International Journal of Scientific Research in Knowledge, 2(11), pp.

517-522, 2014
Available online at http://www.ijsrpub.com/ijsrk
ISSN: 2322-4541; 2014; Author(s) retain the copyright of this article
http://dx.doi.org/10.12983/ijsrk-2014-p0517-0522

Full Length Research Paper

Presentation of Tuberculosis in Gynecology
Samar Dawood Y. Sarsam
Assistant Professor-Al Kindy College of Medicine, University of Baghdad, Iraq; Email: samarsarsam4@yahoo.com
Received 09 October 2014; Accepted 20 November 2014

Abstract. Female genital tract tuberculosis is a rare disease, the exact incidence is not accurately known as it is under reported
due to asymptomatic cases and lack of reliable confirmatory investigations. Observational study held at Elwiya maternity
teaching hospital, from the beginning of June 2012 until the beginning of October 2014. During this period, nine patients
diagnosed as cases of female genital tract tuberculosis. Patients admitted as emergency or elective cases, symptoms at
presentation were fever, vomiting, loss of weight, loss of appetite, mild abdominal pain, acute abdomen, abdominal mass,
ascites, ovarian cyst with elevated CA-125 serum levels, infertility, infected cesarean section wound. All these nine cases were
diagnosed and followed up for one year. The diagnostic dilemma arises due to varied clinical presentation so clinical suspicion
with detailed general physical examination should always be there especially in high prevalence areas of tuberculosis.
Keywords: pulmonary tuberculosis, extra pulmonary tuberculosis, ovarian cysts, infertility

mainly young women in the reproductive age group

(Duggal et al., 2009).
The exact incidence of genital tuberculosis is
difficult to assess as it is not well reported like
pulmonary tuberculosis and many times it is
asymptomatic and due to not readily available
laboratory test which is easy to perform and reliable
(Sharma, 2008). Almost invariably, tuberculosis of the
female genital tract is secondary to a primary lesion
elsewhere and the latter is usually quiescent by the
time pelvic involvement is diagnosed. Sexual
transmission from a male partner is extremely rare.
Another mode of involvement of ovaries, tubes and
serosa and uterus is peritoneal spread from an intraabdomen lesion in minority of cases. However,
generally infection reaches the genital tract (tubes in
most cases) by blood spread usually from pulmonary
lesion (Malhotra, 2012). Pelvic peritonitis is present in
40-50% of cases and can be executive type or
adhesive type (Daftray and Patki, 2009).
The aim of this study is aim to demonstrate the
possible different presentation of extra pulmonary
tuberculosis in female genital tract.

1. INTRODUCTION
Tuberculosis (TB) is as old as human civilization
(Rao, 1981). In 2012, 8.6 million people fell ill with
TB and 1.3 million died from TB. Over 95% of TB,
deaths occur in low- and middle-income countries,
and it is among the top three causes of death for
women aged 15 to 44 (Tuberculosis Fact sheet, 2013).
Tuberculosis is a preventable and curable infective
disease, caused mainly by Mycobacterium
tuberculosis, it exists in two forms: pulmonary and
extra pulmonary tuberculosis (Sarawat et al., 2010).
Tuberculosis is seen in all ages and Mycobacterium
tuberculosis is the causative organism in 90-95% of
cases where as Mycobacterium bovis can also cause
the disease (Duggal et al., 2009).
In humans, tuberculosis can affect any organ
including genital system. Manifestations include the
traditional symptoms of fever, night-sweats and
weight-loss. There is a host of different clinical,
radiological, microbiological and pathological features
that are used to diagnose TB. In 2009, World Health
Organization (WHO) reported that there was a global
reduction in the number of TB cases since 2006
(WHO, 2013). TB can affect the female genital
system and can cause a variety of symptoms and
signs, spanning from fertility problems to pregnancy
complications including pregnancy losses. Genital
system tuberculosis represents 15-20% of extrapulmonary TB and is usually asymptomatic affecting

2. PATIENTS AND METHODS

Observational study held at Elwiya maternity teaching
hospital, from the beginning of June 2012 until the
beginning of July 2014 during this period, nine
patients were diagnosed as having tuberculosis of the

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Sarsam
Presentation of Tuberculosis in Gynecology

female genital tract and tuberculosis peritonitis. All

patients admitted as emergency or elective cases. Full
history and examination were done. Symptoms at
presentation were fever, vomiting, loss of weight, loss
of appetite, mild abdominal pain, acute abdomen,
abdominal mass, ascites, ovarian cyst with or without
elevated serum levels CA-125, infertility and blocked
tubes by hysterosalpigography (HSG), infected
cesarean section wound.
Two cases (number 2 and 3) admitted as
emergency with acute abdomen, ascites and ovarian

cysts, both ended with emergency laparotomy, there

was severe adhesions, pus collection and yellowishwhite tubercles all over the peritoneum, drainage and
evacuation done, it revealed wet type peritoneal
tuberculosis, biopsy taken revealed granulomatous TB
peritonitis. One of them was 15 years old unmarried
girl. The other one had cesarean section two months
before presenting to us; the indication was
chorioamnitis in her 28 weeks of pregnancy, fig. 1
shows intra operative findings of case no. 2.

Table 1: Demographic features

Cases
Age
Social status
occupation
job
Medical history
of the patient

Family history
of tuberculosis

1
33
high
urban
Health
worker
Chest
infection
with plural
effusion four
months
before
presentation
-ve

2
32
low
rural
House wife

3
15
middle
urban
student

4
24
low
rural
House wife

Fever during
pregnancy 2
months before
presentation was
diagnosed as
chorioamnitis
and ended with
cesarean section
+ve

-ve

Chest
infection 8
months
before
presentation.
She is
diabetic

-ve

+ve

Other two cases (number 1 and 4) admitted for

abdominal pain, ovarian cyst and high ca 125 with
suspicion of malignancy. One had ascites so PCR for
ascetic fluid revealed tuberculosis. The other patient
had no ascites so laparoscopy was performed, it
revealed severe adhesions and the abdominal cavity
was studded with yellowish-white tubercles as shown
in fig.2, biopsy from these tubercles revealed
peritoneal tuberculosis it was dry type this lady gave
history of severe chest infection with plural effusion
four months before presentation which was treated as
severe chest infection as the PCR was negative for
tuberculosis at that time.

5
24
middle
urban
House
wife
-ve

6
22
low
rural
House
wife
-ve

7
30
low
rural
House
wife
-ve

8
17
middle
urban
House
wife
-ve

9
25
middle
urban
worker

+ve

-ve

+ve

+ve

-ve

-ve

The fifth patient presented with infected wound of

cesarean section not responding to treatment for 14
days, the decision was to do debridement and cleaning
of the wound under general anesthesia, biopsy showed
granulomatous tuberculosis, The other four cases
presented with primary and secondary infertility, one
case had only blocked tubes by hysterosalpigography,
two had amenorrhea, small ovarian cysts and blocked
tubes and one had only small ovarian cyst and blocked
tubes. For all these four cases laparoscopy, dilatation
and curettage done revealed tuberculosis of fibro
adhesive type, fig.3 shows the laparoscopic finding of
case number 8, and in cases with amenorrhea TB
endometritis was the biopsy result. All these patients

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International Journal of Scientific Research in Knowledge, 2(11), pp. 517-522, 2014

were managed at chest and respiratory diseases

specialized center in Baghdad, and were treated for 69 months and followed for one year.

Table 3 shows the Investigations at presentation.

ESR is high in 6 cases, CA 125 is high in two cases,
tuberculin test was +ve in 3 cases, ultrasound showed
ovarian cyst in seven cases, chest x ray was normal in
all patients and CT scan showed omental caking in
one patient with bilateral ovarian cysts. As seen in
table -4 PCR was diagnostic in case number four and
misleading in case number one and biopsy was the
definite diagnosis.
All patients were managed at chest and respiratory
diseases specialized center in Baghdad with antituberculosis drugs for six to nine months and were
followed for one year. Those with infertility and
amenorrhea they responded to treatment menstruation
restored in three of them one continued to have
amenorrhea in spite of anti TB and hormone
replacement and two of them regained patency of the
tubes. Those with ovarian cysts and high ca 125 the
cysts disappeared. These results are shown in table 5.

3. RESULTS
As shown in Table 1, all patients were of reproductive
age, of different social status. Five patients were from
rural areas, one of the patients was a health worker,
two patients gave history of chest infection more than
four months before presentation and one had fever
with pregnancy diagnosed as chorioamnitis and ended
with cesarean section.
Five patients had family
history of tuberculosis and one discovered to be
diabetic. Table 2 shows the symptoms at presentation.
Three cases presented with acute abdominal pain and
abdominal mass, two had high CA125 with ovarian
cysts and four cases presented with infertility.

Table 2: symptoms at presentation

Cases
Fever
Vomiting
Loss of appetite
Loss of weight
Abdominal pain
Acute abdomen
Amenorrhea
Abdominal mas
Ascites
Ovarian cyst

2
yes
yes
yes
-ve
yes
yes
yes
yes
yes
Right
ovarian
cyst

3
yes
yes
yes
-ve
-ve
yes
-ve
yes
yes
Right
ovarian
cyst

4
yes
yes
yes
yes
yes
yes
-ve
-ve
yes
Left
ovarian
cyst

5
yes
-ve
yes
yes
yes
-ve
Yes
-ve
-ve
-ve

6
-ve
-ve
-ve
-ve
-ve
-ve
-ve
-ve
-ve
Left
ovarian
cyst

7
-ve
-ve
-ve
-ve
-ve
-ve
yes
-ve
-ve
Left
ovarian
cyst

8
-ve
-ve
-ve
-ve
-ve
-ve
-ve
-ve
-ve
Bilateral
ovarian
cysts

9
-ve
-ve
-ve
-ve
-ve
-ve
Yes
-ve
-ve
-ve

Infertility

1
-ve
-ve
-ve
yes
yes
-ve
-ve
-ve
-ve
Bilateral
ovarian cyst
for three
months
-ve

-ve

-ve

-ve

hysterosalpigography

Not done

Not done

Not done

Infected cesarean
section wound

-ve

-ve

-ve

Secondary
infertility
Patent
tubes
-ve

Primary
infertility
Blocked
tubes
-ve

Primary
infertility
Blocked
tubes
-ve

Secondary
infertility
Blocked
tubes
-ve

Primary
infertility
Blocked
tubes
-ve

Not
done
yes

Table 3: The Investigations at presentation

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Sarsam
Presentation of Tuberculosis in Gynecology

Table 4: The root of diagnosing, either by biopsy or by PCR

Case no
1
diagnosis Laparoscopy
Dry TB
peritonitis
Biopsy done
from miliary
nodules on
the
peritoneum
Result
epithelioid
of
granulomas
biopsy
with central
caseous
necrosis
with
histiocytes
and
Langhans
cells

2
Laparoto
my
Wet TB
Biopsy
done

3
Laparotomy
Wet TB
Biopsy
done

4
PCR
from
ascetic
fluid
Wet
TB

5
Biopsy from
the infected
wound not
responding to
treatment
Biopsy done

6
Laparoscopy
Fibro
adhesive
Biopsy done

7
Laparoscopy
Fibro
adhesive

8
Laparoscopy
fibroadhes
ive
Biopsy
done

9
Laparoscopy
Beaded
tubes with
small right
ovarian cyst
biopsy done

Caseating
granulom
a with
histiocyte
s and
Langhans
cells

Caseating
granuloma
with
histiocytes
and
Langhans
cells

Not
done

non-caseating
granulomatous
inflammation
with
histiocytes and
Langhans cells

Caseating
granuloma
with
histiocytes
and
Langhans
cells

Caseating
granuloma
with
histiocytes
and
Langhans
cells

Caseating
granuloma
with
histiocytes
and
Langhans
cells

Caseating
granuloma
with
histiocytes
and
Langhans
cells

Table 5: The outcome of follow up

Case no.
Outcome

1
Ovarian
cysts
disappeared

2
Responded
to treatment

3
Responded
to treatment

4
Ascites and
ovarian
cyst
disappeared

5
Got
well

6
She
regained
tubal
patency

7
Still having
amenorrhea
and blocked
tubes

8
Responded
to
treatment

9
Undergoing
In Vitro
Fertilization
program

ended with emergency laparotomy, infertility with

blocked tubes and amenorrhea were diagnosed
through laparoscopy after taking biopsy. In addition
one of our cases presented with infected wound of
cesarean section, so our advice is to do visual
exploration of the abdomen during cesarean section to
detect any abnormality because we had two cases one
presented with infected cesarean section wound and
the other presented with acute abdomen and
abdominal mass two months after doing cesarean
section for chorioamnitis when she was 28 weeks
pregnant. It can be noticed also that in two patients
out of nine, unnecessary laparotomy was done which
can be distressing to the patient and the surgeon as
well, while if tuberculosis was suspected we could
have diagnosed and treated it in a simple noninvasive
way. Four cases presented with infertility and blocked
tubes; two of them had endometrial tuberculosis.
The important issue was the variable presentation
and difficulty in diagnosis especially the chest x ray
and the ESR were normal at time of presentation and
in one of our patients the PCR did not detect the
disease in pleural effusion. As we can see, the definite
diagnosis was by biopsy which showed caseating and
non caseating granuloma with histeocytes and
Langerhans cells. Tuberculosis in different organ
systems may mimic alternate pathology so
histopathological or laboratory evidence is often
needed to support suspicions on imaging, before
treatment is commenced (Federle et al., 2009 and
Dhnert, 2011).

4. DISCUSSION
The World Bank provides data about tuberculosis in
Iraq from 1990 to 2012. The average value for Iraq
during that period was 49.61 cases of tuberculosis per
100,000 people with a minimum of 45 cases per
100,000 people in 2010 and a maximum of 54 cases
per 100,000 people in 1990. Doctors say TB had been
largely under control in Iraq for the past 50 years but
is now making a comeback due to widespread
poverty, large amounts of dust in the air and a lack of
health awareness programs and medicines. "The
spread of TB after more than 50 years is something
worrying," The Iraqi health system was badly affected
by extended years of conflict and international
sanctions. Due to the absence of a national census in
Iraq, estimation of national prevalence of TB cases
was a significant challenge. Disease patterns have
changed, with a higher incidence of disseminated and
extra pulmonary disease now found (The World Bank,
2012; Golden and Vikram, 2005).
Tuberculosis annual report in Iraq 2012 republic of
Iraq ministry of health chest and respiratory diseases
specialized center reported 9099 cases of TB in the
year 2012, of these 3261 were extra pulmonary
(35.82%) of all detected cases of tuberculosis.
This study revealed, female genital tract
tuberculosis is present and it can present in different
presentation as we can see in these cases, ovarian cyst
is an important presentation with high CA 125 there
will be suspicion of malignancy, acute abdomen and
abdominal mass was another presentation which

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International Journal of Scientific Research in Knowledge, 2(11), pp. 517-522, 2014

TB in Iraq is still a medical and social problem; we

have problems in diagnosis and registration of
tuberculosis. Extra pulmonary tuberculosis is still a
medical challenge to physicians. There is no one
particular test in all cases. There are varieties of tests
may be required to make the diagnosis of female
genital tract tuberculosis. Clinical suspicion should
always be there especially in high prevalence areas,
since it is a pauci-bacillary disease so demonstration
of tuberculosis is many times quite difficult. Nucleic
acid amplification rapid molecular techniques using
nucleic acid and amplification can detect DNA within
48 hours of infection, it has a sensitivity of 87-100%
specificity of 92-98% (Malhorta, 2012), but in Iraq
PCR is still not properly used, regarding our patients it
was diagnostic in one case and in the other was
misleading.
Female genital tract tuberculosis is a rare disease,
yet its sequel and complications can have profound
effects on the affected women health. Women from
areas where TB is more prevalent and lacks response
to medication should prompt physicians to take into
consideration the possibility of TB as an underlying
cause of the problem (Alhakeem and Schneider,
2013).

Daftray SN, Patki A (2009). Reproductive

Endocrinology and infertility: principles and
clinical practice. New Delhi : BI Publications,
pp 450.
Dhnert W (2011). Radiology Review Manual.
Lippincott
Williams
&
Wilkins,
ISBN:1609139437.
Duggal S, Duggal N, Hans C, Mahajan RK (2009).
Female genital TB and HIV co-infection. Indian
J. Med. Microbiol, 27:361-363.
Federle MP, Jeffrey RB, Woodward PJ, Borhani A
(2009). Diagnostic imaging, Abdomen.
AMIRSYS Publishing, pp: 1288.
Golden MP, Vikram HR (2005) Extrapulmonary
Tuberculosis: An Overview. Am Fam
Physician., 72 (9):1761-1768.
The World Bank (2012). Iraq Tuberculosis: cases per
100,000
people,
source:
http://www.ntpiraq.zaghost.com.
Malhotra H (2012). Genital tuberculosis. Apollo
Medicine, 9(3): .224-227.
Rao KN (1981). History of Tuberculosis in Text book
of Tuberculosis - 2nd Edition. Vikas Publishing
House.
Sarawat P, Swarankar ML, Bhandari A, Soni R
(2010). Detection of active female genital
tuberculosis by molecular method. Int J Pharm
Bioscience, 1(4): B-238.
Sharma JB (2008) Tuberculosis and Obs & Gynae.
Practice, Progress in Obs and Gynae , volume
18.
Tuberculosis annual report in Iraq (2012) Republic of
Iraq, Ministry of Health; chest and respiratory
diseases specialized center.
Tuberculosis Fact sheet N104 (2013). World Health
Organization. Updated October.
World Health Organization (WHO). Global
Tuberculosis Control (2009) - Epidemiology,
Strategy,
Financing.
http://www.
who.int/TB/publications/global_report/2009/en/
index.html.

5. CONCLUSION
Extra pulmonary tuberculosis is unpredictable and
female genital tract tuberculosis can present in
unusual presentation, it is recommended that Clinical
suspicion with detailed general physical examination
should always be there in consideration to the
prevalence of tuberculosis in Iraq.
REFERENCES
Alhakeem M, Schneider A. (2013).
Genital
tuberculosis: A rare cause of vulvovaginal
discharge
and
swelling.
Journal
of
Microbiology and Infectious Diseases, 3 (3):
141-143.

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Presentation of Tuberculosis in Gynecology

Assistant prof. Dr. Samar Dawood Y. Sarsam was born in Baghdad (1960), got
her M.B.Ch.B Degree (1984); Post graduate diploma in Obs. & Gye. (D.O.G)
1992; Board in Obs. & Gye. (C.A.B.O.G) 1992; Worked as Specialist in Mosul
(1992-2006); She joined the academic staff at University of Mosul (2002- 2005);
She joined the academic staff at University of Baghdad, Al Kindey Medical
College (2005 Until now) and got the assistant professor degree at (2008). Areas
of specialization and interest: infertility and laparoscopy.

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