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Pelvic Tuberculosis
Pelvic Tuberculosis Its Relationship to Sterility, Present and Future
Donald W. deCarie, M.D.
OF
ALL THE disease entities that affect the organs of the pelvis, especially those of reproduction, tuberculosis is probably the most serious. For a clear understanding of the depredations of this disease and its profound effect on fertility, it is necessary only to review anyone of the standard textbooks on gynecology. In discussing its pathology in his most recent edition of Operative Gynecology, Te Linde gives a detailed description of the terrific havoc caused by pelvic tuberculosis. It is the intent of this report to consider the effects of this disease upon fertility and pregnancy up to the present time. The results of various forms of treatment during this time will be evaluated, along with those of 4 patients of the author. With this as a basis, an attempt will then be made to prognosticate the most advantageous methods of the future handling of patients with pelvic tuberculosis, in the future, especially in its relation to fertility.
GYNECOLOGIC EFFECTS
It is indeed unfortunate that the very process which activates healing in tuberculosis has certain untoward sequelae. In tuberculosis of the pelvis, these processes have a very detrimental effect upon future pregnancies. Healing of the tubes in this disease is through a process of fibrous infiltration into the walls of these structures, according to Te Linde and others. This primarily interferes with a normal function of these organs-tubal peristalsis. It further results in multiple strictures, both inside and outside the tubes. These, in turn, may cause either distention and hydrosalpinx or Presented at the 1954 Meeting of the \Vestern Branch of the American Society for the Study of Sterility at Palm Springs, Calif., November 12-14, 1954. 534
Vol. 6. No.6. 1955
"
PELVIC TUBERCULOSIS
535
further shrinkage with distortion and obliteration of the lumen. It should also be noted that this same healing process can seriously involve the ovary. Thus, there may be enough disruption of normal ovarian function to prevent satisfactory ovulation. As a result, up to the present time, subsequent pregnancies are comparatively rare in the presence of pelvic tuberculosis.
PREGNANCY
•
.....
In his discussion of the association of pregnancy with this disease, Donaldson has found that the incidence is difficult to assess with any degree of accurac.y. He believes that the literature is misleading. This, according to him, leaves the impression that pelvic tuberculosis is more common than is usually assumed. Further, it has been his experience that inability on the part of the physician to recognize unsuspected pelvic tuberculosis in an otherwise healthy woman has been another reason for this difficulty. As a result, he has found that pregnancy has rarely been reported in the presence of a proved case of this disease. In his experience, this is true of ectopic as well as intrauterine gestation. Of the former, he cites but 9 such cases from the literature. Bland, however, in reporting a case of ectopic pregnancy in which pelvic tuberculosis was found at surgery, included 32 other such cases collected from the literature up to 1940. Since then, as reported by Donaldson, cases of a similar nature have been described by Hicks; Shannon and Heller; Mann and Meranze; and by Geisendorf in 1951. Pink, in 1944, commented in detail on the case of a patient in whom 2 such pregnancies were found in the presence of associated genital tuberculosis within a period of 2 years. 3 From a further review of the literature, the occurrence of a normal intrauterine pregnancy would seem equally rare in the presence of pelvic tuberculosis. The fact, however, that it does occur was discussed and actually shown at autopsy by Cooper; Vineburg; and Thorn, Schmorl, and Kockel during the last century and more recently by Wiseman and Retan, and Puxedder.3 As opposed to this group, however, case histories of patients in whom intrauterine pregnancie!': Gccurred following conservative surgery in the presence of pelvic tuberculosis have appeared from time to time in the literature. Fruhinsholz and Feuillade,3 as early as 1924, described one of the first of such patients. This was followed by similar case reports by other authors such as Roulland3 and Donaldson.
536
deCARLE
Fertility & Sterility
THERAPY
However, in spite of the marked advances made by this form of treatment, pelvic surgery in the presence of tuberculosis of this area has in the past carried a 20 per cent mortality, according to Brown, Gilbert and Te Linde. It was not until the introduction of streptomycin that our modern treatment of tuberculosis in general and pelvic tuberculosis in particular began. Here, for the first time, medical treatment with a specific agent aimed at the acid-fast tubercle bacilli was introduced. Although bed rest and sanitarium care still form the bases of treatment for this disease, nevertheless the introduction of this antibiotic markedly changed our attitude toward tuberculosis in general. As an example, interruption of a pregnancy associated with this disease, even though it happens to be an active pulmonary lesion, is no longer considered necessary to save a patient's life. Along with para-amino salicylic acid, which delays the development of resistance to streptomycin on the part of the tubercle bacillus, 4 this antibiotic is widely used in the treatment of pelvic tuberculosis. Although this combination of drugs has not replaced surgery in the treatment of pelvic involvement, it has made such treatment safer and far more effective. It has markedly lowered the mortality of pelvic surgery in its presence. Sired, Falls, and Zummo used these drugs preoperatively and in the postoperative period in some 16 such patients with the loss of only 1. Brown, Gilbert, and Te Linde had similarly good results. Greenhill quotes Ryden, who found 9 out of 13 patients cured at surgery following the use of these drugs preoperatively. In 1951, the first reported case of a patient with pelvic tuberculosis treated exclUSively with streptomycin and PAS was referred to by Ewart Williams. In the author's opinion, this marks the basis for future treatment of pelvic tuberculosis. Along with some of the newer drugs (such as Rimifon, isonicotinic acid, and isoniazid of the so-called LN.H. group) which have been found to increase still further the tissue permeability and effectiveness of streptomycin, streptomycin and PAS could conceivably replace surgery to an increasingly marked degree. PERSONAL EXPERIENCE All forms of active treatment of patients with tuberculosis notwithstanding, it should never be forgotten that preventive medicine is and will continue to be the chief agent in combating this disease and any other of its
\1'.
....
..
,
Vol. 6, No.6, 1955
..
~
PELVIC TUBERCULOSIS
537
kind. Thanks to the various national and local agencies, gynecologists see comparatively few patients with tuberculosis of the pelvic organs. It is for this reason primarily that there is a paucity of material. Conclusions must therefore be made from comparatively small, isolated groups of such case reports. Since 1950, there have been but 11 patients who have come to my attention in private practice in whom a diagnosis of pelvic tuberculosis was established. Of these, 2 had positive endometrial biopsies, 1 showed pathognomonic tubercles among the curettings and 1 was diagnosed by the process of elimination. In the remaining 7, tubercles of the pelvic organs were found at surgery. Only 4 of these 11 patients sought medical help because of inability to conceive. The case reports are presented because they are typical examples of the sterility problems associated with pelvic tuberculosis at the present time. Unfortunately, the last case may not be included as that of a patient who was successfully treated medically. Pelvic tuberculosis was never positively established as the underlying cause of her sterility.
Case 1 ~
J
This patient was treated intermittently for sterility over a period of some 15 years before repeated endometrial biopsies showed tubercles. A previous biopsy taken elsewhere had been diagnosed as a possible corpus carcinoma. This patient was clinically cured following almost 1 year's treatment with bed rest, streptomycin, and PAS. She is now approaching the menopause, and it is therefore doubtful that she will ever conceive.
Case 2 Because of this patient's inability to conceive, a myomectomy was advised and a large intramural fibroma was removed from the anterior uterine wall, at which time tubercles covering the pelvic organs were discovered. Following 9 months of sanitarium treatment along with streptomycin and PAS, the patient was clinically cured. Repeated hysterosalpingography, however, showed both tubes to be dilated, typical of hydrosalpinx resulting from the healing process of this disease. Because of the apparent loss of all tubal peristalsis, surgery seemed inadvisable because of the poor prognosis, although it was considered.
Case 3 The patient was a 21-year-old nullipara who had been previously confined to a sanitarium with pulmonary tuberculosis. Because of lower abdominal pain, irregular menses, and progressive dysmenorrhea, she was seen by a gynecologist.
538
deCARLE
Fertility & Sterility
Pelvic surgery was advised for an adnexal mass. Because of her desire to have children, a second opinion in regard to her pelvic condition was requested, at which time I saw her. In spite of medical treatment and conservative surgeryunilateral salpingo-oophorectomy-this patient has failed to conceive.
Case 4 This patient reported for investigation within a year after marriage because of her inability to become pregnant. Because her pelvis gave the impression of having some inHammatory process present and because she at one time had had a questionable pulmonary infection, a diagnosis of probable pelviC tuberculosis was made by the process of elimination. After a course of streptomycin and PAS, the patient was entirely free from any subjective or local symptoms. This treatment was given in a sanitarium under the supervision of a specialist in the field of tuberculosis. Unfortunately, this patient was compelled shortly thereafter to move elsewhere. A report has been received, but unfortunately not substantiated, that she did eventually conceive but subsequently miscarried.
CONCLUSIONS If one may be allowed the privilege of prognosticating on the basis of information gleaned from the past, it would seem that some rules in the handling of pelvic tuberculosis could be made. This not only refers to this entity in general but particularly to its relationship to infertility. First, it must be a foregone conclusion that with continued improvement in public health methods in the field of preventive medicine, there will be a diminishing number of patients seen with pelvic tuberculosis, especially in this country. Secondly, although there are many gynecologists who are not ready to accede to the concept of medical treatment alone in cases of this kind, the trend, in my opinion, will be definitely away from surgery. With the drugs already established, especially streptomycin in its various forms in combination with PAS, the trend should be toward medical treatment exclusively. This belief is founded on the continued introduction of newer drugs. The so-called I.N.H. group, of which isoniazid is an example, have already shown a definite advantage-increased effectiveness of streptomycin. Their one advantage is a greater ability to penetrate the caseous masses, with less distortion in the healing. This is a quality absolutely necessary in tubal and ovarian tuberculosis, if futur~ pregnancies are to occur. Again, if more pregnancies are to be obtained, some method other than that of endometrial biopsy, dilatation and curettage, and/or the process of
...
Vol. 6, No.6, 1955
PELVIC TUBERCULOSIS
539
elimination must be found for earlier and more accurate diagnosis. We hope that as time goes on this will result in the establishment of treatment sufficiently early to forestall the destructive effects following the healing processes of pelvic tuberculosis. 2000 Van Ness Ave. San Francisco, Calif. REFERENCES
,.
1. 2. 3. 4.
5. 6.
7. 8.
BLAND, P. B. Am.]. Obst. & Gynec. 40:271, 1940. BROWN, A. B., GILBERT, R. C., and TE LINDE, R. W. Obst. & Gynec. 2:476, 1953. DONALDSON, 1. A. Brit. M. ]. 2:128, 1952. DOUGLASS, B. E. Proc. Staff Meet., Mayo GUn. 28:381, 1953. GREENHILL, J. P. The 1950 Year Book of Obstetrics and Gynecology. Chicago, IlL, Yr. Bk. Pub., 1951, p. 420. SIRED, R., FALLS, F. R., and ZUMMO, B. P. Am.]. Obst. & Gynec. 66:823, 1953. TE LINDE, R. W. Operative Gynecology. Philadelphia, Lippincott. WILLIAMS, E. Brit. M. J. 2:52, 1951.
Grants-in-A.id The Ortho Pharmaceutical Corporation is providing two $500.00 grantsin-aid for 1956. Applications for these grants should be sent to Dr. Robert Greenblatt, Chairman of the Research Correlating Committee of the American Society for the Study of Sterility, at the Medical College of Georgia, Augusta, Ga. A brief outline of the research project for which the grant will be used should accompany the application.
Donald W. deCarie, M.D.
OF
ALL THE disease entities that affect the organs of the pelvis, especially those of reproduction, tuberculosis is probably the most serious. For a clear understanding of the depredations of this disease and its profound effect on fertility, it is necessary only to review anyone of the standard textbooks on gynecology. In discussing its pathology in his most recent edition of Operative Gynecology, Te Linde gives a detailed description of the terrific havoc caused by pelvic tuberculosis. It is the intent of this report to consider the effects of this disease upon fertility and pregnancy up to the present time. The results of various forms of treatment during this time will be evaluated, along with those of 4 patients of the author. With this as a basis, an attempt will then be made to prognosticate the most advantageous methods of the future handling of patients with pelvic tuberculosis, in the future, especially in its relation to fertility.
GYNECOLOGIC EFFECTS
It is indeed unfortunate that the very process which activates healing in tuberculosis has certain untoward sequelae. In tuberculosis of the pelvis, these processes have a very detrimental effect upon future pregnancies. Healing of the tubes in this disease is through a process of fibrous infiltration into the walls of these structures, according to Te Linde and others. This primarily interferes with a normal function of these organs-tubal peristalsis. It further results in multiple strictures, both inside and outside the tubes. These, in turn, may cause either distention and hydrosalpinx or Presented at the 1954 Meeting of the \Vestern Branch of the American Society for the Study of Sterility at Palm Springs, Calif., November 12-14, 1954. 534
Vol. 6. No.6. 1955
"
PELVIC TUBERCULOSIS
535
further shrinkage with distortion and obliteration of the lumen. It should also be noted that this same healing process can seriously involve the ovary. Thus, there may be enough disruption of normal ovarian function to prevent satisfactory ovulation. As a result, up to the present time, subsequent pregnancies are comparatively rare in the presence of pelvic tuberculosis.
PREGNANCY
•
.....
In his discussion of the association of pregnancy with this disease, Donaldson has found that the incidence is difficult to assess with any degree of accurac.y. He believes that the literature is misleading. This, according to him, leaves the impression that pelvic tuberculosis is more common than is usually assumed. Further, it has been his experience that inability on the part of the physician to recognize unsuspected pelvic tuberculosis in an otherwise healthy woman has been another reason for this difficulty. As a result, he has found that pregnancy has rarely been reported in the presence of a proved case of this disease. In his experience, this is true of ectopic as well as intrauterine gestation. Of the former, he cites but 9 such cases from the literature. Bland, however, in reporting a case of ectopic pregnancy in which pelvic tuberculosis was found at surgery, included 32 other such cases collected from the literature up to 1940. Since then, as reported by Donaldson, cases of a similar nature have been described by Hicks; Shannon and Heller; Mann and Meranze; and by Geisendorf in 1951. Pink, in 1944, commented in detail on the case of a patient in whom 2 such pregnancies were found in the presence of associated genital tuberculosis within a period of 2 years. 3 From a further review of the literature, the occurrence of a normal intrauterine pregnancy would seem equally rare in the presence of pelvic tuberculosis. The fact, however, that it does occur was discussed and actually shown at autopsy by Cooper; Vineburg; and Thorn, Schmorl, and Kockel during the last century and more recently by Wiseman and Retan, and Puxedder.3 As opposed to this group, however, case histories of patients in whom intrauterine pregnancie!': Gccurred following conservative surgery in the presence of pelvic tuberculosis have appeared from time to time in the literature. Fruhinsholz and Feuillade,3 as early as 1924, described one of the first of such patients. This was followed by similar case reports by other authors such as Roulland3 and Donaldson.
536
deCARLE
Fertility & Sterility
THERAPY
However, in spite of the marked advances made by this form of treatment, pelvic surgery in the presence of tuberculosis of this area has in the past carried a 20 per cent mortality, according to Brown, Gilbert and Te Linde. It was not until the introduction of streptomycin that our modern treatment of tuberculosis in general and pelvic tuberculosis in particular began. Here, for the first time, medical treatment with a specific agent aimed at the acid-fast tubercle bacilli was introduced. Although bed rest and sanitarium care still form the bases of treatment for this disease, nevertheless the introduction of this antibiotic markedly changed our attitude toward tuberculosis in general. As an example, interruption of a pregnancy associated with this disease, even though it happens to be an active pulmonary lesion, is no longer considered necessary to save a patient's life. Along with para-amino salicylic acid, which delays the development of resistance to streptomycin on the part of the tubercle bacillus, 4 this antibiotic is widely used in the treatment of pelvic tuberculosis. Although this combination of drugs has not replaced surgery in the treatment of pelvic involvement, it has made such treatment safer and far more effective. It has markedly lowered the mortality of pelvic surgery in its presence. Sired, Falls, and Zummo used these drugs preoperatively and in the postoperative period in some 16 such patients with the loss of only 1. Brown, Gilbert, and Te Linde had similarly good results. Greenhill quotes Ryden, who found 9 out of 13 patients cured at surgery following the use of these drugs preoperatively. In 1951, the first reported case of a patient with pelvic tuberculosis treated exclUSively with streptomycin and PAS was referred to by Ewart Williams. In the author's opinion, this marks the basis for future treatment of pelvic tuberculosis. Along with some of the newer drugs (such as Rimifon, isonicotinic acid, and isoniazid of the so-called LN.H. group) which have been found to increase still further the tissue permeability and effectiveness of streptomycin, streptomycin and PAS could conceivably replace surgery to an increasingly marked degree. PERSONAL EXPERIENCE All forms of active treatment of patients with tuberculosis notwithstanding, it should never be forgotten that preventive medicine is and will continue to be the chief agent in combating this disease and any other of its
\1'.
....
..
,
Vol. 6, No.6, 1955
..
~
PELVIC TUBERCULOSIS
537
kind. Thanks to the various national and local agencies, gynecologists see comparatively few patients with tuberculosis of the pelvic organs. It is for this reason primarily that there is a paucity of material. Conclusions must therefore be made from comparatively small, isolated groups of such case reports. Since 1950, there have been but 11 patients who have come to my attention in private practice in whom a diagnosis of pelvic tuberculosis was established. Of these, 2 had positive endometrial biopsies, 1 showed pathognomonic tubercles among the curettings and 1 was diagnosed by the process of elimination. In the remaining 7, tubercles of the pelvic organs were found at surgery. Only 4 of these 11 patients sought medical help because of inability to conceive. The case reports are presented because they are typical examples of the sterility problems associated with pelvic tuberculosis at the present time. Unfortunately, the last case may not be included as that of a patient who was successfully treated medically. Pelvic tuberculosis was never positively established as the underlying cause of her sterility.
Case 1 ~
J
This patient was treated intermittently for sterility over a period of some 15 years before repeated endometrial biopsies showed tubercles. A previous biopsy taken elsewhere had been diagnosed as a possible corpus carcinoma. This patient was clinically cured following almost 1 year's treatment with bed rest, streptomycin, and PAS. She is now approaching the menopause, and it is therefore doubtful that she will ever conceive.
Case 2 Because of this patient's inability to conceive, a myomectomy was advised and a large intramural fibroma was removed from the anterior uterine wall, at which time tubercles covering the pelvic organs were discovered. Following 9 months of sanitarium treatment along with streptomycin and PAS, the patient was clinically cured. Repeated hysterosalpingography, however, showed both tubes to be dilated, typical of hydrosalpinx resulting from the healing process of this disease. Because of the apparent loss of all tubal peristalsis, surgery seemed inadvisable because of the poor prognosis, although it was considered.
Case 3 The patient was a 21-year-old nullipara who had been previously confined to a sanitarium with pulmonary tuberculosis. Because of lower abdominal pain, irregular menses, and progressive dysmenorrhea, she was seen by a gynecologist.
538
deCARLE
Fertility & Sterility
Pelvic surgery was advised for an adnexal mass. Because of her desire to have children, a second opinion in regard to her pelvic condition was requested, at which time I saw her. In spite of medical treatment and conservative surgeryunilateral salpingo-oophorectomy-this patient has failed to conceive.
Case 4 This patient reported for investigation within a year after marriage because of her inability to become pregnant. Because her pelvis gave the impression of having some inHammatory process present and because she at one time had had a questionable pulmonary infection, a diagnosis of probable pelviC tuberculosis was made by the process of elimination. After a course of streptomycin and PAS, the patient was entirely free from any subjective or local symptoms. This treatment was given in a sanitarium under the supervision of a specialist in the field of tuberculosis. Unfortunately, this patient was compelled shortly thereafter to move elsewhere. A report has been received, but unfortunately not substantiated, that she did eventually conceive but subsequently miscarried.
CONCLUSIONS If one may be allowed the privilege of prognosticating on the basis of information gleaned from the past, it would seem that some rules in the handling of pelvic tuberculosis could be made. This not only refers to this entity in general but particularly to its relationship to infertility. First, it must be a foregone conclusion that with continued improvement in public health methods in the field of preventive medicine, there will be a diminishing number of patients seen with pelvic tuberculosis, especially in this country. Secondly, although there are many gynecologists who are not ready to accede to the concept of medical treatment alone in cases of this kind, the trend, in my opinion, will be definitely away from surgery. With the drugs already established, especially streptomycin in its various forms in combination with PAS, the trend should be toward medical treatment exclusively. This belief is founded on the continued introduction of newer drugs. The so-called I.N.H. group, of which isoniazid is an example, have already shown a definite advantage-increased effectiveness of streptomycin. Their one advantage is a greater ability to penetrate the caseous masses, with less distortion in the healing. This is a quality absolutely necessary in tubal and ovarian tuberculosis, if futur~ pregnancies are to occur. Again, if more pregnancies are to be obtained, some method other than that of endometrial biopsy, dilatation and curettage, and/or the process of
...
Vol. 6, No.6, 1955
PELVIC TUBERCULOSIS
539
elimination must be found for earlier and more accurate diagnosis. We hope that as time goes on this will result in the establishment of treatment sufficiently early to forestall the destructive effects following the healing processes of pelvic tuberculosis. 2000 Van Ness Ave. San Francisco, Calif. REFERENCES
,.
1. 2. 3. 4.
5. 6.
7. 8.
BLAND, P. B. Am.]. Obst. & Gynec. 40:271, 1940. BROWN, A. B., GILBERT, R. C., and TE LINDE, R. W. Obst. & Gynec. 2:476, 1953. DONALDSON, 1. A. Brit. M. ]. 2:128, 1952. DOUGLASS, B. E. Proc. Staff Meet., Mayo GUn. 28:381, 1953. GREENHILL, J. P. The 1950 Year Book of Obstetrics and Gynecology. Chicago, IlL, Yr. Bk. Pub., 1951, p. 420. SIRED, R., FALLS, F. R., and ZUMMO, B. P. Am.]. Obst. & Gynec. 66:823, 1953. TE LINDE, R. W. Operative Gynecology. Philadelphia, Lippincott. WILLIAMS, E. Brit. M. J. 2:52, 1951.
Grants-in-A.id The Ortho Pharmaceutical Corporation is providing two $500.00 grantsin-aid for 1956. Applications for these grants should be sent to Dr. Robert Greenblatt, Chairman of the Research Correlating Committee of the American Society for the Study of Sterility, at the Medical College of Georgia, Augusta, Ga. A brief outline of the research project for which the grant will be used should accompany the application.