Tuberculosis (TB) is largely a disease of the lungs, but extrapulmonary tuberculosis can manifest as pelvic tuberculosis, also known as genital tuberculosis. The wide variation in prevalence across the globe underscores the need for gynecologists to be aware of pelvic TB and the gynecologic problems it can raise.
Tuberculosis Overview
Mycobacterium tuberculosis, the bacteria that causes TB, spreads through the air. The World Health Organization (WHO) writes that around a quarter of the world's population is infected with TB. However, not all of these people are symptomatic.
Most TB infections are latent, only becoming active in 5 to 10 percent of infected people—usually within the first two years after exposure. Latent TB is not contagious. TB tends to become active in people who are immunosuppressed, meaning that people with HIV or other immune conditions are more likely to develop active TB. TB may also be more likely to become active in people who are diabetic, are undernourished, abuse alcohol or smoke. Active TB, when untreated, active TB has a 50 percent mortality rate.
Tuberculosis Treatment and Prevention
Although people with latent TB cannot spread it to others, the Centers for Disease Control and Prevention recommends treating them, since it is not possible to determine whose disease will become active. Treatment should be a high priority for those most at risk for developing active TB, such as people with HIV or other immunosuppressive factors (such as taking daily prednisone). Other patient populations whose treatment should be a high priority include:
- People living in or emigrating from countries where TB is common
- People who inject illegal substances
- Workers in labs handling mycobacteria
- Residents of nursing homes, homeless shelters and correctional facilities
- Children with exposure to adults in these categories
Proactively testing for TB among patients in at-risk populations is one way to help keep the disease under control. However, TB skin tests can show a false negative if the exposure was too recent or a false positive if the person has received a TB vaccine. Guidelines from Clinical Infectious Diseases recommend blood tests for people who have been vaccinated for TB or who may not be able to easily return to the office to have their skin test read. A positive test should be followed with additional tests such as chest X-rays as well as sputum or urine testing to determine whether the infection is active since treatments differ between latent and active TB.
Early identification and treatment of TB, even when latent, is key to reducing the number of infections worldwide. StatPearls states that recurrence rates after treatment may be as high as 12 percent but notes that imperfect compliance with drug therapy may play a role.
Tuberculosis Infections Across the Globe
The greatest TB burden, accounting for two-thirds of new cases, is in India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa, according to the WHO. However, although India has the highest number of cases, it does not have the highest rate per 100,000 people. The WHO estimates that in 2019, India had an estimated incidence rate of 193 per 100,000 population and 2.6 million cases; South Africa had a much higher incidence rate of 615 per 100,000 yet reported 360,000 cases. The United States had a 2019 incidence rate of 3, and 9,800 cases, while the United Kingdom was estimated to have 8 and 5,400, respectively.
Tuberculosis as a Women's Health Issue
One issue largely missing from the public health information about TB incidence and prevalence in women's health. Extrapulmonary TB, specifically pelvic tuberculosis, is a known cause of infertility. Research from the Indian Journal of Medical Research (IJMR) finds that genital TB, despite accounting for nine percent of extrapulmonary TB cases, is likely greatly underestimated, and the reason is surprising: most cases of genital TB are found during infertility treatment. The authors cited a study showing that among women with tubal factor infertility, 45 percent were found to have genital TB.
Although the condition can spread through sexual contact, pelvic or genital TB is mostly caused by spread within the body, secondary to TB of the lungs. The IJMR study states that the fallopian tubes are affected by this condition in almost all cases, followed by the endometrium in about half, the ovaries in about 25 percent, and the cervix in 5-15 percent. Both the myometrium and vagina or vulva can be affected, but this only occurs in 1-3 percent of cases.
Research published in Touch Endocrinology reports that TB in the genital tract "may present singularly or as part of abdominal TB," and mentions symptoms such as lower abdominal pain, dyspareunia, fever, loss of appetite, and weight loss. If a patient does have pelvic TB, a pelvic exam may reveal cervical ulcers or a tender uterus. Cytology and blood tests can be used to find ascites, and ultrasound is a critical step for finding tubo-ovarian or uterine masses. The longer active TB goes untreated, the more likely it is to cause permanent damage to the reproductive system.
Clinicians who practice in areas of low prevalence may never see a patient with pelvic TB, but in an increasingly globalized world, it is impossible to rule out. Clinicians in high-prevalence countries such as India or the Philippines should expect to diagnose TB and potentially support patients through the long-term effects of untreated pelvic TB.
