Document Type : Pictorial Review
Female genital tuberculosis (FGTB) is one form
of extrapulmonary manifestations of tuberculosis
and includes 5% of all female pelvic infections
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 resistants trains of
Mycobacterium tuberculosis (
Diagnosis of genital TB may be difficult because
majority of cases are asymptomatic; furthermore, in
high prevalence-countries, culture facilities for mycobacterium and histopathologic diagnosisare limited
This part of pictorial review illustrates and describes endometrial changes following genital tuberculosis detected by HSG.
Tubal tuberculosis is disseminated to the endometrium in approximately 50% of cases (
The pathognomonic findings for tuberculosisinclude specific and non-specific features. Specific
radiographic features are "collar-stud abscess",
"T-shaped" uterus and unicornuate uterus-likeappearance (the "pseudounicornuate" uterus). Other
uterine changes due to tuberculosis known as nonspecific features include endometritis, synechiae,
distortion of uterine contour, and venous and lymphatic intravasations (
Uterine manifestations in tuberculosis may vary
from mild endometritis to severe scarring and deformity leading to total obliteration of the uterine
A. Hysterosalpingographic appearance of genital TB in a patient with primary infertility. Uterine cavity is normal in shape and size. Terminal sacculation are seen in both tubes. B. Irregularity, multiple filling defects and obliteration of right ostium secondary to extensive synechiae formation in this site. Obstruction of left tube is also seen. C. Complete obliteration of uterine cavity due to extensive synechiae formation following chronic uterine TB.
Later with progression of TB, caseation and ulceration of endometrium occur, and intrauterine scarring may result in synechiae and intrauterine
adhesions. In this stage, the uterine cavity is usually normal in size, but irregularity of uterine contour, filling defects, lack of uterine contractility
and tubal patency may be seen (
With progression of disease, irregularity of
uterine contour and filling defects may result
in a denticulate cavity (
Indentation of the cavity due to synechiae resembles a denticulate uterus .Obstruction of the isthmic portion in both tubes is present.
T-shaped configuration in two different patients. A. "T-shaped" tuberculosis uterus. Irregular contour of the uterine cavity with diminished capacity resembling a T-shaped uterus. Both tubes are obstructed from isthmic portion. B. T-shaped uterus due to DES exposure. Narrow endocervical canal and small uterine cavity. Note both tubes are normal.
A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an asymmetric intrauterine obliteration, resembling a unicornuate uterus. Note the irregular contour and vertical orientation of long axis. B. True unicornuate uterus. Note the smooth contour, more horizontal orientation of long axis and normal ipsilateral fallopian tube.
A dwarfed uterus which is characterized with a small and shrived uterus with irregularity and disproportion between uterine cavity and cervix, while trifoliate shaped uterus are other presentations of uterine tuberculosis (Figs 5, 6) (17).
A. Dwarfed uterus. HSG shows a very small, shrived and deformed uterine cavity. Disproportion between uterine cavity and cervical canal is obvious. Both tubes are occluded
Trifoliate shaped uterus. Synechiae formation at the uterine borders and partial obliteration in the fundus produce a trifoliate like appearance. Both tubes are obstructed in the isthmic portion.
After long duration of infection, extensive destruction of endometrium and myometrium followed by fibrosis and complete obliteration of the uterine cavity may occur as the "Netter syndrome" (21). Hysterosalpingographic characteristic of Netters syndrome is called "glove’s finger" consisted of a cervical canal and a small part of the uterus (Fig 7) (21). Other radiographic findings of tubercular affection of the uterus include the formation of a "collar-stud abscess", which is pathognomonic for tuberculosis (14). This feature should be differentiated from intracavitary changes due to necrosis in an adjacent uterine leiomyoma. A collar-stud abscess classically has a narrow neck with a broader base which is away from the endometrial cavity.
Netter syndrome. Obliteration of entire uterine cavity due to extensive synechiae formation giving of glove’s finger appearance.
The venous and lymphatic intravasation in
uterine and adnexal vessels is acomplicated
disorder which occurs due to progressive destruction and ulceration of endometrium.The
most important cause of intravasation is the entry of contrast medium to the venous and
lymphatic canals through unprotected ves-
sels. Although this feature is not specific for
tuberculosis, it can be detected by HSGs performed early in the menstrual cycle, shortly
after endometrial instrumentation or pathological deficiency of endometrium (
In hysterosalpingography filling of multiple, parallel beaded channels are seen.
Contrast in thin delicate lymphatics are differentiated from blood vessels by their narrower caliber and reduced draining of contrast
Complete obliteration of the uterine cavity. Extrauterine intravasation of contrast into the pelvic vein and lymphatic system is seen.
Cervical tuberculosis is rare due to the nature of stratified squamous epithelium of the
ectocervix which causes to be resistance to
bacterial penetration (
In the cervix, the tuberculous lesion can be ulcerative or proliferative. In the ulcerative form, the ulcers have wavy borders, clean cut edges and a yellow base. The proliferative lesion has papillary formations which may be pedunculated or sessile.
On HSG, caseous ulceration of the mucosa produces ragged irregular contours and diverticular outpouching with a feathery appearance (Fig 9). The other various features such as adhesions, distortion and a serrated endocervical canal have also seen in some cases.
Cervical tuberculosis. Uterine cavity has small size, diverticular outpunching, ragged irregular contours and obvious deformity. Cervical filling defects, irregularity of cervical lumen and diverticular outpouchings are present. Occlusion of both tubes is also seen.
There are useful differential diagnostic criteria suggested by Klein et al. (
Calcified lymph nodes or smaller irregular calcifications in the adnexal area.
Obstruction of the fallopian tube in the zone of transition between the isthmus and the ampulla.
Multiple constrictions along the course of the fallopian tube.
Endometrial adhesion and/or deformity or obliteration of the endometrial cavity in the absence of curettage or of surgical termination of pregnancy.
Pelvic tuberculosis in patient with chronic genital
TB. Uterine cavity is small, deformed with irregular contour. Both tubes are occluded. Several calcified lymph nodes
in the pelvis and intravasation of contrast into the veins are
Uterine tuberculosis may show a range of mild to severe endometritis, restricted to superficial layers of endometrium or endometrial ulcer leading to progressive destruction, obliteration and deformity of the uterus in the late stages.
Some of the hysterosalpingographic findings of uterine tuberculosis, such as "T-shaped" tuberculosis uterus, "pseudounicornuate" uterus, "collarstud abscess" and "dwarfed" uterus with lymphatic intravasation and occluded tubes, are specific for female genital tuberculosis and have not been encountered in the majority of non-tuberculosis cases. Diagnosis of these radiographic characteristics is reliable evidence of genital tuberculosis and iscrucial in the infertility workup in order to make a proper decision.