Tuberculosis is an infectious disease caused by mycobacterium (the bacterium Koch). Genital tuberculosis, as a rule, develops a second time, as a result of the transfer of infection from the primary lesion (more often from the lungs, less often from the intestine). Despite the advances in medicine, the incidence of tuberculosis in the world is increasing, especially in countries with a low standard of living. The defeat of the urinary organs is in the first place among the extrapulmonary forms of tuberculosis. Probably, the defeat of genital tuberculosis occurs much more frequently than it is registered, since in vivo diagnosis does not exceed 6.5%.
Etiology and pathogenesis. From the primary focus while reducing the immune resistance of the body (chronic infections, stress, malnutrition, etc.) mycobacteria enter the genitals. The infection is mainly spread through the hematogenous route, more often during the initial dissection in childhood or during puberty. In case of tubercular peritoneal affection, the pathogen enters the fallopian tubes lymphogenically or by contact. Direct infection through sexual contact with a patient with genital tuberculosis is only possible theoretically, since the multi-layered flat epithelium of the vulva, vagina and vaginal portion of the cervix is resistant to mycobacteria.
In the structure of genital tuberculosis, the first place in frequency is taken by the defeat of the mathematics, and the second by the endometrium. Less common is tuberculosis of the ovaries and cervix, extremely rarely – tuberculosis of the vagina and external genitalia.
Morphohistological changes typical for tuberculosis develop in lesions: exudation and proliferation of tissue elements, caseous necrosis. Tuberculosis of the fallopian tubes often ends with their exudation, exudative-proliferative processes can lead to the formation of pyosalpinx, and when it is involved in a specific proliferative process of the muscular layer of the fallopian tubes, tubercules are formed in it, which is called nodal inflammation. In case of tuberculous endometritis, productive changes also predominate – tuberculous tubercles, caseous necrosis of certain areas. Tuberculosis of the uterus is often accompanied by involvement in the process of peritoneum with ascites, intestinal loops with the formation of adhesions, and in some cases fistulas. Genital tuberculosis is often associated with damage to the urinary tract.
Classification. In accordance with the kdiniko-morphological classification distinguish:
chronic forms – with productive changes and mild clinical symptoms;
subacute form – with exudative-proliferative changes and significant lesions;
caseous form – with severe and acute processes; completed tuberculous process – with encapsulation of calcified foci.
Clinical picture. The first symptoms of the disease may appear as early as puberty, but mostly women of 20-30 years are ill with genital tuberculosis. In rare cases, the disease occurs in older patients or in postmenopausal women.
Genital tuberculosis has a largely erased clinical picture with a large variety of symptoms, which is explained by the variability of pathological changes. Reduction of generative function (infertility) is the main and sometimes the only symptom of the disease. The causes of infertility, often primary, include endocrine disorders, damage to the fallopian tubes and endometrium. More than half of the patients have impaired menstrual function: amenorrhea (primary and secondary), oligomenorrhea, irregular menstruation, algomenorrhea, less often meno- and metrorrhagia occurs. Violations of the menstrual function are associated with damage to the ovarian parenchyma, endometrium, as well as tuberculous intoxication. Chronic disease with a predominance of exudation causes subfebrile temperature and pulling, aching pains in the lower part of the lymphis due to adhesions in the small pelvis, damage to the nerve endings, vascular sclerosis and hypoxia of the internal genital organs. Other manifestations of the disease include signs of tuberculous intoxication (weakness, recurrent fever, night sweats, loss of appetite, weight loss) associated with the development of exudative or caseous changes in the internal genital organs.
In young patients, genital tuberculosis can begin with signs of “acute abdomen,” which often leads to surgical interventions in connection with suspected acute appendicitis, ectopic pregnancy, ovarian apoplexy.
Due to the absence of pathognomonic symptoms and abrasion of clinical symptoms, diagnosis of genital tuberculosis is difficult. The correct and carefully collected history with indications of patient contact with a patient with tuberculosis, past pneumonia, pleurisy, observation in an antituberculosis dispensary, the presence of extragenital foci of tuberculosis in the body, and the occurrence of inflammation in the appendages of the uterus and the appearance of an inflammatory process in the body, as well as the occurrence of an inflammatory process in the body, as well as the occurrence of an inflammatory process young patients who were not sexually active, especially in combination with amenorrhea, and prolonged subfebrile temperature. A gynecological examination sometimes reveals an acute, subacute or chronic inflammatory lesion of uterine appendages, most pronounced with a predominance of proliferative or caseous processes, signs of adhesions in the small pelvis with displacement of the uterus. These gynecological studies are usually non-specific.
To clarify the diagnosis using tuberculin test (Koch test). Tuberculin * is administered subcutaneously at a dose of 20 or 50 TE, after which a general and focal reaction is evaluated. The overall reaction is manifested by an increase in body temperature (more than 0.5 ° C), including in the cervical area (cervical electrothermometry), increased pulse (more than 100 per minute), an increase in the number of stab neutrophils, monocytes, a change in the number of lymphocytes, an increase in ESR. The overall reaction occurs regardless of the location of the tuberculous lesion, focal – in its zone. Focal reaction is expressed in the doyashchy or increased pain in the lower abdomen, swelling and pain during palpation of the uterine appendages. Tuberculin tests are contraindicated in the active tuberculous process, diabetes mellitus, expressed impaired liver function and kidney function.
The most accurate methods for the diagnosis of genital tuberculosis remain microbiological, allowing to detect mycobacterium in the tissues. Examine the discharge from the genital tract, menstrual blood, endometrial scrapings or washes from the uterus, the contents of inflammatory foci, etc. The material is sown on special artificial nutrient media at least three times. However, the germination rate of mycobacteria is small, due to the peculiarities of the tuberculosis process. A highly sensitive and specific method for the detection of the pathogen is PCR, which allows to determine the DNA regions characteristic of Mycobacterium tuberculosis. However, the material for the study may contain PCR inhibitors, which leads to false-negative results.
Laparoscopy allows to identify specific changes in the pelvic organs – adhesions, tuberculous tubercles on the visceral peritoneum covering the uterus, tubes, caseous foci in combination with inflammatory changes in the appendages. In addition, during laparoscopy, you can take the material for bacteriological and histological studies, as well as, if necessary, carry out surgical correction: lysis of adhesions, restoration of patency of the fallopian tubes, etc.
Histological examination of tissues obtained by biopsy, separate diagnostic curettage (it is better to carry out 2-3 days before menstruation), reveals signs of tuberculosis damage. A cytological method is also used to study aspirate from the uterus, cervical smears, which can detect specific tuberculosis-specific giant Langhans cells.
The diagnosis of genital tuberculosis helps hysterosalpingography. On radiographs, the following signs are characteristic of tuberculous lesions of the genital organs: displacement of the uterus due to adhesions, intrauterine synechia, obliteration of the uterus (Asherman syndrome), uneven contours of the tubes with closed fimbrial regions, extension of the distal parts of the tubes in the form of an onion, clearly changing tubes , cystic dilatations or diverticula, pipe rigidity (absence of peristalsis), calcinates. On radiographs of the pelvic organs, pathological shadows are revealed — calcinates in the tubes, ovaries, lymph nodes, foci of caseous decay. To avoid exacerbation of the tuberculous process, hysterosalpingography is carried out in the absence of signs of acute and subacute inflammation.
Diagnostics complements the ultrasound scan of the pelvic organs. However, the interpretation of the data obtained is very difficult and accessible only to a specialist in the field of genital tuberculosis. Other diagnostic methods are less important – serological, immunological. Sometimes the diagnosis of tuberculous lesions of the internal genital organs is made with a celiac section for suspected volume lesions in the uterine appendages.