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The Relative Infrequency of Unsuspected Genital Tuberculosis as a Cause of Tubal Occlusion
The Relative Infrequency of Unsuspected Genital Tuberculosis as a Cause of Tubal Occlusion S. leon Israel, M.D., and David R. Meranze, M.D.
genital tuberculosis generally presents itself in the form of gross salpingitis, which later affords an apparent cause for the concomitant involuntary barrenness. There is, however, a type of genital tuberculosis which may exist without clinically detectable salpingitis. Such subclinical tuberculosis occurs as scattered tubercles in the endometrium of patients who, on examination, present no evidence of infection in the fallopian tubes or elsewhere. The patient with such occult endometrial tuberculosis is not ill, the lesion being recognized initially by histologic study of endometrial curettings. When found, it is presumed that occult tuberculous salpingitis is also present and the patient is generally regarded, despite her apparent well-being, as having tuberculosis. The pathogenesis of such quiescent tuberculous endometritis must involve some prior focus in most instances, reaching the genital organs by a hematogenous route. This viewpoint is supported by Halbrecht's experience in searching for the source of infection in 18 instances of unsuspected genital tuberculosis. 3 His careful history-taking elicited unmistakable evidence of previous tuberculosis in 7 of the 18 patients-2 had had youthful pleurisy, 2 had recovered from tuberculous peritonitis, and 3 bore scars of surgical forms of the disease (pararectal fistula, adenitis, and hip disease). Thus we may conclude that the endometrium mav harbor tuberculosis a ' long time. CLINICALLY RECOGNIZABLE
.'
From the Departments of Gynecology and Pathology, Mount Sinai Hospital, Philadelphia. 523
524
ISRAEL & MERANZE
[Fertility & Sterility
It is difficult because of its occult character to gauge the proper incidence of subclinical tuberculosis of the female genital organs. It occurs in patients who are apparently in good health. On examination, they are found to have neither a palpable nor a visible abnormality of the reproductive organs. Yet a diagnostic uterine curettage, performed because of a menstrual disorder or involuntary barrenness, reveals histologic evidence of tuberculous endometritis. The frequency with which tubercles are unexpectedly found in routinely recovered endometrial curettings is less than 1 per cent. 6 • 11 However, in women complaining of sterility, the incidence of such accidentally encountered endometrial tuberculosis is allegedly much higher, approximating 5 per cent in each of four well-known surveys conducted amongst barren women outside the United States. 4 • 7 • 10 • 11 Nevertheless, it has not been regarded as a frequent cause of sterility in this country. The experience here may be epitomized by that of Rubin who encountered but 4 unsuspected cases in his long series. 8 Bearing this impression, we were scmewhat taken aback, as were the editors of the Lancet, 1 to have Halbrecht conclude from an analysis of a group of involuntarily barren women in Tel Aviv that subclinical tuberculous endometritis is one of the cardinal causes of sterility in general and of tubal occlusion in particular. 3 Among 48 sterile women who had partly or completely occluded fallopian tubes, Halbrecht found 18 ( 37.5 per cent) -by means of diagnostic uterine curettage-to have unsuspected tuberculous endometritis. This is more than seven times the rate ( 5 per cent) reported for this disease in unselected sterile women. The incidence, 37.5 per cent, is also in striking contrast to that reported by Grant and Mackey who found a single instance of tuberculosis in a group of 247 sterile Australian women with tubal occlusion. 2 These facts seemed sufficiently contradictory to warrant a review of the pertinent clinical material at our disposal. This report comprises an analysis of the tubal and endometrial findings in all of the involuntarily barren women who had simultaneously undergone transuterine insufflation (Rubin test) and diagnostic uterine curettage at the Mount Sinai Hospital from 1935 through 1945. This selection of the sterility patients insured the fact that the tubal status and endometrial histology would be concurrent for each patient, enabling an evaluation of any possible relation between tubal occlusion and whatever incidence of tuberculous endometritis would be uncovered by the survey. During the ten-year period covered, there were 177 sterile women subjected, by 13 different physicians, to the dual procedure described.
~
Vol. 1, No. 6, 1950]
525
INFREQUENCY OF GENITAL TUBERCULOSIS
The state of tubal patency, as reflected by the transuterine insuffiation of carbon dioxide gas measured in mm. of mercury, of the women in this series is shown in Table 1. Of the 177 sterile women, 104 ( 58.8 per cent) had normal tubal patency, 40 ( 22.6 per cent) showed complete occlusion, and the remaining 33 ( 18.6 per cent) exhibited some degree of tubal stricture. Uterotubal spasm may be eliminated as having been a factor in the determination of these occluded tubes because general (inhalation or intravenous) anesthesia had been employed in each instance. It is interesting to note that the combined incidence of both partial and complete tubal occlusion ( 41.2 per cent) encountered in this group approximates the expected, generally reported frequency of this condition among sterile women. 5 • 8 • 9 TABlE 1.
Status of Fallopian Tubes as Determined by Transuterine Insufflation (Rubin Test) in 177 Sterile Women
Condition of Tubes
No. of Patients
Percentage
Open freely Occluded Open but strictured
104 40 33
58.8 22.6 18.6
Endometrium was recovered by diagnostic curettage pedormed immediately following the Rubin test in 172 of the 177 sterile women; in the remaining 5, adequate tissue was not obtained. Since a high degree of suspicion in the mind of the pathologist is an aid in the recognition of any sought after process in routine curettings, it was appreciated that tubercles may have been overlooked in the original study of each endometrium. For that reason, the entire collection of histologic preparations was reviewed by one of us ( Meranze). In conformity with the original reports obtained from the records of the Department of Pathology, no instance of tuberculous endometritis was found. TABLE 2.
Pattern of Endometrium Obtained by Curettage in 172 Sterile Women
Endometrial Pattern
Secretory Proliferative Hypoplastic Hyperplastic Mixed
No. of Patients
Percentage
74
43.1 22.1 19.2 10.4
38 33 18 9
5.2
No especial significance may be attached to the types of endometrium found because the material was obtained during all phases of the menstrual cycle. The histologic findings have been listed in Table 2, however, to express
526
ISRAEL & MERANZE
[Fertility & Sterility
the fact that the preparations were of sufficient adequacy to be thoroughly reviewed.
SUMMARY AND CONCLUSIONS It is believed that the endometrium may harbor occult tuberculosis for a long time. Such subclinical tuberculosis has been reported as having an average incidence of less than 1 per cent but, in some parts of the world, attaining a rate of 5 per cent in involuntarily barren women. It has not been considered so frequent in the United States. It was, therefore, something of a shock to learn of the unexpectedly high ( 37.5 per cent) incidence of unsuspected endometrial tuberculosis encountered by Halbrecht among sterile women showing tubal occlusion in Israel. It was believed that study of the endometrium obtained by curettage from sterile women at the very time the status of their fallopian tubes was established would be of value. This prompted a review of the endometrial findings in 177 involuntarily barren women who had undergone transuterine insuffiation (Rubin test) and uterine curettage at the same time. Of the 177 women, 104 ( 58.8 per cent) had normal tubal patency, 40 ( 22.6 per cent) showed complete occlusion, and 33 ( 18.6 per cent) exhibited some degree of tubal stricture. None of the endometriums revealed the presence of tuberculosis. It is concluded that unsuspected genital tuberculosis is not a universally frequent cause of tubal occlusion. The suggestion is ventured that the high incidence found in the Israeli series may be historically conditioned. Indeed, the relation of unsuspected genital tuberculosis and tubal occlusion may well vary with the geographic, the endemic, incidence of tuberculosis. REFERENCES I. Annotation: Lancet 251:354, 1946. 2. Grant, A., and Mackey, R.: M. J. Australia 2:199, 1948. 3. Halbrecht, I.: Lancet 250:235, 1946. 4. Halbrecht, I.: Schweiz. med. Wchnschr. 76:708 (Aug. 3), 1946. 5. Mazer, C., and Israel, S. L.: Diagnosis and Treatment of Menstrual Disorders and Sterility. (Ed. 2.) New York, Paul B. Roeber, Inc., 1946. 6. Novak, E.: Gynecological and Obstetrical Pathology. Philadelphia, W. B. Saunders Co., 1947. 7. Rabau, E.: Harefuah, pp. 1-12 (Sept.), 1945. 8. Rubin, I. C.: Uterotubal Insutfiation. St. Louis, C. V. Mosby, 1947. 9. Siegler, S. L.: Fertility in Women. Philadelphia, J. B. Lippincott Co., 1944. 10. Sharman, A.: J. Obst. & Gynaec., Brit. Emp. 51:85, 1944. 11. Sutherland, A. M.: J. Obst. & Gynaec., Brit. Emp. 50:161, 1943.
genital tuberculosis generally presents itself in the form of gross salpingitis, which later affords an apparent cause for the concomitant involuntary barrenness. There is, however, a type of genital tuberculosis which may exist without clinically detectable salpingitis. Such subclinical tuberculosis occurs as scattered tubercles in the endometrium of patients who, on examination, present no evidence of infection in the fallopian tubes or elsewhere. The patient with such occult endometrial tuberculosis is not ill, the lesion being recognized initially by histologic study of endometrial curettings. When found, it is presumed that occult tuberculous salpingitis is also present and the patient is generally regarded, despite her apparent well-being, as having tuberculosis. The pathogenesis of such quiescent tuberculous endometritis must involve some prior focus in most instances, reaching the genital organs by a hematogenous route. This viewpoint is supported by Halbrecht's experience in searching for the source of infection in 18 instances of unsuspected genital tuberculosis. 3 His careful history-taking elicited unmistakable evidence of previous tuberculosis in 7 of the 18 patients-2 had had youthful pleurisy, 2 had recovered from tuberculous peritonitis, and 3 bore scars of surgical forms of the disease (pararectal fistula, adenitis, and hip disease). Thus we may conclude that the endometrium mav harbor tuberculosis a ' long time. CLINICALLY RECOGNIZABLE
.'
From the Departments of Gynecology and Pathology, Mount Sinai Hospital, Philadelphia. 523
524
ISRAEL & MERANZE
[Fertility & Sterility
It is difficult because of its occult character to gauge the proper incidence of subclinical tuberculosis of the female genital organs. It occurs in patients who are apparently in good health. On examination, they are found to have neither a palpable nor a visible abnormality of the reproductive organs. Yet a diagnostic uterine curettage, performed because of a menstrual disorder or involuntary barrenness, reveals histologic evidence of tuberculous endometritis. The frequency with which tubercles are unexpectedly found in routinely recovered endometrial curettings is less than 1 per cent. 6 • 11 However, in women complaining of sterility, the incidence of such accidentally encountered endometrial tuberculosis is allegedly much higher, approximating 5 per cent in each of four well-known surveys conducted amongst barren women outside the United States. 4 • 7 • 10 • 11 Nevertheless, it has not been regarded as a frequent cause of sterility in this country. The experience here may be epitomized by that of Rubin who encountered but 4 unsuspected cases in his long series. 8 Bearing this impression, we were scmewhat taken aback, as were the editors of the Lancet, 1 to have Halbrecht conclude from an analysis of a group of involuntarily barren women in Tel Aviv that subclinical tuberculous endometritis is one of the cardinal causes of sterility in general and of tubal occlusion in particular. 3 Among 48 sterile women who had partly or completely occluded fallopian tubes, Halbrecht found 18 ( 37.5 per cent) -by means of diagnostic uterine curettage-to have unsuspected tuberculous endometritis. This is more than seven times the rate ( 5 per cent) reported for this disease in unselected sterile women. The incidence, 37.5 per cent, is also in striking contrast to that reported by Grant and Mackey who found a single instance of tuberculosis in a group of 247 sterile Australian women with tubal occlusion. 2 These facts seemed sufficiently contradictory to warrant a review of the pertinent clinical material at our disposal. This report comprises an analysis of the tubal and endometrial findings in all of the involuntarily barren women who had simultaneously undergone transuterine insufflation (Rubin test) and diagnostic uterine curettage at the Mount Sinai Hospital from 1935 through 1945. This selection of the sterility patients insured the fact that the tubal status and endometrial histology would be concurrent for each patient, enabling an evaluation of any possible relation between tubal occlusion and whatever incidence of tuberculous endometritis would be uncovered by the survey. During the ten-year period covered, there were 177 sterile women subjected, by 13 different physicians, to the dual procedure described.
~
Vol. 1, No. 6, 1950]
525
INFREQUENCY OF GENITAL TUBERCULOSIS
The state of tubal patency, as reflected by the transuterine insuffiation of carbon dioxide gas measured in mm. of mercury, of the women in this series is shown in Table 1. Of the 177 sterile women, 104 ( 58.8 per cent) had normal tubal patency, 40 ( 22.6 per cent) showed complete occlusion, and the remaining 33 ( 18.6 per cent) exhibited some degree of tubal stricture. Uterotubal spasm may be eliminated as having been a factor in the determination of these occluded tubes because general (inhalation or intravenous) anesthesia had been employed in each instance. It is interesting to note that the combined incidence of both partial and complete tubal occlusion ( 41.2 per cent) encountered in this group approximates the expected, generally reported frequency of this condition among sterile women. 5 • 8 • 9 TABlE 1.
Status of Fallopian Tubes as Determined by Transuterine Insufflation (Rubin Test) in 177 Sterile Women
Condition of Tubes
No. of Patients
Percentage
Open freely Occluded Open but strictured
104 40 33
58.8 22.6 18.6
Endometrium was recovered by diagnostic curettage pedormed immediately following the Rubin test in 172 of the 177 sterile women; in the remaining 5, adequate tissue was not obtained. Since a high degree of suspicion in the mind of the pathologist is an aid in the recognition of any sought after process in routine curettings, it was appreciated that tubercles may have been overlooked in the original study of each endometrium. For that reason, the entire collection of histologic preparations was reviewed by one of us ( Meranze). In conformity with the original reports obtained from the records of the Department of Pathology, no instance of tuberculous endometritis was found. TABLE 2.
Pattern of Endometrium Obtained by Curettage in 172 Sterile Women
Endometrial Pattern
Secretory Proliferative Hypoplastic Hyperplastic Mixed
No. of Patients
Percentage
74
43.1 22.1 19.2 10.4
38 33 18 9
5.2
No especial significance may be attached to the types of endometrium found because the material was obtained during all phases of the menstrual cycle. The histologic findings have been listed in Table 2, however, to express
526
ISRAEL & MERANZE
[Fertility & Sterility
the fact that the preparations were of sufficient adequacy to be thoroughly reviewed.
SUMMARY AND CONCLUSIONS It is believed that the endometrium may harbor occult tuberculosis for a long time. Such subclinical tuberculosis has been reported as having an average incidence of less than 1 per cent but, in some parts of the world, attaining a rate of 5 per cent in involuntarily barren women. It has not been considered so frequent in the United States. It was, therefore, something of a shock to learn of the unexpectedly high ( 37.5 per cent) incidence of unsuspected endometrial tuberculosis encountered by Halbrecht among sterile women showing tubal occlusion in Israel. It was believed that study of the endometrium obtained by curettage from sterile women at the very time the status of their fallopian tubes was established would be of value. This prompted a review of the endometrial findings in 177 involuntarily barren women who had undergone transuterine insuffiation (Rubin test) and uterine curettage at the same time. Of the 177 women, 104 ( 58.8 per cent) had normal tubal patency, 40 ( 22.6 per cent) showed complete occlusion, and 33 ( 18.6 per cent) exhibited some degree of tubal stricture. None of the endometriums revealed the presence of tuberculosis. It is concluded that unsuspected genital tuberculosis is not a universally frequent cause of tubal occlusion. The suggestion is ventured that the high incidence found in the Israeli series may be historically conditioned. Indeed, the relation of unsuspected genital tuberculosis and tubal occlusion may well vary with the geographic, the endemic, incidence of tuberculosis. REFERENCES I. Annotation: Lancet 251:354, 1946. 2. Grant, A., and Mackey, R.: M. J. Australia 2:199, 1948. 3. Halbrecht, I.: Lancet 250:235, 1946. 4. Halbrecht, I.: Schweiz. med. Wchnschr. 76:708 (Aug. 3), 1946. 5. Mazer, C., and Israel, S. L.: Diagnosis and Treatment of Menstrual Disorders and Sterility. (Ed. 2.) New York, Paul B. Roeber, Inc., 1946. 6. Novak, E.: Gynecological and Obstetrical Pathology. Philadelphia, W. B. Saunders Co., 1947. 7. Rabau, E.: Harefuah, pp. 1-12 (Sept.), 1945. 8. Rubin, I. C.: Uterotubal Insutfiation. St. Louis, C. V. Mosby, 1947. 9. Siegler, S. L.: Fertility in Women. Philadelphia, J. B. Lippincott Co., 1944. 10. Sharman, A.: J. Obst. & Gynaec., Brit. Emp. 51:85, 1944. 11. Sutherland, A. M.: J. Obst. & Gynaec., Brit. Emp. 50:161, 1943.