Туберкулез женских половых органов. Клиническая лекция

Кульчавеня Е.В. Туберкулез женских половых органов. Клиническая лекция. Гинекология. 2022;24(5):413–420. DOI: 10.26442/20795696.2022.5.201818

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Kulchavenya EV. Female genital tuberculosis: a clinical lecture. Gynecology. 2022;24(5):413–420.
DOI: 10.26442/20795696.2022.5.201818

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Аннотация

Проблема внелегочного туберкулеза (ВЛТ) остается актуальной, поскольку наряду со снижением заболеваемости отмечается увеличение числа запущенных, поздно диагностированных случаев. Туберкулез женских половых органов (ТЖПО) является относительно редким и трудно диагностируемым заболеванием, встречается в среднем в 0,5–2,0 случаях на 100 тыс. населения; в последние годы также отмечают рост этой локализации ВЛТ. Туберкулезом может поражаться любой орган половой системы женщин, как изолированно, так и в комбинации. Наиболее часто в процесс вовлекаются трубы (95–100%), эндометрий (50–60%), яичники (20–30%), шейка матки (5–15%), миометрий (2,5%) и влагалище/вульва (1%). Самым частым симптомом ТЖПО, по поводу которого женщины обращаются к врачу, является бесплодие. К другим симптомам ТЖПО относят нарушения менструального цикла (олиго-, гипо-, дис-, аменорею, а также мено- и метроррагию), тазовую боль и патологические выделения из влагалища. У женщин в постменопаузе ТЖПО характеризуется симптомами, напоминающими злокачественное новообразование эндометрия, такими как постменопаузальное кровотечение, стойкие бели и пиометра. Диагноз ставят на основании тщательного сбора анамнеза, клинического обследования и надлежащего исследования полученного с помощью эндоскопии патологического материала. Туберкулиновая проба с внутрикожным введением 2 ТЕ туберкулина (проба Манту) оказалась положительной у 42,6% пациентов с генитальным туберкулезом. Важным методом диагностики ТЖПО является гистеросальпингография, которая позволяет оценить внутреннюю структуру женских половых путей и проходимость маточных труб. При ультразвуковом исследовании фаллопиевы трубы могут оказаться расширенными, утолщенными, быть заполненными серозным отделяемым (гидросальпинкс) или казеозом (пиосальпинкс). Лапароскопия и гидротубация с красителем являются надежным инструментом для диагностики генитального туберкулеза, особенно при заболеваниях маточных труб, яичников и брюшины. Микробиологическое исследование патологического материала при ТЖПО методом посева на плотные питательные среды малоинформативно, необходимо выполнять полимеразную цепную реакцию и применять другие молекулярно-диагностические методы. Следует признать, что ТЖПО не является редким заболеванием, но его часто упускают из виду. Основных причин для поздней диагностики 2: нечеткие клинические признаки и низкий уровень настороженности. Поскольку бесплодие – это частое осложнение ТЖПО, всех инфертильных женщин необходимо обследовать на туберкулез в полном объеме: туберкулинодиагностика, ультразвуковое исследование, гистеросальпингография, в сложных случаях – диагностическая лапароскопия с обязательным взятием материала для патоморфологического и микробиологического исследований.

Ключевые слова: туберкулез гениталий, туберкулез женских половых органов, урогенитальный туберкулез, туберкулез мочеполовой системы, туберкулез эндометрия, бесплодие

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The problem of extrapulmonary tuberculosis (EPT) remains urgent since, along with a decrease in the incidence of the disease, there is an increase in the number of neglected, late diagnosed cases. Female genital tuberculosis (FGT) is a relatively rare disease difficult to diagnose, occurring on average in 0.5–2.0 cases per 100,000 population; in recent years, an increase of EPT in this localization has been observed. Tuberculosis can affect any organ of the female genital system, either single or in combination. The most frequently involved are the tubes (95–100%), endometrium (50–60%), ovaries (20–30%), cervix (5–15%), myometrium (2.5%) and vagina/vulva (1%). The most common symptom of FGT that makes patients seek medical advice is infertility. Other symptoms of FGT include menstrual irregularities (oligo-, hypo-, dis-, amenorrhoea as well as meno- and metrorrhagia), pelvic pain, and abnormal vaginal discharge. In postmenopausal women, FGT is characterized by symptoms resembling endometrial malignancy, such as postmenopausal bleeding, persistent leukorrhea, and pyometra. The diagnosis is based on a thorough history, clinical examination, and proper examination of the sample material obtained by endoscopy. Tuberculin test with intradermal injection of 2 TU of tuberculin (Mantoux test) was positive in 42.6% of patients with genital tuberculosis. Hysterosalpingography is an important method for diagnosing FGT, which assesses the internal structure of the female reproductive tract and the patency of the fallopian tubes. On ultrasound, the fallopian tubes may appear dilated, thickened, or filled with serous discharge (hydrosalpinx) or caseous mass (pyosalpinx). Laparoscopy and dye hydrotubation are reliable tools for the diagnosis of genital tuberculosis, especially for the involvement of the fallopian tubes, ovaries, and peritoneum. Microbiological examination of sampled material in FGT using solid media is low-informative; polymerase chain reaction and other molecular diagnostic methods should be used. It should be acknowledged that FGT is not a rare condition, but it is often overlooked. The two main reasons for late diagnosis are vague clinical signs and low alertness. Since infertility is a frequent complication of FGT, all infertile women should be screened for tuberculosis: tuberculin, ultrasound, hysterosalpingography, and in complicated cases, diagnostic laparoscopy with obligatory tissue sampling for pathomorphological and microbiological studies.

Keywords: genital tuberculosis, female genital tuberculosis, urogenital tuberculosis, endometrial tuberculosis, infertility

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6. Pang Y, An J, Shu W, et al. Epidemiology of Extrapulmonary Tuberculosis among Inpatients, China, 2008–2017. Emerg Infect Dis. 2019;25(3):457-64. DOI:10.3201/eid2503.180572
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8. Diriba G, Tola HH, Alemu A, et al. Drug resistance and its risk factors among extrapulmonary tuberculosis in Ethiopia: A systematic review and meta-analysis. PLoS One. 2021;16(10):e0258295. DOI:10.1371/journal.pone.0258295
9. Solonko II, Gurevich GL, Skryagina EM, Dyusmikeeva MI. Extrapulmonary tuberculosis: clinical, epidemiological characteristics and diagnostics. Tuberculosis and Lung Diseases. 2018;96(6):22-8 (in Russian). DOI:10.21292/2075-1230-2018-96-6-22-28
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Авторы

Е.В. Кульчавеня*1–3

1 ФГБУ «Новосибирский научно-исследовательский институт туберкулеза» Минздрава России, Новосибирск, Россия;
2 ФГБОУ ВО «Новосибирский государственный медицинский университет» Минздрава России, Новосибирск, Россия;
3 ЗАО «Медицинский центр ”АВИЦЕННА”», Новосибирск, Россия
*urotub@yandex.ru

________________________________________________

Ekaterina V. Kulchavenya*1–3

1 Novosibirsk Tuberculosis Research Institute, Novosibirsk, Russia;
2 Novosibirsk State Medical University, Novosibirsk, Russia;
3 "AVICENNA" Medical Center, Novosibirsk, Russia
*urotub@yandex.ru

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