Hysterosalpingographic Appearances of Female Genital Tract Tuberculosis: Part II: Uterus

Tubal tuberculosis is disseminated to the endometrium in approximately 50% of cases (8) and persists in the basal layer, whereas is not shed during menstruation, or becomes re-infected from the tubes following menstruation. Thus, tubercles in the endometrium are always young. Tuberculous uterus may show a range of mild to severe endometritis including epitheliod granulomas with sparse, endometrial ulcer leading to partial or complete intrauterine adhesions, obliteration and deformity of the uterus. The involvement of myiometrium is seen in 2.5% of patients with abscess formation (2).

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 (14, 15).

Uterine manifestations in tuberculosis may vary from mild endometritis to severe scarring and deformity leading to total obliteration of the uterine cavity (Fig 1A-C) (16). In mild endometritis, the endometrial involvement is usually superficial, while uterine cavity has normal size, shape, and tonicity, whereas there is always obstruction of both tubes.

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 (17).

With progression of disease, irregularity of uterine contour and filling defects may result in a denticulate cavity (Fig 2) (18, 19), or may convert the triangular uterine cavity into a T- shape which is very similar to diethylstilbestrol uteri (14, 19). A "T-shaped" tuberculosis uterus should be differentiated from a "T-shaped" in diethylstilbestrol (DES) exposure. The characteristic appearances of DES uterus are usually T-shaped with multiple constriction bands, a boxlike lower uterine cavity, a narrow endocervical canal and a hypoplastic uterine cavity; however, the fallopian tubes are usually normal (Fig 3) (20). Sometimes, unilateral scarring of the cavity results in obliteration of cavity on one side of uterus giving rise to a unicornuateappearance called a "pseudounicornuate" uterus (19). True unicornuate uterus can be differentiated from a pseudo unicornuate uterus by having a smooth contour, a more horizontally oriented long axis and normal ipsilateral fallopian tube (Fig 4A, B) (14).

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).

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.

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 (22). It is a good indicator for suggesting endometrial tuberculosis.

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 (Fig 8).

Cervical tuberculosis is rare due to the nature of stratified squamous epithelium of the ectocervix which causes to be resistance to bacterial penetration (23- 26). The disease is commonly secondary to tuberculous salpingitis and endometritis, while in primary form is usually transmitted by the partner with genitourinary TB (25, 26). TB cervix can coexist with carcinoma In-situ and infertility. Other common presentations are abnormal vaginal discharge/bleeding and menstrual irregularities (23, 24).

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.

There are useful differential diagnostic criteria suggested by Klein et al. (27) for diagnosis of tuberculosis as follows (Fig 10):