Ultrasound Diagnosis

of Pelvic Tuberculosis
from Indonesian
Experiences
ANDI DARMA PUTRA, MD
Oncology Division, Obstetric and Gynecology Departement
Cipto Mangunkusumo Hospital, Jakarta
Introduction
TB can affect any organ in the body including genital, particularly in
communities where pulmonary TB or other extrapulmonary TB are
common 1
Approximately 5-9% females worldwide have genital TB 1,2
Most cases occur during the childbearing period (15-45 years)1,2
Most of patients are asymptomatic and discovered incidentally1
Mycobacterium tuberculosis or Mycobacterium bovis3

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298.
Pathogenesis
Hematogeneous1,2,3 Lympathic1,2,3 Direct Spread2
• Fallopian tube forms a • Occurs if primary lesion • Extension from
most favorable nidus is in the abdomen tuberculous
• Bilateral abdominal viscera
• Earliest lesion found in along the peritoneal
mucosa surface
• Pelvic involvement -> • Granulomata
TB peritonitis containing viable TB
• Dissemination -> form within pelvic
rupture of a caseous organ thus dorman
abdominal LN or spread period happens (1-10
from an interstinal years)
focus. • Reactivated and
1.
2.
3.
symptoms occurs
Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
Criteria for Diagnosing Primary Genital TB
• The genital lesions should be the first TB infection in the body
• Regional lymph nodes should demonstrate the same stage of
tuberculous development as do the genital organs.

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
TB of the Pelvis
• Exist as Tuberculous Adenitis with involvement of the mesenteric
or the pelvic lymph nodes, but without genital tract involvement
• Generalized miiliary peritoneal TB imvolve serosal surface of both
abdominal and pelvic organ without penetrating to the mucosa

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
Frequency of TB in Genital Organs
Organ Frequency (%)
Fallopian Tubes 90-1001,2
Endometrium 50-601,2
Ovaries 20-301,2
Cervix 5-151,2
Myometrium 2,52
Vulva/Vagina 11,2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Tuberculous Salpingitis
• Fallopian tube is the initial focus of genital TB1
• TB accounted 5% of all cases of salphingitis world wide1
• May present as congestion, military tubercles, hydrosalpinx,
pyosalpinx, and tubo-ovarian masses.2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of India. 2015;65(6):362-371.
Microscopic Appearance
1. Granulomata and chronic inflammatory infiltrate (lymphocytes,
epithelioid cell granulomata, giant cells) may involve the full
thickness of the wall1
2. Non-caseating granulomas in the early stage2
3. Caseation necrosis is common in advanced stage1
4. Single or multiple confluent epithelioid granulomas in the lamina
propria in the advanced stage2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
Microscopic Appearance
5. The mucosa exhibits hyperplastic, adenomatous pattern1
6. Large cystic space – pseudofollicular salpingitis1
7. Schaumann bodies1

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
Types of TB Salpingitis
Exudative Productive-Adhesive
• The tube may be significantly • The tubes are studded with
enlarged tubercles
• Large pyosalpinx may form • Densely adherent to the
• Adhesion (+) surrounding organs
• Large amount of caseous • The tubercles are seen near the
material + purulent exudate attachment of the tube to the
• This is acute phase mesosalpinx
• The tube wall is thickened
• Fimbriae slightly swollen
• Calcification and fibrosis found
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.

in healing process
 Tuberculous Endometritis
• Extention to the uterus along the endometrium and rarely into the
myometrium1
• The size and shape of uterus appear normal1
• The tuberculous process most extensive in the fundus and
decreases towards the cervix1
• The infected tissue is shed during the menstruation1
• The endometrium present caseation, ulcerative, granular, or
fungating lesions1,2,3
• Intrauterine adhesion may occurs (Asherman’s syndrome)1,2,3
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of India. 2015;65(6):362-371
3. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res
Note. 2017;10:683
 Microscopic Appearance
• Infrequent, isolated, small tubercles scattered irregularly though the
endometrium
• Noncaseating granuloma composed of epithelial cells, Langhans
giant cells, and lymphocytes.
• The granulomata are located throughout the endometrium,
occasionally perforate into gland lumina causing acute
inflammatory reaction and give appaearance of microabscesses

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
 Microscopic Appearance

• Caseation, fibrosis, and calcificarion rarely seen due to regular

cyclical shedding of the endometrium during menstruation
• Endometriual glands adjacent to granulomata not reveal a
secretory response or may become compressed, resulting in a
pseudoadenomatous appearance

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
 TB of the Ovary
• The ovary involvement is bilateral1
• Caseation is rare and granulomas usually found in cortical area2
• Two forms of ovarian TB :
1. Perioophoritis (ovary surrounded by or encased in adhesions
and studded with tubercles caused by direct extention from the
tube. Frequently adherent to omentum and intestine) 1
2. Oophoritis(infection starts in the stroma of the ovary from
hematogeneous spread and produce caseating granuloma
within the parenchyma) 1
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Tuberculous Cervicitis
• Cervix involved in 5-25% of genital cases1,3
• Macroscopically the cervix may appear normal or inflamed grossly
or with the colposcope1
• Infected by lympathic spread or direct extension3
• Epitheliod granulomas may present2
• The most common type is the ulcerative form, papillomatous and
milliary forms may also occur1
• Diagnosis only made by histologic or bacteriologic examination1
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298.
 Tuberculous Cervicitis
• The symptoms including white color, fould smelling discharged
per vaginum, irregular vaginal bleeding, postcoital blood-stained
discharge1,2
• Speculum examination : erythematous, congested and bleeding
cervix, white color discharge.1

1. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298.
2. Kulchavenya E, Dubrovina S. Typical and unusual cases of female genital tuberculosis. IDCases. 2014;1(4):92-94.
 Tuberculous Cervicitis
• Mantoux test : (+)
• Papsmear : granulomatous cervicitis and acid fast bacilli found on
microscope
• Cervical and endometrial biopsy : tuberculosis of cervix and
endometrium

1. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298.
 Tuberculous Cervicitis
• Bacteriologic examination : M. tuberculosis found in endocervical
mucus (gold standard) 1,2
• Cytologic examination : multinucleated giant cells, histiocytes, and
epithelioid cells arranged in clusters. May be associated with
epithelial atypia1
• Histopathologic examination (endocervical curretings and cervical
biopsy) : granulomatous inflammation, sometimes marked
inflammatory atypia along with frequent hyperplastic mucosal
changes. Caseation may be seen. Increased secretion of mucin
from endocervical involvement1,2,3
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298.
3. Kulchavenya E, Dubrovina S. Typical and unusual cases of female genital tuberculosis. IDCases. 2014;1(4):92-94.
 Tuberculous of the Vulva and Vagina
• The rarest form of genital TB (<2%) 1
• Symptoms : extensive painful genital ulcers3
• Vulva : nodule on the labia or in the vestibular region, which
breaks down and forms an irregular ragged ulcer. Sometimes
with sinuses discharging caseous material and pus1

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Kulchavenya E, Dubrovina S. Typical and unusual cases of female genital tuberculosis. IDCases. 2014;1(4):92-94.
 Tuberculous of the Vulva and Vagina
• Vagina : caseation and acid fast bacilli is rare entity.2
hypertrophic lesion or a nonhealing ulcer mimicking malignancy.4
Rarely can cause involvement of Bartholin’s glands,
vesicovaginal and rectovaginal fistula.4

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Kulchavenya E, Dubrovina S. Typical and unusual cases of female genital tuberculosis. IDCases. 2014;1(4):92-94.
4. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Microscopic Appearance

• Granulomatous inflamation with central caseation and associated

chronic inflammatory infiltrate

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
 Tuberculous Peritonitis
• Prevalence approximately 45%1
• Three types :
1. Dry-Plastic variety : less common. Tender abdominal masses and
an abdomen “doughy” to palpation. Enlarged mesenteric lymph
nodes with central caseation necrosis and adhesion. Healed
fibrotic 1,2,3
2. Wet-ascitic/Serous variety : more common. Ascitis, pocket of
loculated fluid with thickened mesentery, sign of peritoneal
inflammation, fever, abdominal pain, weight loss, and anorexia.1,2,3
3. Fibrotic-fixed type : thickened omentum and a mass2
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Lee H, Lim JH, Ko YT, Yoon Y. Sonographic Findings in Tuberculous Peritonitis of Wet-Ascitic Type. Clinical Radiology. 1991;44:306-310.
3. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125
 Tubeculous Peritonitis
• Disseminated form of TB with tubercles all over the peritoneum,
intestines, and omentum and may cause ascites and abdominal
mass2
• Advance disease :
1. All pelvic organs are densely matter together often with tubercles
studding peritoneal surfance, foci of caseation, and calcified
plaques, which represent attempts at healing
2. The peritoneal fluid is exudative and contains 500-2000 cells with
predominance of lymphocytes.
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Paprikar M, Biswas M, Bhattacharyav S, Sodhi B, Mukhopadhyay I. Tuberculosis of Cervix. Med J Armed Forces India. 2008;64(3):297-298
 Tubeculous Peritonitis
Diagnosis :
• CA 125 levels may raised as in ovarian cancer
• CT scan and MRI giving similar picture as ovarian cancer
• Diagnosis may be made only on laparotomy
• Ascitic fluid tapping for bio-chamical analysis (elevated adenosine
deaminase level in ascitic fluid) is useful in diagnosis
• Laparoscopic biopsy with frozen section evaluation should be
suggested to avoid laparotomy
1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Tubeculous Peritonitis
Diagnosis :
• Laparoscopic biopsy with frozen section evaluation should be
suggested to avoid laparotomy
• FGD-PET sucessfully used for the preoperative diagnosis of
peritoneal tuberculosis and tuberculous tubo-ovarian masses

1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Symptoms of Genital TB
• Asymptomatic up to 11%3
• Systemic : weight loss, fatigue, low-grade fever, night sweat, loss
of appetite1,3
• Infertility : primary, secondary1,2,3,4
• Menstrual dysfunction : amenorrhea (primary and secondary),
menorrhagia, metrorrhagia, oligomenorrhea, hypomenorrhea1,2,3,4
• Abdominal swelling/lump1,3,4

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
4. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Symptoms of Genital TB
• Postcoital bleeding1
• Abnormal vaginal discharge1,3
• Dyspareunia1,2
• Pelvic Inflammatory Disease2
• Abdominal pain3
• Chronic pelvic pain3
• Acute abdomen3
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Symptoms of Genital TB
• Unusual symptoms : vaginal or vulva ulcers, labial swelling,
retention urinary, urinary incontinence, fecal incontinence

1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Suspected Patients
• Chronic PID not responding to standerd antibiotic treatment1
• Unexplained infertility1
• Women with irregular menstrual cycle or postmenopausal
bleeding1
• Persistent vaginal discharge after exclude the possibility of
genital neoplasia1

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Risk Factor
• Contact with a smear-positive pulmonary TB patient
• Past history of TB infection
• Residence in or recent travel to endemic areas
• Low socio-economic background
• Poeple living with HIV and drug abuse

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Four Major Presenting Complaints
• Infertility : 85% patients with genital tract TB have never been
pregnant1,2
• Abnormal bleeding : 10-40% patients. May be oligohypomenorrhea,
menorrhagia, postmenopausal bleeding, or amenorrhea.1,2
• Pelvic pain : 25-50% patients. May accompanied by swelling of the
abdomen1
• General Malaise : persisting over a period of months or years1

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Physical Signs
• Normal (>50% cases)1,2
• Systemic examination : fever, lymphadenopathy, crepitations on
chest auscultation, etc) 1,2
• Abdominal examination : mass, ascites, doughy feel, tenderness
1,2

• Pelvic mass1

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Physical Signs
• Vaginal examination : Excessive vaginal discharge, uterine
enlargement (pyometra), adnexal tenderness and induration,
adnexal masses and tubo-ovarian mass, fullness and
tenderness in cul-de-sac1,2
• Rare sign : Ulcer/hypertrophic lesion in the vulva, vagina or
cervix, fistula, labial mass (Bartholin swelling). 1,2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Investigation to Confirm Diagnosis
• Complete blood count • Hysterosalpingography

• Chest X-ray • USG

• Tuberculin test • Cervical cytology

• Mnestrual blood for culture • Endoscopy

• Endometrial curettage • Laparoscopy

• Histologic examination • Hysteroscopy

• Culture : peritoneal fluid, • Cystoscopy

peritoneal biopsy
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
 Diagnosis of EPTB based on WHO
• WHO diagnosis of Extra Pulmonary TB (EPTB) based on:
-One culture positive specimen
-Positive histology or strong clinical evidence consistent with
active EPTB.

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Diagnosis of Genital TB
• Detection of acid fast bacilli on microscopy or culture on
endometrial biopsy, or
• Histopathological detection of epithelioid granuloma on
biopsy

1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of India. 2015;65(6):362-371.
 Differential Diagnosis of Genital TB
• Pain and adnexal mass :
1. Acute and chronic pelvic infection
2. Ectopic pregnancy
3. Endometriosis
4. Ovarian cancer
5. Appendicitis

1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Differential Diagnosis of Genital TB
• Granulomatous lesions in the pelvis:
1. Syphilis 7. Silicosis

2. Actinomycosis 8. Brucellosis

3. Granuloma inguinale venereum 9. Histoplasmosis

4. Filariasis 10. Leprosy

5. Crohn’s disease
6. Scistosomiasis
1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Differential Diagnosis of Genital TB
• Ulcerative or hypertrophic lesions:
1. Vaginal cyst 7. Silicosis

2. Vulval and vaginal warts 8. Brucellosis

3. Condiloma lata 9. Histoplasmosis

4. Condiloma acuminata 10. Leprosy

5. Bartholin abscess
6. Vulval/vaginal/cervical cancer
1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
 Role of Imaging
• Imaging is not a gold standard for diagnosing Tuberculous
Endometritis but may help to confirm2
• The two imaging techniques useful in the diagnosis of
Female Genital TB (FGTB)1
1. Hysterosalpingography (HSG) : evaluates the internal
structure of the female genital tract and tubal patency1
2. Ultrasonography (USG) : simultanous evaluation of
ovarian, uterine, and extrapelvic involvement1

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res
Note. 2017;10:683
 Role of Hysterosalpingography
• Fallopian tube :
1. No specific change,
2. Tubal dilatation,
3. Tubal occlusion especially at the transition between istmus
and ampulla, multiple occlusion alog the tube from scarring
causing “beaded” appearance or a “rigid pipe stem”
appearance1,2,3
4. Irregular contour,

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
3. Sharma R, Radswiki et al. Tuberculosis (fallopian tube). Radiopaedia.org.
 Role of Hysterosalpingography
• Fallopian tube :
5. Calcification showing up as linear streaks2
6. Diverticular outpouching (salpingitis isthmica nodosa)2
7. Hydrosalpinx show as tubal dilatation with thick mucosal folds
giving specific patterns (cotton wool plug, pipestem tube, golf
club tube, cobblestone tube, beaded tube, leopard skin tube)1,2

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Role of Hysterosalpingography
• Fallopian tube :
8. Tubal occlusion (common in isthmus and ampulla) and
adhesions in the peritubal region which may present as
straight spill, corkscrew appearance and peritubal halo1,2,3

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
2. Sharma R, Radswiki et al. Tuberculosis (fallopian tube). Radiopaedia.org.
3. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Role of Hysterosalpingography
• Fallopian tube :
9. Strongly suspected if : synechiae, tubal obstruction in the
transition zone between isthmus and ampulla, multiple
constrictions, calcified lymph nodes, irregular linear or
nodular calcifications in the adnexal area1

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Role of Hysterosalpingography
• Uterus:
1. Specific features : collar-stud abscess, T-shaped uterus,
pseudounicornuate uterus1
2. Non-specific features : synechiae formation, uterine
contour distortion, obliteration of the uterine cavity,
venous and lympatic intravasations1,2

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Role of Hysterosalpingography
• Uterus:
3. Chronic infection : extensive destruction of the
endometrium and myometrium resulting in complete
narrowing of the uterine cavity -> Netter syndrome
appears as gloved finger consisting of cervical canal and
small part of the uterus1

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Role of Hysterosalpingography
• Cervix:
1. Irregularity in contours and diverticular outpouching with
a feathery appearance, cervical distortion and serrated
endocervical canal

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Role of Ultrasonography
• Loculated ascitis1
• Calcification of lymph nodes, and adnexal region. Appear as
bilateral, predominantly solid masses with echo content
similar to uterus, containing scattered small calcification.
Acoustic shadow appears posterior to the calcific focus3
• Adhesions : most common are peritubal and those attaching
the viscera and pelvic walls to the anterior abdominal wall.
The adhesions become more prominent in the presence of
ascites.4
1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Walzer A, Koenigsburg M. Ultrasonography Demonstration of Pelvic Tuberculosis. J Ultrasound Med. 1993;2:139-140
4. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125
 Role of Ultrasonography
• Fallopian tube dilated, thickened, filled with clear fluid
(hydrosalpinx) or thick caseous material (pyosalpinx) ,
showing low echogenicity. Multiloculated, thick capsulated
cystic and solid adnexal masses2,4,5
• Thickened and/or nodular omentum : sheet-like diffuse
echogenecity of the greater omentum or irregular thickening
associated with clusters of small nodes or nodal masses1,4
• Thickened peritoneum1

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Walzer A, Koenigsburg M. Ultrasonography Demonstration of Pelvic Tuberculosis. J Ultrasound Med. 1993;2:139-140
4. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125
5. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
Role of Ultrasonography
• Endometrial involvement.1 Heterogeneous with hyperechoic
areas representing foci of calcification or fibrosis, intrauterine
adhesions, and a distorted uterine cavity2. endometrial cavity
may be filled with material of low echogenicity.4 Endometrial
thickening5
• Cornual obliteration2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125
4. Walzer A, Koenigsburg M. Ultrasonography Demonstration of Pelvic Tuberculosis. J Ultrasound Med. 1993;2:139-140
5. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
Role of Ultrasonography
• Calcification of the subendometrium2
• Free and loculated peritoneal fluid2
• Heterogeneous enlargement of ovaries2
• Adnexal fixation2

1. Varma T. Tuberculosis of the female genital tract. Glob. Libr. Women’s med. 2008.
2. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
3. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculous peritonitis with female genital tract tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125
4. Walzer A, Koenigsburg M. Ultrasonography Demonstration of Pelvic Tuberculosis. J Ultrasound Med. 1993;2:139-140
5. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Role of Ultrasonography
• Ascites : numerous, thin complete septations, and fine,
delicate, incomplete and mobile strands of deposited fibrin.
May be particulate or tend to loculate in some areas.1

1. Yapar EG, Ekici E, Karasahin E, Gokmen O. Sonographic features of tuberculouos peritonitis with female genital trasct tuberculosis. Ultrasound Obstet Gynecol. 1995;6:121-125.
 Role of Ultrasonography
• Findings with greater specificity :
1. Oligemic myometrial cysts1
2. Follicles with echogenic rims1
3. Presence of endometrial fluid along with a hydrosalpinx1

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Ascites Patterns of Tuberculous Peritonitis

Ascites nature Cases (%)

Clear fluid 52
Membranes, septa, and debris 17
Floating debris 13
Mobile strands or membranes 9
Fixed septa 9

1. Lee H, Lim JH, Ko YT, Yoon Y. Sonographic Findings in Tuberculous Peritonitis of Wet-Ascitic Type. Clinical Radiology. 1991;44:306-310
 Associated findings
Associated findings Total (%)
Omental ‘cake’ 26
Hepatomegaly 24
Bowel and mesentery adhesion 22
Splenomegaly 20
Pleural effusion 17
Lymphadenopathy 13
Ileal wall thickening 7

1. Lee H, Lim JH, Ko YT, Yoon Y. Sonographic Findings in Tuberculous Peritonitis of Wet-Ascitic Type. Clinical Radiology. 1991;44:306-310
 Laparoscopy
• Aids in visual inspection of the ovaries, fallopian tubes,
peritoneal cavity, and biopsy of the tubeculous lesions
• Findings may vary from normal to tubercles on the surface,
fibrial block, fimbrial phimosis, tubal beading, peritubal
adhesions, periovarian adhesions, tubo-ovarian mass,
hydrosalpinx, and rigid tubes
• Sensitivity(85,7%), specificity(22,2%), and NPV(77%)
compared to PCR

1. Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res. 2017;145(4):425-436
 Laparoscopy

• Sub acute stage :

1. Congestion, edema, adhesion in pelvic organ. 1,2
2. Multiple fluid filled pockets. 1
3. Miliary tubercles, white yellow and opaque plaques over
the fallopian tubes and uterus, or on the peritoneal
surface1,2
4. Inflamed or blue-colored uterus2

1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683
 Laparoscopy
• Chronic stage :
1. Yellow small nodules on tubes (nodular salpingitis)1
2. Short and swollen tubes with agglutinated fimbriae (patchy
salpingitis)1
3. Unilateral or bilateral hydrosalpinx with retort-shaped
tubes due to agglutination of fimbriae.1,2
4. Pyosalpinx or caseosalpinx1
5. Caseous nodules or in the cul-de-sac1,2
1. Sharma JB. Current diagnosis and management of female genital tuberculosis. The journal of obstetrics and gynecology of india. 2015;65(6):362-371
2. Djuwantono T, Permadi W, Septiani L, Faried A, Halim D, Parwati I. Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and Literature Review. BMC Res Note. 2017;10:683