Reproductive tuberculosis

　　Infection often occurs secondary to tuberculosis or digestive tract tuberculosis, spreading to the reproductive organs through hematogenous transmission, followed by direct spread from peritoneal reproductive organ tuberculosis. It often first invades the fallopian tubes. A few fallopian tubes may present as millet-like nodules, while most changes are similar to those of general chronic inflammation, which can be manifested as hydrosalpinx or hydromyoma, or interstitial and nodular inflammation, etc. The fallopian tubes often become thickened or nodular. In the late stage, ulcers, necrosis, and caseous degeneration may occur, leading to close adhesion with surrounding tissues.

　　Endometrial tuberculosis, almost all from tubal tuberculosis, superficial granuloma-like nodules can be seen, sometimes ulcers and caseous necrosis can occur, and finally scars are formed, which can cause uterine cavity adhesion, deformation, and shrinkage.

　　Complications of genital tuberculosis:

　　1. Corpus uteri tuberculosis infection:It mainly occurs in the endometrium, which can cause endometrial hyperplasia or ulcers; in severe cases, most of the endometrium is destroyed, leading to amenorrhea and infertility.

　　2. Tubal tuberculosis:It is more common, which can make the bilateral fallopian tubes become thick and hard, the cilia on the mucosal surface of the fallopian tubes are destroyed, the tube wall is adherent, the lumen is blocked, and the normal function is lost, leading to infertility.

　　3. Cervical tuberculosis:Superficial ulcers occur on the surface of the cervix, sometimes presenting as papillary or cauliflower-like hyperplasia, which can increase leukorrhea and cause contact bleeding.

　　The onset is usually slow, often without自觉 symptoms, with a few patients experiencing night sweats, fatigue, and hot flashes. Menstruation is often irregular, and can be excessive, prolonged, or irregular bleeding due to inflammation. In the late stage of inflammation, due to endometrial atrophy, menstrual blood will decrease, leading to amenorrhea in recent years. Some patients may have lower abdominal pain and increased leukorrhea. Due to tubal obstruction, and endometrial tuberculosis can interfere with the implantation of the ovum, most patients are unable to conceive. In primary infertility, genital tuberculosis is often one of the main causes. ① Menstrual blood volume is excessive or continuous. ② Leukorrhea is abundant. ③ Lower abdominal pain, dysmenorrhea. ④ Slight fever in the afternoon, general fatigue. Some statistics show that about 5-10% of infertility in women is caused by genital tuberculosis.

　　2. First, in childhood, BCG vaccine should be administered to prevent tuberculosis. When the physical condition declines, they should keep away from tuberculosis patients. If there is fever during the menstrual period, lower abdominal pain, and primary infertility, a thorough examination should be conducted to rule out genital tuberculosis.

　　1. For women who have tuberculosis, whether it is genital tuberculosis or pulmonary tuberculosis, they should be treated actively. During the treatment period, they should have a nutritious diet to enhance their ability to resist the disease. Acute patients should rest in bed, while chronic patients can participate in physical exercise appropriately.

　　1. Laboratory examination

　　Routine laboratory tests are not very helpful for diagnosis. The total white blood cell count and classification of most patients are basically normal. The erythrocyte sedimentation rate acceleration in chronic mild genital tuberculosis is not as obvious as in purulent or gonococcal pelvic inflammatory disease, but it often indicates that the focus is still active, which can be used as a reference for diagnosis and treatment. Therefore, erythrocyte sedimentation rate should be listed as a routine examination item.

　　2. Chest X-ray examination

　　The vast majority of patients with this disease are secondary to pulmonary infection, therefore, chest X-ray examination should be listed as a routine examination item. The focus is to pay attention to the presence of old tuberculosis foci or pleural tuberculosis signs. Positive findings have certain reference value for the diagnosis of suspected patients, but a negative result should not be used to rule out the possibility of the disease.

　　III. Tuberculin test

　　The standard technique is intradermal injection of 0.1ml tuberculin (purified protein derivative-PPD tuberculin, equal to 5 times the tuberculin unit), and detection of skin induration and erythema size within 48 to 72 hours. A positive skin test indicates previous infection but does not mean that there is an active tuberculosis focus at the time of the test. The reference value lies in increasing the suspicion index, especially for patients with strong positive results or adolescent girls in puberty, to determine whether more specific tests are needed. It should be noted that a negative result can sometimes not completely rule out tuberculosis, such as in subjects with severe tuberculosis infection, the use of adrenal cortical hormones, the elderly, malnutrition, etc.

　　IV. Serological diagnosis

　　In recent years, the purification protein antigen enzyme-linked immunosorbent assay of tuberculosis bacilli has been used to detect specific antibodies IgG and IgA against purified protein derivative (PPD) in serum, and it has also been used in clinical diagnosis of active tuberculosis in China. In addition, indirect immunofluorescence tests for detecting specific antibodies in patient serum, using appropriate monoclonal antibody technology, may increase the sensitivity and specificity of tuberculosis identification. The introduction and popularization of these technologies have provided rapid and sensitive diagnostic methods for reproductive organ tuberculosis

　　V. Special examinations

　　More than half of reproductive organ tuberculosis involves the endometrium, and endometrial tissue is easy to obtain. Therefore, the pathological examination of the endometrium and the bacterial culture and animal inoculation of uterine cavity secretions are all methods for diagnosing reproductive organ tuberculosis. However, when the tuberculosis bacilli have reached the uterine cavity from the fallopian tube without causing significant endometrial lesions, pathological histological examination cannot identify them, but bacterial culture or animal inoculation can yield positive results, and drug susceptibility testing can be used to understand the drug resistance of the strain, as a reference for the selection of drugs in clinical treatment. Therefore, bacteriological examination becomes even more important. However, the results of the culture are affected by factors such as the sensitivity of the culture medium, the time of sampling, and the nature of the material, and the difficulty of culture and the long time required (6 to 8 weeks to get results) limit the clinical practical value of bacteriological examination. At present, the above three examinations are generally used simultaneously, which significantly improves the positive rate of diagnosis

　　1. Diagnostic curettage:The most suitable time for performing the operation is within 2 to 3 days before the menstrual period or within 12 hours after the onset of menstruation. Endometrial tuberculosis often occurs in the vicinity of the uterine cornu, and special attention should be paid to obtaining samples from this area. Due to the small and scattered nature of early endometrial tuberculosis lesions, the entire endometrium should be scraped to obtain sufficient material. At the same time, the cervical endometrium and cervical biopsy should be collected and sent for examination in groups to avoid overlooking the presence of cervical tuberculosis. The endometrial specimens are divided into two groups: one is fixed in 10% formalin solution for pathological examination, and the other is placed in a dry tube for immediate shipment for bacterial culture and animal inoculation. The pathological examination specimens are best made into continuous sections to avoid missed diagnosis. Patients with a long history of amenorrhea may not be able to scrape the endometrium, and uterine cavity blood can be collected for bacterial culture and animal inoculation. Laparoscopic surgery can activate pelvic tuberculosis foci, and to prevent the spread of tuberculosis, intramuscular injection of 1g streptomycin should be started 3 days before the operation, and continued for 4 days after the operation. Even if the pathological examination results are negative, tuberculosis cannot be ruled out. Clinical suspects should repeat the diagnostic curettage every 2 to 3 months, and if three consecutive checks are negative, it can be considered that there is no endometrial tuberculosis or it has been cured.

　　2. Bacterial culture and animal inoculation:Since the number of tubercle bacilli in the endometrium is relatively small, direct smearing, staining, and microscopic examination of the endometrial or uterine secretion has a very low positive rate and no clinical practical value. Generally, half of the uterine scraping specimens are collected for bacterial culture and animal inoculation. The endometrial fragments are ground up in sterile containers and planted on appropriate culture media. The culture is checked once a week until 2 months or until a positive result appears. In addition, the ground-up endometrial suspension is injected subcutaneously on the abdominal wall of guinea pigs. After 6 to 8 weeks, the experimental animals are killed and regional lymph nodes, lumbar lymph nodes, and spleen are taken as smear specimens. After staining, they are directly examined under a microscope, or further bacterial culture and inoculation are performed. To avoid the risk of spreading tuberculosis from uterine scraping, some people suggest collecting menstrual blood for culture. The method is to collect menstrual blood for culture by placing a cervical cap on the patient's cervix during the menstrual period, or to collect menstrual blood for culture under the direct vision of a speculum on the first or second day of the menstrual period. However, the positive rate of this method is lower than that of endometrial bacteriological examination. The culture of cervical secretions during the menstrual interval is not time-limited and can be performed repeatedly, but the positive rate is even lower. Although the above bacterial culture and animal inoculation can determine the diagnosis, sometimes it is necessary to perform them repeatedly to obtain a positive response of tubercle bacilli, so it is generally considered that at least 3 negative tests are required to exclude tuberculosis

　　3. Iodine contrast agent hysterosalpingography of the uterus and fallopian tube:Radiography of the uterine tube in cases of tuberculous lesions of the reproductive organs can show certain characteristics. Based on these characteristics, combined with a high suspicion of tuberculosis, a diagnosis of tuberculous lesions of the reproductive organs can be made. There are two types of contrast agents for iodine imaging: iodinated oil and water-soluble iodine. Since iodine water is less irritating and absorbed faster than iodinated oil, it does not cause granuloma or oil embolism, and can also show fine fallopian tube fistulas, etc. Currently, iodine water is mostly used as a contrast agent, but its disadvantage is that if the film is not taken in time, the iodine agent disappears quickly. The best time to perform the contrast examination is 2 to 3 days after the menstrual period. It is contraindicated for patients with inflammatory masses and fever. To prevent the activation and spread of the focus, streptomycin can be injected intramuscularly a few days before and after the operation. Liu Buning divided the characteristics of tuberculous lesions of the reproductive organs on the X-ray film of hysterosalpingography into two categories according to their diagnostic value:

      First category: More reliable signs: If there is any suspicion of tuberculosis in clinical practice, and any of the following characteristics are present, it can be basically diagnosed as tuberculous lesions of the reproductive organs.

     (1) There are numerous calcification points in the pelvis: There are not many cases of pelvic pathological calcification in the field of gynecology. Most of the calcification points in the fallopian tube area, except for tuberculous lesions of the reproductive organs, are extremely rare. (2) Obstruction of the middle segment of the fallopian tube, accompanied by defects in the infusion due to iodinated oil entering the interstitial ulcers or fistulas of the fallopian tube. (3) The fallopian tube has multiple narrowings, presenting a bead-like appearance. (4) Severe stenosis or malformation of the uterine cavity. (5) Infusion of iodinated oil into the lumen of the fallopian tube, i.e., iodinated oil entering the lymphatic vessels, blood vessels, or interstitial tissues. Accompanied by stenosis or deformation of the uterine cavity. (6) Ovarian calcification: Calcification signs appear in the area corresponding to the ovary

       Second category: Possible signs: If a patient has clinical suspicion of tuberculosis and has two or more of the following signs, it can be basically diagnosed as genital tuberculosis.

     (1) Isolated calcification points are shown in the pelvic plain film (2) The fallopian tube is rigid,呈直管状, and the distal end is blocked (3) The fallopian tube is irregular and blocked (4) One side of the fallopian tube is not visible, and the middle segment of the other side is blocked with intramural iodine oil perfusion (5) The distal end of the fallopian tube is closed, and there is a perfusion defect in the lumen (6) Bilateral fallopian tube isthmus obstruction (7) The uterine cavity margin is irregular and saw-toothed (8) Iodine oil perfusion is present in the uterine stroma, lymphatic vessels, or veins

　　4. Laparoscopic examination:The condition of the lesion can be directly observed, and biopsy can be performed under the microscope for pathological examination. Abdominal fluid can be directly smeared, acid-fast staining, examined under a microscope, or sent for bacterial culture with a highly increased sensitivity. It is of great value in distinguishing endometriosis or ovarian cancer. Many cases that cannot be diagnosed by B-ultrasound and CT scans can be diagnosed by laparoscopic examination.

　　Principles of dietary nourishment:

　　1. Provide adequate calories, supply high-quality and sufficient protein, supplement calcium-rich foods to promote calcification. Provide a rich supply of vitamins to help the body recover health, reduce the side effects of antituberculosis drugs, and aid in the absorption of calcium. Appropriately supplement minerals and water, such as iron, potassium, sodium, and water.

　　2. During the chemotherapy for genital tuberculosis patients, the diet must meet the requirements of high calories, high protein, rich vitamins, and trace elements. This is because tuberculosis patients often have low fever, night sweats, and even hemoptysis, leading to a gradual thinning of the body and a high consumption of energy. In addition to the toxic and side effects of chemical drugs, their pathogenic effects also damage the body's constitution.

　　According to the principle of reinforcing the healthy and expelling the pathogenic factors in traditional Chinese medicine, it is advisable to choose a diet rich in nutrition. However, due to the weakness of the spleen and stomach in tuberculosis patients and low digestive and absorptive capacity, the choice of food should be light and avoid excessive sweetness and greasiness. Foods such as fish, eggs, milk, lean meat, old hens, honey, peanuts, lotus seeds, lilies, jujubes, chestnuts, pears, persimmons, sesame seeds, tangerines, green vegetables, winter melon, lotus root, tomatoes, carrots, radishes, beans, and bean products can all be eaten.

　　Once the diagnosis of genital tuberculosis is confirmed, active treatment should be given regardless of the severity of the condition, especially for mild cases. It is difficult to be sure whether the focus has become stationary or cured. In order to prevent the possibility of disease progression if the patient's immune function decreases in the future; even if there are no obvious symptoms, the potential risks and benefits should be explained to persuade the patient to accept treatment.

　　The current treatment for genital tuberculosis includes general treatment, antituberculosis drug therapy, and surgical treatment.

　　Firstly, it is recommended to strengthen nutrition and rest more when there is fever, pelvic mass, and elevated erythrocyte sedimentation rate during the acute active stage.

　　Two, anti-tuberculosis therapy Streptomycin 1g is injected intramuscularly once daily, and after 2-3 weeks, it is changed to 2g weekly, continuing for half a year to a year or longer (discontinue medication if tinnitus or dizziness occurs). At the same time, isoniazid 100mg and vitamin B6 100mg are taken orally three times a day, continuously for 1 to 2 years, or sodium aminosalicylate 12g daily, taken in 3 to 4 doses, for 4 to 6 months. If patients cannot tolerate the aforementioned medications, rifampin and ethambutol can be taken. Rifampin is taken 400-600mg daily one hour before meals to facilitate absorption, with half a year as one course. Ethambutol is taken orally at a dose of 15-25mg/kg daily, reduced to 15mg/kg after 60 days, with 4 to 6 months as one course. The combination of two anti-tuberculosis drugs is effective, such as using streptomycin and isoniazid first for half a year to a year, then stopping streptomycin and replacing it with a combination of isoniazid and sodium aminosalicylate for 4 to 6 months, followed by the use of isoniazid alone for half a year, with a total course of about two years. In severe cases, the combination of three drugs can also be used; in stable cases, isoniazid can be taken orally for one year.

　　Three, surgical therapy In cases where drug efficacy is poor or pelvic masses persist, the adnexa and uterus can be surgically removed. To improve efficacy, anti-tuberculosis treatment should be continued for more than half a year after surgery.

　　Four, traditional Chinese medicine should follow the principle of reinforcing the body's resistance, diagnose and treat according to differentiation, and be combined with anti-tuberculosis treatment.

　　1. General treatment

　　Genital tuberculosis is a chronic consumptive disease, like other organ tuberculosis. The strength of the body's immune function plays an important role in controlling the progression of the disease, promoting the healing of lesions, and preventing recurrence after medication. Therefore, patients in the acute stage should at least rest in bed for 3 months. After the lesions are suppressed, patients can engage in light activities, but they should also pay attention to rest, increase nutrition and vitamin-rich foods, have sufficient sleep at night, and maintain a cheerful spirit. Especially for women with infertility, it is important to provide comfort and encouragement, alleviate their mental concerns, and promote the recovery of overall health.

　　2. Treatment with anti-tuberculosis drugs

　　The emergence of anti-tuberculosis drugs has brought about a major revolution and leap in the treatment of tuberculosis, and most other treatment measures have been abandoned. Cases that previously required surgery have been replaced by safer, simpler, and more effective drug therapy. However, in order to achieve ideal efficacy, it is necessary to implement the five principles of rationalized treatment, namely, early treatment, combination therapy, appropriate dosage, full course, and regular use of sensitive drugs. Early tuberculosis lesions are in the stage of bacterial proliferation, and the earlier the lesions, the fresher they are, the better the blood supply, and the easier it is for drugs to penetrate; active treatment can prevent delay and the formation of refractory chronic caseous foci. Combination therapy can greatly reduce the opportunity for naturally resistant bacteria to survive or to reproduce and produce drug-resistant tuberculosis bacteria. However, due to the long duration of drug treatment, patients often find it difficult to persist, leading to early discontinuation of medication or irregular medication, which can result in treatment failure. For this reason, clinical doctors should pay more attention to the principles of regularity and full course, monitor the patient's treatment status, strengthen supervision of the patient, and avoid premature discontinuation of medication or arbitrary changes in medication, leading to incomplete treatment and causing adverse consequences such as drug resistance and refractoriness.

　　Since the number of patients with genital tuberculosis is relatively small, it is difficult to conduct a well-designed clinical control trial, and therefore, the treatment plans adopted all come from the experience of treating pulmonary tuberculosis.

　　(One) The mechanism of action of antituberculosis drugs: The therapeutic goal of antituberculosis drugs is to rapidly and completely kill a large number of actively multiplying tuberculosis bacilli (A strain) in the focus, as well as to eliminate the slow and intermittent proliferation of B, C tuberculosis bacilli, in order to reduce recurrence. Currently, the most commonly used antituberculosis drugs are five in number.

　　(1) Isoniazid (I, isoniazid): It has inhibitory and bactericidal effects on tuberculosis bacilli and is the most commonly used drug in various treatment regimens. Its characteristics are good efficacy, small dosage, and ease of oral administration. The daily dose is 300mg orally or intramuscularly; if given twice a week, the daily dose is 15mg/kg body weight. The disadvantage is that it can cause peripheral neuritis, with prodromal symptoms of formication and foot burning sensation, which is related to a deficiency of vitamin B6 (due to the increased excretion of vitamin B6 caused by the use of I), so vitamin B6 30mg/d should be taken during the treatment process. In addition, I has a liver-damaging effect. About 10-20% of patients with mild liver function abnormalities (elevated serum transaminases) may occur during the treatment process, but even if the treatment continues, the serum SGOT level can still return to normal. Progressive liver damage may occur occasionally, reaching 2-3% in those over 50 years old, and alcohol increases its harmfulness, but

　　(2) Rifampicin (R.rifampicin): It is a semi-synthetic derivative of rifamycin, and tuberculosis bacilli are highly sensitive to it. It is the only drug that has a bactericidal effect on all three strains (A, B, C). The oral dose is 10mg/(kg·d) up to 600mg/d or twice a week. Generally, it has low toxicity, with the most common being gastrointestinal reactions and general allergic reactions, such as fever, headache, muscle and joint pain (collectively known as influenza syndrome), rash, etc. Platelet reduction may occur occasionally, so patients should be advised to pay attention to the appearance of skin ecchymosis, purpura, or hematuria.

　　(3) Streptomycin (S): Has a stronger bactericidal effect on extracellular tuberculosis bacilli (A strain) than on intracellular (B, C strain) bacilli. The dose is 1g/d, if taken twice a week, the daily dose is 20-30mg/kg body weight, which requires intramuscular injection and brings inconvenience to clinical application. The main adverse reactions are chronic damage to the auditory and vestibular organs, causing deafness, tinnitus, dizziness, and balance disorders. For this reason, about 10% of patients need to discontinue medication. During the treatment process, when patients visit the clinic, attention should be paid to inquire about their hearing and vestibular function, and those over 50 years old should have regular high-frequency hearing tests. In addition, renal toxic complications may occur occasionally. 4. Pyrazinamide (pyrazinamid, Z): It is a highly effective tuberculosis bactericidal agent, but it only has a bactericidal effect on intracellular bacilli. The oral dose is 20-40mg/kg, up to a daily dose of 2g; the daily dose for twice-a-week treatment is 50-70mg/kg, and adverse reactions are rare, with hyperuricemia and hepatotoxicity being more common. 5. Ethambutol (ethambutol: E): It has a similar strong inhibitory effect on both intracellular and extracellular tuberculosis bacilli and is currently a commonly used antituberculosis drug in clinical practice. The usual dose is 15-25mg/(kg·d) or 50mg/kg, twice a week. Visual neuritis may occur occasionally, but the dose

　　(2) The relationship between anti-tuberculosis drugs and some characteristics of the tuberculosis bacilli: As mentioned above, there are four types of tuberculosis bacilli in the focus of tuberculosis, and anti-tuberculosis drugs have different bactericidal and inhibitory effects on different types of bacterial populations and the acidity and alkalinity of the surrounding environment of the bacteria. For example, I has a bactericidal effect on active bacterial populations (A, B populations) outside the cells and those growing in phagocytes, S can exert the maximum effect on extracellular bacterial populations (A population) only in alkaline microenvironments, while Z is effective against intracellular B populations in acidic environments. Therefore, the effects of the aforementioned anti-tuberculosis drugs vary greatly with the progression of the disease. In the early stage of the disease, the local pH value of the tissue is slightly acidic (pH 6.5-7), with A populations being predominant, and I plays the main bactericidal role, followed by S. As the disease progresses, the pH value of the tissue decreases, and the populations of B and C increase, with Z and R exerting bactericidal effects, while I has only an inhibitory effect. After treatment, the inflammatory response is suppressed, and the pH value rises, at which point R is the main bactericidal drug, with S and I also having some effect, and Z's effect is weakened. If inflammation recurs, the pH value decreases, and the state of B populations being predominant is restored. Combination therapy with I and Z is superior to I alone.

　　The selection of drugs and the duration of medication in some treatment regimens are designed and formulated according to the aforementioned rules.

　　(3) Common treatment regimens: In the past, due to the inhibitory effect of anti-tuberculosis drugs on latent tuberculosis bacilli, treatment should continue until the host's immune system is strong enough to control the residual infection. Therefore, drugs with strong effects such as rifampicin (R) and ethambutol (E) were excluded from the standard treatment course and listed as second-line drugs, to be considered only when the standard treatment is ineffective or resistance has developed. To meet these requirements, it is generally necessary to persist with treatment (8 months), which is why such a long duration of treatment is called long-term therapy. Patients often find it difficult to persist, leading to treatment failure.

　　Over the past 10 years or so, through animal experiments and a large amount of clinical experience in treating pulmonary tuberculosis, treatment regimens containing I, R, E, or Z, as short as 9 months, even 6 months, have yielded results that can be compared to long-term therapy, with high cure rates and few recurrences, making them widely used today. The only drawback of short-term therapy is that it has a greater liver toxicity, and in case of treatment failure, R cannot be used as a backup drug.

　　In addition, to ensure that patients can take their medication on time, it is advocated to administer a single dose on an empty stomach in the morning, which is easy for patients to accept and results in a higher concentration of the drug in the blood. The bactericidal effect of the peak drug concentration is better than that of a constant low blood concentration; during the consolidation stage of the treatment course, intermittent administration is used, which is similar in effect to continuous administration. The current common symbols for anti-tuberculosis drug treatment regimens are used, such as 2IRSZ/4I3R3E3, which indicates that the first 2 months are the intensive phase, involving the combined use of isoniazid (I), rifampicin (R), streptomycin (S), and pyrazinamide (Z); and the following 4 months are the consolidation phase, with isoniazid, rifampicin, and ethambutol (E) administered three times a week.

　　1. Long-course therapy:(1) The standard treatment plan in the past: including S (daily dose 0.75-1g, intramuscular injection), I (daily dose 300mg), para-aminosalicylic acid (PAS) (daily dose 9-12g, taken in 2-3 doses), for a total of 2-3 months; then I, PAS, for 10-15 months, with a total course of 12-18 months, this plan has been basically abandoned. (2) IRS (S daily dose 0.75g, intramuscular injection, if intermittent administration, 2-3 times a week, each time 1g; R daily dose 600mg taken on an empty stomach in the morning; I conventional dose), for 2-3 months, then I, R, with a total course of 12 months. (3) IRE (daily dose: I 300mg, R 600mg, E 750mg), for 2-3 months, then I, E, with a total course of 12 months.

　　2. Short-course therapy:(1) I (daily dose 300mg), R (daily dose 600mg), with the addition of S (daily dose 1g, intramuscular injection) or Z (daily dose 1g), for a total of 2 months; followed by I and R, for 4 months; if there is a possibility of resistance to I, E (daily dose 0.75-1g) should be used from the beginning, and treatment should be strictly carried out according to the requirements, which is an important measure to prevent the occurrence of drug-resistant strains. (2) 1IRSZ/5S2I2Z2 (3) 2IRSZ/4R2I2Z2 It is generally believed that the combination of R and I is more effective than any other treatment plan, and the recurrence rate after discontinuation is lower than that of any other drug treatment of the same duration. However, there is no advantage in the continuous combined use of these two drugs for 18 months, and the liver toxicity is the highest. If R cannot be continued due to adverse reactions, it should be changed to the combination of ISE three drugs, and S should be discontinued after 2 months, while the other two drugs should be continued for another 16 months. 3. The application of corticosteroid hormones: Some people propose to use corticosteroids as adjuvant therapy to improve the inflammatory reaction caused by the lesion. If chemotherapy is appropriate, it has no adverse effect on the development of the disease. The indications include various tuberculous serositis, such as tuberculous genital tuberculosis complicated with tuberculous peritonitis, pelvic tuberculosis with severe toxic symptoms. On the basis of effective combined treatment with anti-tuberculosis drugs, prednisone (daily dose 30-40mg) can be taken, and gradually reduced after 1-2 weeks, with a course of 4-8 weeks. For patients with severe weakness and systemic symptoms, a smaller dose of prednisone (daily dose 30mg) can often improve symptoms and reduce fever in a timely manner. 4. The application of ofloxacin: Ofloxacin belongs to the quinolone class of antibacterial drugs. This class of drugs is a completely new, fully synthetic antibacterial drug with a broad spectrum of antibacterial activity, good oral absorption, and fewer adverse reactions, with gastrointestinal discomfort.

　　3. Surgical Treatment:Tuberculosis of the reproductive organs is primarily treated with antituberculosis drugs, and surgery is generally not performed. Only in the following cases should surgical treatment be considered: ① The pelvic mass persists after 6 months of drug treatment; ② Resistance to multiple drugs; ③ Symptoms (pelvic pain or abnormal uterine bleeding) persist or recur; ④ Lesions recur after drug treatment; ⑤ Fistulas do not heal; ⑥ Suspected concurrent existence of reproductive tract tumors, etc.

　　To avoid the spread of infection during surgery, reduce the difficulty of surgical manipulation due to widespread adhesions and congestion of pelvic organs, and also promote the healing of abdominal wall incisions, anti-tuberculosis treatment should be carried out one or two months before surgery.

　　Although surgical complications are rare at present, high vigilance should still be maintained during surgery. For severe adhesions of inflammatory masses, damage to adjacent organs may occur during separation, and fistulas may occur. Therefore, it is necessary to avoid forceful钝性剥离 during the separation of adhesions. Once a separation line is made between organs, perform mirror-like stripping, which should be less each time and proceed step by step. There is no need to separate the adhesions between old intestinal tracts. Adhesive adhesions may leave a small part of the uterine wall or fallopian tube attached to the intestinal tract or bladder, which is safer than forced resection of the whole. If there are severe and extensive adhesions in the pelvic organs, the round ligament should be identified first, and the fundus of the uterus should be mobilized to facilitate the determination of the surgical direction and the stripping process.

　　If there are fistulas formed by pelvic tuberculosis, a urinary system and whole digestive tract X-ray examination should be performed before surgery to understand the entire situation of the fistula before surgery. Begin to take neomycin for intestinal preparation several days before surgery. The uterus and both adnexa have been completely removed, and all lesions in the abdominal cavity have been removed. If there is no concurrent tuberculosis in other organs, anti-tuberculosis treatment for one or two months after surgery is sufficient to avoid recurrence.

　　After antituberculosis drug treatment, a close follow-up stage is needed. It is extremely rare for recurrence or dissemination to other organs after combined, moderate, regular and whole-course treatment. At the end of the course, it is advisable to repeat chest X-ray, urine tuberculosis culture and curettage. Repeat the examination every 6 to 12 months within two to three years.