Laparoscopic observations of pelvic organs in pulmonary tuberculosis

Laparoscopic observations of pelvic organs in pulmonary tuberculosis

129 Int. J. Gynecol. Obstet,, 1990,32: 129-131 International Federation of Gynecology and Obstetrics Laparoscopic tuberculosis S.N. Tripathy observ...

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129

Int. J. Gynecol. Obstet,, 1990,32: 129-131 International Federation of Gynecology and Obstetrics

Laparoscopic tuberculosis S.N. Tripathy

observations

of pelvic organs

in pulmonary

(Mrs) and S.N. Tripathy

Department of Tuberculosis and Chest Diseases, V.S.S. Medical College Hospital, Burla, Orissa (India) (Received September 19th, 1988) (Revised and accepted April 12th, 1989)

Abstract

Sixty-two cases of bacteriologically positive pulmonary tuberculosis were studied in the Department of Tuberculosis and Chest Diseases at the V.S.S. Medical Collage Hospital, Burla, India. Apart from other investigations, all patients underwent laparoscopy to determine the incidence of genital involvement. Positive findings were observed in 37 women; tubercles werepresent in the tubes of 15 women. At dilatation and curettage, the endometrium was obtained in 37 women. Tuberculous endometritis was detected in 4 women. Keywords: Laparoscopy; Tuberculosis; ercle; Ovary; Tubes; Uterus.

Tub-

Introduction

For over a decade, we have studied different aspects of female genital tract involvement in confirmed cases of tuberculosis. Our observations have documented genital tract involvement in about 80% of cases of pulmonary tuberculosis [l-4]. The endometrium, the tubes, and the ovaries all may be affected. In the past, only laparotomy was available to detect any structural changes of the tubes and 0020-7292/90/$03.50

0 1990 International Federation of Gynecology and Obstetrics Published and Printed in Ireland

ovaries. In recent years, however, laparoscopy has become an alternative to laparotomy with many advantages. We believe that it is particularly useful to correlate the findings at laparoscopic examination with vaginal findings and endometrial biopsy. Materials and methods

This is a laparoscopic study of 62 patients treated at the tuberculosis section of V.S.S Medical College Hospital, Burla, India, from March lst, 1985 to April 31st, 1987. To be included in the study, a woman had to be between 15 and 45 years of age and have bacteria positive pulmonary tuberculosis. All patients were newly diagnosed as having uncomplicated and untreated tuberculosis. Each patient was thoroughly examined and studied for the presence of pulmonary and extrapulmonary lesions. The duration and radiological staging of the cases were recorded, and each patient submitted to a detailed gynecological history and physical examination. Dilatation and curettage was performed and the endometrium was sent for histopathological study. All patients underwent laparoscopic examination of the pelvic organs, including the pelvic peritoneum, tubes, ovaries, uterus, and intestines in the tuberculosis ward. Local anesthesia was used. Clinical and Clinical Research

130

Tripathy and Tripathy

Atropine was given 20 min prior to the laparoscopy; one ampule of pentazocin and one ampule of diazepam of 5 mg were mixed and injected intravenously just before the laparoscopy. Though CO, or NO, is preferable to room air for pneumoperitoneum, in all the developing countries including India, laparoscopic examinations are performed with instillation of room air without complication. In this series, pneumoperitoneum was established using room air instilled with an Ambu bag. The standard technique of laparoscopy was used. Statistical analysis using chi-squared tests was performed. Results Of the 62 women, 37 showed some abnormalities (bands, adhesions, hypermia, tubercles, and variation in the size of the uterus and ovaries). Only one woman had clinical evidence of abdominal tuberculosis, but on laparoscopic examination, 14 additional women had tubercles on the tubes. Regardless of whether or not the women had tubercles on the tubes, all received effective antitubercular treatment. The majority of patients ranged from 21 to 25 years of age (10 cases of tubercles were detected in this age group). Abnormalities of the uterus were detected in 23 women by pelvic examination, whereas they were observed by laparoscopy in 34 women. Similarly, in 26 women there were palpable abnormalities in the tubes in contrast to 37 by laparoscopy. Similar results

Table I.

Pelvic findings in relation to laparoscopy.

Table II.

Intestine and Pouch of Douglas as seen through

laparoscope.

Pouch of Douglas Intestine

Normal

Adhesion

Tubercle

n

@lo

n

%

n

%

54 45

87.1 12.6

7 15

11.3 24.2

1 2

1.6 3.2

were found on the ovaries and the Pouch of Douglas (P< 0.001). Abnormal ovaries of small size, cystic and adherent, were seen in 3, 3, and 4 cases, respectively. In two women, there were tubercles on the surface of the ovary, along with the tubes. Both tubes were normal in 25 patients. Of the 37 abnormal tubes, 15 had peritoneal adhesions and an equal number had tubercles on their surface. The left tube was blocked in 2, the right tube in 1, and both in 4 cases, respectively. Out of the 34 abnormal uteri seen through the laparoscope, 15 were small in size, 4 were bulky, 3 were hypermic, and 10 had tubercles on their surface. Two uteri were fixed and adherent to the Pouch of Douglas. Intestinal adhesions were detected in 15 women and Pouch of Douglas adhesion in 7. Tubercles all over the intestines and Pouch of Douglas were present in 2 women and 1 respectively. Incidentally, both woman, women had tubercles on the tubes as well as hemorrhagic peritoneal fluid (Table II). Table

Table III.

Tubercles in different sites as seen through the

laparoscope. Organs

Uterus Tubes Ovary Pouchof Douglas

Pelvic findings

Laparoscopic findings

Normal

Abnormal

Normal

Abnormal

39 36 57 62

23 26 5 0

28 25 50 54

34 31 12 8

Int J Gynecol Obstet 32

Findings

n

%

Only tubes Tubes + uterus Tubes + ovary Tubes + uterus + Pouch of Douglas Tubes + uterus f intestines + Pouch of Douglas

3 7 2 1

4.8 11.3 3.2 1.6

2

3.2

Laparoscopic observations in pelvic tuberculosis

Table IV. tubercles. Duration

Duration

of tuberculosis

Presence

in relation

of tubercles

Of

Total no.

Table V. cal status.

Relationship

Radiological

status

n 10 2 3 15

% 31.4 18.1 15.8 24.2

(n) 32 11 19 62

III shows the presence of tubercles in different sites. In all, tubercles were present in 15 cases. Tubercles were more apparent in women with shorter duration of illness (Table IV) and were directly related to the extent of the pulmonary disease (Table V). However, these findings were not statistically significant (P> 0.05). The finding of tubercles was equally distributed in patients with different menstrual 18 cases of normal patterns. Among menstruation, 33 cases of secondary amenorrhea, and 11 cases of scanty periods, tubercles were present in 4,9, and 2 cases, respectively. A history of infertility was not always present prior to laparoscopy. Eleven patients were nulliparous, 15 were para 1, 15 para 2, 13 para 3, and 8 para 4 or more. After laparoscopy and the institution of medical therapy, one woman (22 years of age, para 2, with bilateral tubal adhesions) conceived after 4 months of treatment for tuberculosis. Voluntary termination of the pregnancy was performed in the first trimester because of the risk resulting from the medications. Followup of the remaining women is continuing. Although laparoscopy was performed in a general medical ward, no complications were observed. In a few cases, localized subcutaneous emphysema was visible in the immediate post-laparoscopic period. Simple analgesics relieved the postoperative pain. Endometrial tuberculosis was detected in 4

between

Presence

the tubercles

of tubercles

and radiologi-

Total no

Vo)

of cases

(months)

O-6 months 7-12 months > 12 months Total

to presence

131

Stage I Stage II Stage III Total

1(20)

5

4 (19) 10 (27.8) 15 (24.2)

21 36 62

cases by histopathological examination. In two of these, tubercles were also present in the tubes. One was associated with blocked tubes and the other with a bulky uterus. No endometrium was present in 60% of cases after thorough dilatation and curettage. This is likely due to hypoestrogenism. Conclusion Laparoscopic examination is a valuable diagnostic tool to detect the genital involvement in pulmonary tuberculosis. References Rejo Xpunnonen: Diagnostic gynaecologic laparoscopy. Asia Oceana J Obstet Gynol ZX(2): 199, 1985. Tripathy (Mrs) SN, Tripathy SN: Genital affection in pulmonary tuberculosis. Int J Obstet GynecolI8: 4, 1981. Tripathy (Mrs) SN, Tripathy SN: Ovarian functions in pulmonary tuberculosis, paper presented at 39th Conference on Tuberculosis and Chest Diseases, Cuttack, 1985. Tripathy (Mrs) SN, Tripathy SN: Ovarian functions after effective treatment of pulmonary tuberculosis, paper presented at the 40th National Conference on Tuberculosis and Chest Diseases, Shillong, India, 1985.

Address for reprints: S.N. Tripathy Department of Tubersulosis and Chest Diseases V.S.S. Medical College Hospital Burla Orissa, India

Clinical and Clinical Research