Pelvic Tuberculosis: On the Rise in the U.S.A.
While pelvic tuberculosis is a common cause of infertility in developing countries and in Asia (India in particular), its rarity as a cause of infertility in the United States has led to the diagnosis often being missed. However, the condition is definitely on the rise in the United States as a result of the influx of immigrants from Asia and other third world countries where tuberculosis is common.
Pelvic tuberculosis is often a silent disease. It may be present for 10 to 20 years without producing any symptoms – the woman remaining in apparent excellent health. Infertility is often one, and sometimes the only, reason that women investigate for the presence of the condition.
Pelvic tuberculosis usually presents with one or more of the following signs and symptoms:
- Pelvic pain, dysmenorrhea (pain with menstruation), dyspareunia (pain with intercourse), chronic lower abdominal pain or discomfort, and chronic back pain
- Abdominal distention, usually due to ascites (collection of free fluid in the abdominal-pelvic cavity
- Tuberculosis-related infertility is most commonly due to tuberculous salpingitis (tubal inflammation) which occurs in 75% of cases, ovulation dysfunction that often presents with absent, excessive or non-cyclical menstruation, largely attributable to ovarian involvement (40% of cases) and uterine (endometrial) tuberculosis (30%)
Local tuberculous lesions may appear on the external genitalia, cervix, and/or vagina.The diagnosis is made is based on:
- Clinical suspicion: Evidence of concomitant, pulmonary tuberculosis, the detection of calcifications on pelvic X-rays, a typical tubal pattern on hysterosalpingogram (dye X-ray test)
- Findings at laparoscopy or laparotomy and the subsequent pathologic examination of biopsy material obtained during these procedures
- Blood tests such as a differential blood count and erythrocyte sedimentation rate
Microscopic and bacteriologic examination is the primary method for diagnosing pelvic tuberculosis:
- Most commonly a dilatation and curettage (D&C;) of the uterus is performed a few days prior to menstruation. The surgeon takes care to avoid using an antiseptic to clean the vagina and cervix while preparing for the D&C;, lest the antiseptic kill any tuberculous bacilli present in the specimen thereby rendering a falsely negative culture result. Instead a physiologic salt solution is used to cleanse the operative field. Upon collection, the specimen of uterine curettings is immediately divided into two parts. The first is placed in a physiologic salt solution and expeditiously delivered to the bacteriologic lab for culturing. A specialized culture medium (e.g., Loewenstein Jensen medium) is used for this purpose. Some of the curettings are also used for Guinea pig inoculation. While menstrual products can also be cultured, this approach is less effective. The second portion of the specimen is fixed and then stained for the detection of the acid-fast Bacillus, mycobacterium tuberculosis. The Ziel Nielsen stain is one of the methods used.
- Biopsy specimens of lesions on the external genitalia, vagina, cervix and pelvic cavity can also be subjected to histopathologic examination, culture and guinea pig inoculation.
Even in the presence of established tuberculosis, histopathologic examination will only be positive about 50% of the time. Cultures, although more reliable, can also yield false-negative results. Accordingly, it is often necessary to repeat such tests several times if the diagnosis is strongly suspected.
Treatment is primarily directed towards the eradication of the infection by means of specific chemotherapeutics such as Para-amino-salicylic acid (PAS), isoniazid (INH), rifampicin (Rifampin) and streptomycin derivatives. Pelvic surgery (other than to remove distended or infected lesions and damaged fallopian tubes) has little therapeutic benefit. Provided that the tuberculous process has not destroyed the uterine lining, in vitro fertilization (IVF) following successful anti-bacterial treatment is the only rational method of treating infertility associated with pelvic tuberculosis.