

Spread Genital tract

Primary Lung
through blood
Infection (ex.: FT)
stream

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 Pathogenesis- Lymphatic Spread

Primary GI
Infection Lymphatic
Genital tract
spread
(ex.: M. bovis)

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 Pathogenesis- Direct Spread

Direct spread via

Primary Abdominopelvic peritoneal surfaces OR
Infection (ex.: rectum, Rupture of TB ulcer with Genital Tract
appendix, bladder) spill into contiguous
organ

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 Pathogenesis- Sexual Transmission ???

q In  very  rare  instances,  TB  can  be  transmitted  to  a  woman  
via  a  partner  with  TB  epididymitis.  

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 CLINICAL
MANIFESTATION
References
 Clinical Manifestation

q There  is  NO  single  reliable  clinical  manifestation  related  to  AP  TB.  

q History  +  PE  +  diagnostics/imaging  +  high  index  of  suspicion  

References
 CLINICAL MANIFESTATION
8 6
MANIFESTATION NOBLE, 2001 BAQUIRAN, SEE, 2015
9
(n = 88) 2010 (n = 61)
(n = 12)
Abdominal pain 28.4% 50% 42.6%
Abdominal enlargement 42% 58% 29.5%

Abdominopelvic mass --- --- 9.8%

Vaginal Bleeding 5.7% --- 1.8%

Amenorrhea 19.3% 42% 8.8%
Weight loss --- 67% 57.9%
Fever --- 25% 33.3%
Anorexia --- 8.33% 29.8%
!References
6See V. (2015). Clinico-demographics of female genital tuberculosis in a tertiary government hospital: a five year retrospective study. Unpublished data.!
8 Noble MJ. (2001). Clinical features of patients with abdominopelvic tuberculosis. Unpublished data.!
9 Baquiran S. (2010). Establishing the relationship of Ca-125 trend with the clinical treatment response of patients with abdominopelvic tuberculosis. Unpublished data. !

 
 Frequency of TB in the Female Genital Tract

Organ Frequency (%)

Fallopian tubes 90-100
Endometrium 50-60
Ovaries 20-30
Cervix 5-15
Vulva/Vagina 1

References
Schaeffer  G.  (1976)  Female  genital  tuberculosis.  Clin  Obstet  Gynecol  19:23.  
Sharma, JB. (2015).Current diagnosis and management of female genital tuberculosis. J
Obstet Gynaecol India. 65(6): 362-371. !
   
 TB Salpingitis

q  Bilateral  involvement  is  seen  in  majority  of  cases  (>90%)  

q  Early  infection  may  show  no  gross  abnormalities.  

q  Progression  of  infection  may  cause  tubal  dilatation  

q  Types:  Exudative  and    Productive-­‐Adhesive  

References
Varma,  T  (2008).  Tuberculosis  of  the  female  genital  tract.  In  Glob.  libr.  women's  med.,  
 (ISSN:  1756-­‐2228)  2008;  DOI  10.3843/GLOWM.10034  
 Spread of TB from the fallopian tubes
TB Salpingitis!

Ovaries! Endometrium!

Cervix!

Vagina!

Vulva!
References
 TB Endometritis

q  Usually  involves  the  fundus  

q  The  endometrium  is  shed  monthly  in  menstruating  women  only  to  be  re-­‐infected  
from  the  tubes  or  the  basalis.  

q  Extensive  involvement  may  cause  amenorrhea  or  uterine  adhesions  leading  to  
infertility  

References
 TB Oophoritis

q True oophoritis- involvement of the stroma

q Peri-oophoritis- involvement of the surface/capsule

q The tunica albuginea may play a protective role.

References
 TB Cervicitis
q The endocervix is mostly affected.

q May look like cervical cancer (ulcerative form)

q Other forms: papillomatous and miliary forms

References
 TB of the vagina and vulva

q Extremely rare

q Nodule à irregular, ragged ulcer

References
 DIAGNOSIS

References
 Some Recommended Tests to
Help Diagnose AP Tuberculosis
Chest radiograph Ultrasonography

Tuberculin test Hysterosalpingography

Menstrual blood for TB culture Cervical cytology or biopsy

Endometrial tissue for culture or biopsy Laparoscopy

Peritoneal fluid for TB culture Hysteroscopy

Peritoneal tissue for biopsy Cystoscopy

!
References
 TB Culture
q Gold Standard – isolation and identification of the organism

q Colonies visible in 6-8 weeks using the L-J media.

q Requires 100 organisms/ml sample

References

Histopathology

q Chronic granulomatous inflammation (CGI) with caseation necrosis

and Langhans giant cells

q Isolated finding of CGI is not solely indicative of TB.

References
 Histopathology

References
 Histopathology

References
 TB-PCR

q Circumvents the limitations of culture (faster results)

q Extrapulmonary specimens tend to be paucibacillary and may

contain inhibitors precluding optimal cell lysis

!
References
!
!

CaulOield  A,  Wengenack  N.  (2016).  Diagnosis  of  active  tuberculosis  disease:  From  microscopy  to  molecular  techniques.  
Journal  of  Clinical  Tuberculosis  and  Other  Mycobacterial  Diseases.  Vol.4  pp  33–43.  
 Cost of TB-PCR in 3 Metro Manila Hospitals

Hospital Cost (Php)

Philippine General Hospital 5,343
Manila Doctors Hospital 8,700
Lung Center of the Philippines 7,592
!

References
 Acid-Fast Staining

q  Identification of acid-fast bacilli on microscopy

q  Typically used for sputum specimens

q  Requires at least 10,000 organisms/mL of sample

q  May also be used for extra-pulmonary specimens (urine, stool, tissue)

q  Other organisms are acid-fast as well (Nocardia, Rhodococcus)

q  Sensitivity (22%- 80%) depends on the microscopist.

References
CaulOield  A,  Wengenack  N.  (2016).  Diagnosis  of  active  tuberculosis  disease:  From  microscopy  to  molecular  techniques.  
Journal  of  Clinical  Tuberculosis  and  Other  Mycobacterial  Diseases.  Vol.4  pp  33–43.  
 
 Imaging

q Imaging is not diagnostic BUT it may raise the clinician’s index of suspicion

q Ultrasound, Hysterosalpingography

References
 Imaging- Ultrasonography
Findings Cabalona, 2004 Sharma, 2006
Adnexal masses! 78! 93!
Ascites with pseudocyst 76! 100!
formation!
Endometrial involvement ! 50! 83!
Thickened peritoneum! 69!
Pelvic adhesions!

Matted bowel loops!

Thickened bowel and uterine

serosa!
References
Cabalona, M (2004). Ultrasound findings in cases of abdominopelvic tuberculosis. Unpublished data.!
Sharma Journal of Obstetrics and Gynecology, India, 2006. Vol. 56. NO. 3: 203-204.!
!
!
 Ultrasonography

References
 Ultrasonography

References
 Ultrasonography

References
 Ultrasonography

References
 Hysterosalpingography
q  Calcification of FT, ovaries or lymph nodes

q  Irregular contour of lumen of tubes

q  Beaded appearance of tubes sec to tubal occlusion

q  Tubal dilatation

q  Peritubal adhesions

q  Intrauterine adhesions, obliteration of uterine cavity

References
 Imaging- Hysterosalpingography

References
 Imaging- Hysterosalpingography

References
 Laparoscopy

q Visualization of tuberculous lesions

q Laparoscopic-guided biopsy

q Usually performed if there is a diagnostic dilemma short

of doing a laparotomy

References
 Laparoscopic Findings in Pelvic TB (n=85)
Laparoscopic Findings Percentage
Various grades of pelvic adhesion 65.8%
Tubercles on the peritoneum 12.9%
Tubo-ovarian masses 7.1%
Encysted ascites 7.1%
Caseous nodules 5.8%
Ovarian tubercles 1.2%
Hydrosalpinx 17.6% (right=11.7%; left=5.9%)
Fallopian tubes not visualized (surgically absent or due to 14.1%
dense adhesions)
Beaded tube 8.2% (right=3.5%; left= 4.7%)
Normal-looking fallopian tubes 7.1%
Pyosalpinx 5.8% (right=3.5%; left=2.35%)
Tubercles on tube 3.52%
Caseous granuloma of the tubes 3.52%
Tobacco pouch appearance of the tubes 2.35%
!
References
.!
Sharma  JB,  Roy  KK,  Pushparaj  M,  Kumar  S,  Malhotra  N,  Mittal  S.  (2008).  Laparoscopic  Oindings  in  female  genital  tuberculosis.  Arch  Gynecol  Obstet.  278(4):359-­‐64
 Laparotomy

q Usually performed inadvertently due to consideration of another

gynecologic pathology

q Common findings: adhesions, complex adnexal masses, ascites,

pseudocyst formation, caseous tubercles

References
 Laparotomy

References
 MANAGEMENT

References
 Medical Management

q  Anti-TB medication is the cornerstone of management

q  PHILCAT – 6 month course (2 months HRZE + 4 months HR)

q  Other experts recommend extending treatment to one year (2 months HRZE + 10
months HRE)

References
 !
. !
Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 Update
 Dosing of anti-TB Drugs

Drug Dose
Isoniazid 5 (4-6) mg/kg
Rifampicin 10 (8-12) mg/kg
Pyrazinamide 25 (20-30) mg/kg
Ethambutol 15 (15-20) mg/kg
!

References
Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 Update. !
 Surgical Management

q  Surgical management is reserved for special cases

•  Drainage of abscesses

•  Concomitant gynecologic pathology

•  Persistent masses despite medical treatment

References
 Monitoring

q There is no standard monitoring scheme for patients with AP

Tuberculosis

q Ca 125 as monitoring tool?

q Repeat biopsy after 6 months

q Clinical improvement: weight gain, resumption of menses

References
 Requirements for Enrollment of Patients in the
TB-DOTS Program

Referral from a physician

Results of sputum AFB (if pulmonary)
Chest radiograph (if pulmonary)
If extra-pulmonary, results of imaging studies or other diagnostic indicating TB
!

References
 SUMMARY

References
 Summary
q  TB is still a global and national public health problem.

q  Female genital TB is usually secondary to infection from another site.

q  There is NO single reliable sign or symptom indicative of AP TB.

q  The gold standard in the diagnosis of AP TB is isolation and identification of the
pathogen (culture)

q  Other diagnostics include histopathology, TB-PCR, AFB staining, imaging, laparoscopy
etc.

References
 Summary

q  Anti-TB medication is the cornerstone of treatment. (6-12 months)

q  Surgery is reserved for special cases.

q  Monitoring can include repeat imaging studies, repeat biopsy and improvement in the
patient’s clinical status.

References
 INTERACTIVE
QUESTIONS

References
 Interactive Question 1
What is the gold standard in the diagnosis of TB?

a. Biopsy/Histopathology

b. AFB staining

c. TB-PCR

d. Culture

References
 Interactive Question 2
A 23 year old nulligravid came for abdominal enlargement of three months duration. She has a
history of inadequately treated pulmonary TB. On ultrasound, there was note of massive ascites. The
uterus was normal in size with a thin endometrium. Which of the following is the best diagnostic test
for this patient?

a. Laparotomy with biopsy

b. Endometrial curettage

c. Ascitic fluid TB-PCR

d. Menstrual blood TB culture

References
 Interactive Question 3

Which of the following is a TRUE statement?

a. All patients with AP tuberculosis will have infertility.

b. For genital TB, the most commonly affected part of the genital tract is the endometrium.

c. If ovarian involvement is hematogenous, the ovarian surface is usually affected.

d. The tunica albuginea may play a role in protecting the ovaries from TB involvement.

References
 Interactive Question 4

Which of the following is a TRUE statement ?

a.  Imaging procedures are diagnostic for AP Tuberculosis

b.  Positive AFB staining is exclusive for Mycobacterium species

c.  The sensitivity of PCR is lower for extra-pulmonary specimens due to their
paucibacillary nature.

d.  Elevated Ca-125 levels are specific for TB infection

References
 Interactive Question 5

What is the cornerstone of TB treatment?

a.  Medical management

b.  Surgery

c.  Combination of surgery and medical management

d.  Depends on the situation

References

ABDOMINOPELVIC TUBERCULOSIS:

DIAGNOSIS !& MANAGEMENT
!

!


Mary Judith Q. Clemente, MD
!
 
!