Tuberculous Vaginitis: Clinical Manifestations, Diagnosis, Treatment

Genital tuberculosis is second in prevalence after pulmonary tuberculosis. The frequency of tuberculous lesions of the female genital organs ranges from 1.5 to 2%.

Tuberculous vaginitis is a specific inflammation of the vagina caused by M. Tuberculosis. Infection with genital tuberculosis occurs hematogenously, less often lymphogenously.

Complaints

The patient may be bothered by pulling pains in the lower abdomen, abnormal vaginal discharge, vaginal bleeding, infertility.

Clinical picture

On gynecological examination with mirrors, a tuberculous ulcer of the vagina can be visualized as superficial, with undermined edges, the base of the ulcer infiltrated, and the bottom covered with yellowish or red-gray plaque. At the edges of the ulcer can be found milky, whitish nodules, which when pressed with a spatula pale. An important additional examination is an examination through the rectum to exclude the formation of rectovaginal fistulae.

Tuberculous ulcers are characterized by a long course. The patient may indicate the presence of general symptoms: subfebrile fever, weakness, increasing loss of strength, rapid fatigue, poor appetite and sleep, night sweats, weight loss, dry skin.

Diagnosis of vaginal tuberculosis

Histologic and cytologic examination – identification of specific tuberculous inflammation in specimens. Bacteriologic or culture samples for M. Tuberculosis may be taken from vaginal secretions, ulcers, menstrual ulcers, or menstrual samples. Tuberculosis may be taken vaginal secretions, ulcer secretions, menstrual blood, aspiration biopsy. In genital tuberculosis, negative bacteriologic results are possible, even if the diagnosis is histologically confirmed. For rapid detection of M. Tuberculosis in the study material, nucleic acid amplification (NAA) tests are used. The Xpert MTB/RIF assay is an NAA test that both detects and identifies the M. Tuberculosis complex, revealing genetic mutations that can predict resistance to rifampicin treatment, one of the most effective drugs used to treat tuberculosis. A tuberculin skin test or a blood test for interferon gamma release assay (IGRA) is also relevant.

1. Histologic examination

Microscopic examination of tissues (biopsy specimens) to detect specific tuberculous granulomas (foci of inflammation with Pirogov-Langhans cells).

2. Cytologic examination

Analyzing the cellular composition of smears or aspirates to detect evidence of tuberculous lesions.

3. Bacteriological method (culture)

Cultivation of mycobacteria on nutrient media from samples: vaginal discharge, menstrual blood, ulcer secretions or biopsy specimens. May give false negative results.

4. Nucleic acid amplification (NAA) tests

Molecular genetic methods (e.g. PCR) for rapid detection of M. Tuberculosis DNA in the material. Tuberculosis DNA in the material.

5. Xpert MTB/RIF

An automated NAA test that not only detects M. Tuberculosis but also determines rifampicin resistance by analyzing genetic mutations.

6. Test with standardized tuberculin

Injection of tuberculin to assess the immune response. It is an additional method on the basis of which alone the diagnosis of tuberculosis cannot be established or excluded.

7. Interferon gamma release assay (IGRA)

Blood is tested for levels of interferon-γ produced in response to mycobacterial antigens. An alternative to skin testing.

The combination of methods increases the accuracy of diagnosis, especially in case of negative cultures. Histologic methods and NAAT tests (Xpert MTB/RIF) are the most informative.

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Treatment of vaginal tuberculosis

The basis of therapy for vaginal tuberculosis is long-term multicomponent antituberculosis chemotherapy conducted in specialized medical institutions. Treatment is selected individually, taking into account the sensitivity of the pathogen, the presence of concomitant diseases and possible side effects.

1. Drug therapy

As a rule, a combination of 3-4 drugs from the following groups is prescribed:

• The main antituberculosis agents:
  • Isoniazid (4-6 mg/kg/day) is a highly effective bactericidal drug;
  • Rifampincin (8-12 mg/kg/day), a key component of therapy, affects intracellular forms of mycobacteria;
  • Pyrazinamide (20-30 mg/kg/day) – particularly active in the acidic environment of inflammatory foci;
  • Ethambutol (15-25 mg/kg/day) – used to prevent the development of resistance.
• Alternative medicines (in case of resistance or intolerance):
  • Rifabutin, Rifapentine (rifampin substitutes);
  • Fluoroquinolones (levofloxacin, moxifloxacin);
  • Aminoglycosides (kanamycin, amikacin);
  • Capreomycin (for multidrug resistance);
  • Bedaquiline (used in the new short-course regimens).

Treatment regimens:

• Standard (sensitive TB): 2 months of intensive therapy (isoniazid + rifampicin + pyrazinamide + ethambutol), followed by 4 months of maintenance treatment (isoniazid + rifampicin);
• In case of resistance: individualized regimens with inclusion of reserve drugs, duration – 18-24 months;
• New shorter regimens: Bedaquiline + Pretomanid + Linezolid + Moxifloxacin (for MDR-TB without fluoroquinolone resistance) or Bedaquiline + Pretomanid + Linezolid (for XDR-TB) – 6 months.

2. Surgical treatment

Indicated in cases of:

• Ineffectiveness of conservative therapy;
• Presence of strictures, fistulas, abscesses;
• Prominent scarring resulting in impaired function.

3. Complementary therapy

• Immunomodulators (as indicated);
• Physiotherapy (in the absence of contraindications);
• Local treatment (antiseptic, anti-inflammatory drugs);
• Correction of microflora (prebiotics and probiotics after the main course).

4. Control of efficiency

• Regular molecular, microbiologic and histologic studies;
• Dynamics of symptoms, physical examination;
• Ultrasound/MRI of the pelvis to assess dynamics;
• Monitoring of side effects (liver tests, ophthalmologic monitoring when taking ethambutol).

Treatment should be carried out under the strict supervision of a phthisiatrist and a gynecologist.