Document Type : Pictorial Review
Female genital tuberculosis (FGTB) is one form
of extrapulmonary manifestations of tuberculosis,
while it includes 5% of all female pelvic infections
and 10% of pulmonary tuberculosis cases (
The reported prevalence of genital tuberculosis
has shown a descending trend in developed countries,
but recently, its rate has started to increase
again due to co-infection with human immunodeficiency
virus (HIV) and the development of drug-resistant
strains of Mycobacterium tuberculosis (
Primary infection of the female genital organs is
very rare (
Diagnosis of genital TB may be difficult because
majority of cases are asymptomatic; in addition,
facilities for mycobacterium culture and histopathology
are limited in high-prevalence countries
This pictorial review describes specific and nonspecific radiographic features of tubes caused by tuberculosis as seen on HSG.
Mycobacterium tuberculosis is responsible for
disease in approximately 90-95% of cases and produces
granulomatous salpingitis and endometritis
leading irregular menstrual bleeding and infertility.
In 5-10% of patients, the infection results from Mycobacterium
bovis, especially when the source of
infection is acquired from the gastrointestinal cases
Genital tuberculosis usually spread to genital
site from three routes, including hematogenous,
lymphatic or adjacent viscera (
Primary infection of genital TB is rare, and may
result from direct introduction of TB bacilli at
sexual intercourse with a male partner with genitourinary
TB. Ascending spread of infection from
the vagina, cervix and the vulva has been reported
Tha fallopian tubes are the initial focus of female
genital tuberculosis, and usually involved bilaterally
not symmetrically (
The transitional region between the isthmus
and ampulla is the most frequent site of tubal
obstruction. Sometimes, hydrosalpinx or pyosalpinx
with thick fibrotic wall is formed at the
distally blocked fallopian tube.The ovaries are
often seen in normal appearance and the diagnosis
is established only on histopathological
In some cases, ovarian tubercle, adhesion, capsular
thickening and ovarian or pelvic abscess are
Most of the cases involved in genital TB have been detected in reproductive age; a range of 20-
45 year-old (
Tuberculous lesions of the cervix present with
postcoital bleeding, abnormal discharge and,
on examination, have appearances similar to
cancer of the cervix (
Hysterosalpingographic presentation of tubal
TB vary from non-specific changes such as hydrosalpinx
to specific pattern such as "beaded
tube", "golf club tube", "pipestem tube", "cobble
stone tube" and the "leopard skin tube"
The presence calcified lymph nodes in the
pelvis or in the course of fallopian tubes may
enable the diagnosis of the TB. Plain films of
the pelvis may show such calcifications which
must be differentiated from other causes of calcifications
such as calcified pelvic nodes, calcified
uterine myomas, urinary calculi, pelvic
phleboliths and calcification in an ovarian dermoid
A. Multiple calcified lymph nodes in a patient with chronic genital tuberculosis. Calcified lymph nodes are present in
the pelvic (long thin arrows) and course of fallopian tubes. Note the irregularity of the uterine contour and diminished uterine
capacity, B. Hysterogram shows a large shadow of a calcified ovary (open arrow) in the left side. Hydrosalpinx is also seen in
the tubal distal portion in the both tubes (
Caseous ulceration of tubal mucosa creates
an irregular, ragged or divertucular appearance
on the contour of the tubal lumen on HSG. Divierticular
cavities surrounding of the ampullar
portion may give it a "tufted" like appearance
(Fig 2). Isthmic diverticula may resemble
salphingitis isthmica nodosa, "TB-SIN" like
appearances can be differentiated from classic
SIN (Fig 3). In "TB-SIN diverticular outpouching
are larger, asymmetric, with a more
bizarre pattern (in size and number) and are
not usually restricted to the isthmic portion
of the tube as compared with those of SIN (
" Tufted tube" . Multiple small diverticular like appearance
surrounding the ampulla produce d by caseous
ulceration gives the tubal outline a Rosette-like appearance
TB SIN-like. Penetration of contrast medium between the mucosal folds produces small diverticular-like outpouchings with a bizarre pattern. Entire of both tube involved (arrows). Moderate hydrosalpinx is seen in the right side (open arrow).
Distribution of contrast medium in a reticular pattern
producing a " cotton-wool plug" appearance [arrow
Terminal sacculation in both fallopian tubes.
Moderate hydrosalpinx and blind ending sinus are seen
in both tubes. Note the fistula in left tube [white arrow
Tubal occlusion in tuberculosis is considered the most common finding seen on HSG and occurs most commonly at the junction between the isthmus and ampulla. in the region of isthmus and ampulla. Although cornual occlusion following ampullar obstruction is the most common site of tubal occlusion caused with any factor, it is not so common in tuberculosis.
Multiple constrictions along the course of fallopian
tube may form due to scarring and present as
"beaded" appearance (
Occlusion of the isthmus or fimbrial end of the
tube filled with serous or clear fluid produce a
retort-shaped dilation of the tube (large-sausageshaped)
which initially is a pyosalpinx that change
to hydrosalpinx. Hydrosalpinx is usually moderate
or slight with a "golf club like appearance" to the
" Beaded tube" . Multiple constrictions along the
fallopian tube giving rise to a " beaded" appearance [arrows
" Pipe stem" appearance in a women with primary infertility. Absence of normal tortuosity and a curved or straight pipe like appearance show fibrotic stage of tuberculous salpingitis. Irregular contour of the uterine cavity with diminished capacity in the fundual portion resembling a septate uterus.
" Golf club" tube. Sacculation of both tubes in distal portion with an associated hydrosalpinx giving a Golf club-like appearance (arrows). Uterine cavity has normal size and shape.
Twisting of the hydrosalpinx may result in a
floral pattern- "the floral hydrosalpinx" (
" Floral appearance" . Twisted hydrosalpinx resembles a floral appearance of left side tube (arrow).
Thickened mucosal folds in the dilated tubes is a
non-specific finding of tubal tuberculosis (
Intraluminal scarring can give rise to a cobblestone
pattern which is an effective radiographic sign of intraluminal
adhesions in hydrosalpinges and associated
with concern of infertility (
Cobblestone appearance (arrows). Intraluminal scarring
of the tube gives rises a cobblestone like appearance which
is an effective radiographic sign of intraluminal adhesions (
Multiple rounded filling defects following intraluminal granuloma formations within the hydrosalpinx, resembling a " leopard skin" appearance [arrows (32)].
In chronic tuberculosis, following repeated episodes of acute exacerbation, a dense peritubal connective tissue scarring occurs in and around the tubes, leading to peritubal adhesions. The tubes become vertically or horizontally fixed, interfering with access of fallopian tubes to the ovary at ovulation and transport of the ovum.
In this non-specific finding, the contrast
spill from a vertically fixed tube appears to be
bounded laterally by adhesions, which gives
rise to straight spill appearance (
Dense adhesions may resemble lead to visualization
of septations and bizarre "criss-cross
spill" pattern. Sometimes, peritoneal granulomas
formation produces small rounded filling
defects seen additionally to these septations.
Everted fimbria with a patent orifice imparting
characteristic "tobacco pouch" appearance
" Straight spill" pattern from a vertically fixed
tube. Contrast spill is bounded by peritubal adhesions
" Vertically fixed tubes secondary to dense peritubal adhesions.
Dense connective tissue causes the lack of tubal mobility.
The hyperconvulated is seen in right tube and manifests
a " cork screw" like appearance [arrows (
" A, B. Peritubal halo. Thickening of the tubal walls due to peritubal adhesions (arrows) represents a cloudy sign on hysterosalpingograms. This finding is a non-specific feature of tubal tuberculosis.
" Tobacco pouch" appearance, A. Terminal hydrosalpinx with the conical narrowing is seen in the right tube (arrow). Eversion of the fimbria secondary to adhesions, with a patent orifice produces the tobacco pouch appearance in the left terminal.
HSG is considered as an important diagnostic tool in the investigation of internal architecture of female genital tract and helpful procedure in diagnosis of female genital tuberculosis. Tubal and uterine lesion scarring remained of genital TB, are presented as specific and non-specific radiographic features which should be differed from other pathological conditions. Since the incidence of genital tuberculosis has been increased during the past two decades, the clinicians increasingly faced with cases of genital TB and its consequences such as infertility, so reviewing of these features are considered in differential diagnosis of the causes of infertility and timing intervention and treatment.