OVERVIEW

What is pelvic peritoneal tuberculosis?

Pelvic peritoneal tuberculosis is an inflammation of the entire pelvic peritoneum caused by Mycobacterium tuberculosis invading the human body.

Patients often seek medical attention due to abdominal pain, pelvic effusion, menstrual abnormalities, infertility, and systemic symptoms. Physical examination may reveal abdominal tenderness, painless pelvic or abdominal masses, a smaller uterus with limited mobility, etc.

Pelvic peritoneal tuberculosis mostly occurs in women of childbearing age between 20 and 40 years old, but can also be seen in postmenopausal women. Most patients have a history of tuberculosis, and about 20% have a family history of tuberculosis during childhood.

SYMPTOMS

What are the manifestations of pelvic peritoneal tuberculosis?

Due to the extensive involvement of pelvic peritoneal tuberculosis lesions, often affecting multiple areas, the clinical presentation is complex and varied, lacking specificity.

Common symptoms include abdominal pain, bloating, infertility, menstrual abnormalities, and systemic toxic symptoms such as fever, night sweats, fatigue, weight loss, and decreased appetite. The abdomen may feel doughy upon palpation (like kneading dough).

CAUSES

What are the causes of pelvic peritoneal tuberculosis?

Pelvic peritoneal tuberculosis often occurs secondary to pulmonary tuberculosis, intestinal tuberculosis, peritoneal tuberculosis, etc.

Because the reproductive system of women of childbearing age is functionally active and has rich blood supply, Mycobacterium tuberculosis can easily spread to the pelvis through the bloodstream, causing inflammatory lesions in the reproductive organs (fallopian tubes, uterus, ovaries) as well as the pelvic peritoneum and connective tissues around the uterus.

Pelvic peritoneal tuberculosis progresses slowly, and the primary lesion (such as pulmonary tuberculosis, intestinal tuberculosis, peritoneal tuberculosis, etc.) may remain asymptomatic for many years or even heal completely.

DIAGNOSIS

How is Pelvic Peritoneal Tuberculosis Diagnosed?

Doctors primarily diagnose pelvic peritoneal tuberculosis through the following steps.

• Medical History Inquiry: If a patient presents with infertility, menstrual abnormalities, pelvic effusion, accompanied by low-grade fever, night sweats, fatigue, weight loss, or has a history of chronic pelvic inflammation that is difficult to cure, or a history of tuberculosis or contact with tuberculosis patients, the possibility of genital tuberculosis and pelvic peritoneal tuberculosis should be considered.

• Physical Examination: Abdominal examination may reveal abdominal tenderness or signs of ascites, as well as painless pelvic or abdominal masses with unclear boundaries, poor mobility, mixed cystic-solid consistency, and a relatively high position. The uterus may appear smaller with limited mobility.

• Endoscopic Examination: Includes laparoscopy and hysteroscopy. Laparoscopy allows direct observation of the pelvic and abdominal cavity and biopsy of suspicious lesions. Patients with pelvic peritoneal tuberculosis may exhibit ascites, miliary nodules on the pelvic peritoneum and bilateral fallopian tubes, and extensive pelvic adhesions. For patients with menstrual abnormalities or infertility, diagnostic curettage should be performed for pathological and bacteriological examination. Hysteroscopy may further reveal possible endometrial tuberculosis infection.

• Imaging Examinations:

  • Routine chest and abdominal X-rays help identify primary lesions.
  • Pelvic X-rays often reveal isolated calcifications, suggesting previous pelvic lymph node tuberculosis.
  • Pelvic ultrasound can classify the condition into effusion-type, mass-type, or mixed cystic-solid mass-type, with minimal blood flow signals in the masses.
  • Abdominal CT and MRI better display peritoneal thickening, intestinal wall thickening, mesenteric and omental adhesions, and nodules.
  • Hysterosalpingography may show multiple strictures in the fallopian tubes (beaded appearance), narrowed or rigid lumens, distal obstruction, or uterine deformities, adhesions, and contractions if the uterus is involved. Antituberculosis drugs should be used before and after the procedure. This examination should be avoided during active tuberculosis to prevent spreading caseous material or bacteria into the abdominal cavity and worsening the infection.

• Laboratory Tests:

  • Menstrual blood, endometrial curettage, or ascitic fluid can be tested for Mycobacterium tuberculosis using acid-fast staining or culture, which confirms the diagnosis.
  • Molecular biology methods, such as PCR or LCR, can detect M. tuberculosis DNA but may yield false positives.
  • Other tests include tuberculin skin tests (PPD), erythrocyte sedimentation rate, serum CA125, and adenosine deaminase levels.

What is the Diagnostic Value of Laparoscopy for Pelvic Peritoneal Tuberculosis?

• Allows collection of ascitic fluid for tuberculosis culture.

• Biopsies can be taken from lesions for pathological and laboratory testing; histopathological examination is a reliable diagnostic method for tuberculosis.

• Direct visualization of pelvic conditions enables diagnosis based on laparoscopic findings without relying solely on pathology results.

• Avoids unnecessary exploratory laparotomy.

• Facilitates early diagnosis and timely treatment.

What Diseases Should Pelvic Peritoneal Tuberculosis Be Distinguished From?

• Endometriosis: Patients may present with infertility, menstrual disorders, low-grade fever, pelvic adhesions, thickening, and nodules. However, endometriosis typically involves severe dysmenorrhea and heavy menstrual bleeding. Diagnostic curettage and hysterosalpingography aid in differentiation.

• Non-Specific Pelvic Inflammatory Disease: Patients often have a history of childbirth, abortion, intrauterine devices, gonorrhea, or acute pelvic inflammation. Heavy menstrual bleeding is common, while amenorrhea is rare. In contrast, pelvic peritoneal tuberculosis often causes infertility, reduced menstrual flow, or amenorrhea, with palpable nodules or masses on gynecological examination.

• Ovarian Tumors: More common in perimenopausal or postmenopausal women, usually without oligomenorrhea or amenorrhea. Symptoms include ascites, pelvic masses, and weight loss, with significantly elevated CA125 levels. Pelvic peritoneal tuberculosis typically affects young women of reproductive age, accompanied by infertility and low-grade fever. Diagnostic curettage or laparoscopy helps differentiate the conditions. A diagnostic trial of antituberculosis therapy for 1–2 weeks may be considered; improvement in symptoms and decreased CA125 levels suggest pelvic peritoneal tuberculosis.

TREATMENT

How to treat pelvic peritoneal tuberculosis?

• Diagnostic treatment. For cases with high clinical suspicion but no confirmed evidence, diagnostic anti-tuberculosis therapy may be considered. If no improvement is observed after one month of diagnostic treatment, exploratory laparotomy should be performed to avoid delaying the condition.

• Anti-tuberculosis drug therapy. This is the primary treatment method, adhering to the principles of early, combined, regular, appropriate, and full-course therapy. Commonly used drugs include isoniazid, rifampicin, ethambutol, and pyrazinamide, administered in combination for 6–9 months. A two-phase short-course drug therapy is recommended: the first 2–3 months as the intensive phase, followed by 4–6 months as the consolidation phase.

• Glucocorticoid therapy. Early use of glucocorticoids, alongside strong anti-tuberculosis treatment, can reduce inflammatory exudation, promote absorption of inflammation and effusion, and prevent or minimize adhesion and thickening of abdominal organs. Prednisone 30 mg/day, divided into three doses, gradually tapered to 5 mg/day, maintained for one week before discontinuation, with a total course of 4–6 weeks.

• Surgical treatment. For patients with unclear diagnoses, laparoscopy or exploratory laparotomy is still recommended. Surgical plans should be tailored to the patient's condition, with attention to pre- and post-operative anti-tuberculosis therapy.

• Interventional therapy. Female pelvic tuberculosis is often accompanied by serous, bloody, or purulent effusions containing serofibrinous or caseous necrotic material. Reports suggest that interventional ultrasound with local application of isoniazid, dexamethasone, and levofloxacin yields excellent therapeutic results.

• Treatment for infertility. Complete anti-tuberculosis therapy first, followed by 3–6 months of estrogen therapy to improve endometrial conditions. Then, perform laparoscopic egg retrieval and hysteroscopic evaluation of the uterine cavity and adhesiolysis. Once the condition stabilizes, proceed with in vitro fertilization-embryo transfer.

Does pelvic peritoneal tuberculosis require surgical treatment?

Anti-tuberculosis drug therapy is the first choice for pelvic peritoneal tuberculosis, and surgery is generally not performed. However, for patients with unclear diagnoses, laparoscopy or exploratory laparotomy is still recommended.

Surgical objectives: First, to confirm the diagnosis; second, to thoroughly remove tuberculous lesions, which can shorten treatment duration and improve cure rates. To prevent infection spread during surgery, 1–2 months of pre-operative anti-tuberculosis therapy is advised.

The extent of surgical resection should be determined based on the patient's overall condition, local lesion scope, and adhesion severity. For women of childbearing age, ovarian preservation should be prioritized.

For patients over 45 years old, regardless of disease severity, total hysterectomy with bilateral salpingo-oophorectomy is recommended to completely remove lesions and prevent recurrence.

For severe cases with dense adhesions forming large masses that cannot be surgically separated, total hysterectomy with bilateral salpingo-oophorectomy is necessary regardless of age.

Regardless of the surgical approach, post-operative anti-tuberculosis therapy must continue to consolidate long-term efficacy.

When is surgical treatment needed for pelvic peritoneal tuberculosis?

• Formation of pelvic tuberculous abscess, recurrence after drug therapy, or enlargement of the mass;

• Pelvic masses that shrink but do not completely resolve after drug therapy;

• Large encapsulated effusions or significant ascites;

• Partial or complete intestinal obstruction;

• Unsatisfactory response to standard full-dose chemotherapy or formation of drug-resistant lesions;

• Severe persistent dysmenorrhea unrelieved by conservative treatment;

• Persistent sinus tracts.

Which patients with pelvic peritoneal tuberculosis cannot undergo surgery?

• Active pulmonary tuberculosis or other extrapulmonary tuberculous lesions;

• High fever;

• Cachexia;

• Rectal or vesical fistulas;

• Extensive and severe adhesions of pelvic organs.

DIET & LIFESTYLE

What should patients with pelvic peritoneal tuberculosis pay attention to in daily life?

Like tuberculosis in other organs, pelvic peritoneal tuberculosis is a chronic wasting disease. The strength of the body's immune function plays a crucial role in controlling disease progression, promoting lesion healing, and preventing recurrence after drug treatment. Therefore, patients in the acute phase need to rest in bed for at least 3 months.

After the disease is suppressed, patients can engage in light activities, but they should also pay attention to rest, increase nutrition, and consume vitamin-rich foods. They should ensure adequate sleep at night and maintain a positive mental state.

Particularly for infertile women, it is important to provide comfort and encouragement, alleviate their concerns, and help restore their overall health.

PREVENTION

How to prevent pelvic peritoneal tuberculosis?

Administer BCG vaccination during childhood, and ensure isolation and treatment when there are tuberculosis patients in the household.

If there is a history of pulmonary or intestinal tuberculosis, and symptoms such as primary infertility, scanty menstruation or amenorrhea, or chronic pelvic inflammation that does not heal, seek medical attention promptly for relevant examinations. Once diagnosed with tuberculosis, undergo formal anti-tuberculosis treatment in a hospital.