 Genital tuberculosis. Now clinical features can be one of these. The most common is infertility due to sequelae, recurrent miscarriages, topic pregnancy, recurrent miscarriages due to endometrial involvement or ectopic pregnancy due to tubal pathology, due to tuberculosis, menstrual irregularities again due to endometrial involvement, chronic pelvic pain and adnexal mass. And there may be history of a previous tuberculosis infection elsewhere like lungs, which may give a clue. Now coming to the male genital tract, the spread is hematogenous and the primary site of involvement is epididymis with contiguous spread to other areas of the genital tract by direct spread. Now clinical presentation can be acute symptoms of prostratitis or it is more commonly nonspecific urinary symptoms and subfertility is 10% of subfertility is due to tuberculosis. Now in a patient's presence with acute symptoms of prostratitis, the prostrate may be normal or it can reveal focal areas of decreased ecogeneity as shown here, which is again nonspecific. You have to go by other features. We will come to that later. Now here this patient presents with again acute symptoms of urinary symptoms and pelvic pain and there is an abscess in the prostate either with or without periprostatic colic. This abscess in the prostate with a periprostatic collection. So this again can be nonspecific but there will be acute symptoms will not be there in tuberculosis or more chronic features will be there. A very rare complication of prostatic tuberculosis is a fistulous tract to perinium like we saw fistulous tract from perinium free space to the skin and we can see in scrotum like that here also there can be a fistulous tract to perinium or a anoeurothral fistula. Now here this is a transrectal scan of prostate. You see gas in the prostate. So then you do a sagittal scan. You see that gas is actually in the prostatic urethra. So that is the prostatic urethra. So you see gas in the prostatic urethra and when you do the transrectal scan and the with the probe you see the tract in the prostatic urethra gas field and it extends to the anal canal and you see the tract extending to the anal canal because it is typical of an anoeurothral fistula. This is the real-time scan showing the pressure and release the gas in the tract moving. So that is the prostatic urethra. This is the anal canal and you see the air filled tract from the prostatic urethra to the anal canal. So anoeurothral fistula due to tuberculosis. There can be a sequel of tuberculosis of the prostate resulting in infertility. So the infertility may be due to a trophy of the ducts or it may be due to a structure of the ejaculatory ducts which is a cause of obstructive esophemia in about 4 to 9% of cases. And on ultrasound you may see the features in the scrotum. This is the epididymis. You see the tubules are dilated minimally and more moderate dilatation of the tubules of the epididymis causing panicomb appearance and there may be an epididymal cyst seen here and or in the testis there can be ectasia of reti testis seen here. Ectasia of reti testis you may see dilated seminal vesicles because of obstruction to ejaculate ducts. So either all or one of these features may be seen in obstruction to ejaculate ducts and again this shows tells you that it is due to obstruction whether it is due to tuberculosis. It depends on the history and previous diagnosis and other features of a tuberculosis elsewhere. Now coming to the secret of tuberculosis of the prostate it can lead to dystrophic calcifications. So you may see dystrophic calcifications in the prostate which is again a non-specific feature. Now coming to the scrotal tuberculosis the patients will present with pain and swelling or it may be in serious and chronic symptoms. Now tuberculosis epididymis one of these features may be present it may be diffusely enlarged heterogeneously hypoechoic epididymis the whole epididymis enlarged or you may get nodular heterogeneous hypoechoic lesions in the epididymis or it may be diffusely enlarged and homogeneously hypoechoic or there may be an abscess mimicking a pyogenic infection most commonly in the tail or there may be a scrotal abscess and a scrotal sinus. Now here you see diffusely enlarged heterogeneously hypoechoic epididymis and when you put color you see there is no flow in the lesions but there is hyperemia around the epididymis in the periphery. So that is a very typical feature of tuberculosis. Here you see a nodular heterogeneous hypoechoic lesion in the epididymis with cavitation and or without cavitation and again color shows hyperemia around it. Now here you see the entire epididymis is enlarged and homogeneously hypoechoic so that is the entire epididymis which is enlarged and hypoechoic and here you see the tail of epididymis there is an abscess there is mass with central abscess and so that is abscess in the tail of epididymis and here you see a scrotal wall abscess this is the enlarged tail of the epididymis there is an abscess in the scrotal wall. So this is both will mimic a pyogenic infection but the patient may not have acute symptoms. So this the abscess in the tail of epididymis it can be the starting point then it can rupture as and appear as a scrotal wall abscess which is can again rupture through the skin outside as a with a tract a fresh tract which is very thick or it may be a chronic tract you can see from the tail of epididymis a tract extending to the skin. So scrotal sinus is a very characteristic feature of tuberculosis. Now testicular tuberculosis is again varied appearance you may get an enlarged testis with multiple small hypoechoic nodules as seen here there may be hydrocea. A very typical feature is blurred separation of between testis and epididymis in the region of the media stamina. So this is testis with nodules and this is epididymis which is enlarged and you see a mass there so in between there is no separation good separation so that is a very good feature and here the testis is enlarged and there is it is homogeneous or heterogeneous hypoechoic structure and that is again we must suspect tuberculosis. Now this is another case of tuberculosis you see larger ecopore masses in the testis there is hydrocea and you see a mass in the tail of epididymis and on the right side you see the entire epididymis is enlarged and ecopore indicating tuberculosis. Now another case of testicular tuberculosis it looks like multiple absences in the testis and on the endopler you see no flow in the lesions but there is hypremia for rest of the testis. But what is the clue for tuberculosis is the thickened vast difference here so that is in favor of tuberculosis. Now tuberculosis can be seen in the vasa differential as single or multiple hypoechoic masses in the vast. Now here this is just a mass irregular mass in the spomatic just above the testis and here you see the vast difference which is thickened and there is a focal necrotic mass in the vast difference. Another other cases of tuberculosis of the vast difference here you see a marked thickening of the vast difference with focal increased thickening in the long axis and the short axis and hypremia and color Doppler and another case of tuberculosis you see the marked thickening of the focal thickening of the vast difference in longitudinal scan and short axis scan. Now coming to tuberculosis of the seminal vesicles can present as a heterogeneous mass or it can present as an abscess. So this feature is again non-specific it cannot be differentiated from pyogenic abscess but the evidence of tuberculosis elsewhere in the urinary tract or in the scrotum or a chronicity of symptoms which should give rise to the suspicion and a biopsy or aspiration from the abscess will give the diagnosis. Of course the absent acute symptoms will be absent. Now coming to tuberculosis of seminal vesicle and vasodifferentiae the fibrosis and healing results in sequelae which results in a very small solid atrophic seminal vesicle. Well I seen here or it can result in calcifications as seen in both seminal vesicles or calcifications in the vast difference which are all features which are non-specific. Now differential diagnosis of the tuberculosis of male genital tract we have to depend on the chronicity of symptoms presence of a sinus tract and lack of response to non-specific antimicrobial agents should give rise to suspicion and of course evidence of tuberculosis in the rest of the genital urinary system and last is a biopsy confirmation by urine smear and culture or biopsy of the lesion which is seen either in the prostate seminal vesicle epididymis or test is wherever it is seen. So that is the confirmatory test for tuberculosis. Now we pass on to tuberculosis of the female genital tract. This is spread is hematogenous and the primary site is fallopian tube with contiguous spread to rest of the female genital tract. Tuberculosis of the fallopian tube it is seen in more than 90% of tuberculosis of female genital tract. It can present as endosalphenitis where the tube fallopian tube will be swollen and edematous or exosalphenitis where there will be features of ositis, malaria tubercles on the serosa which will be seen as irregular contour of the tube and result in additions. Later with fibrosis it may result in idosalphins, tuberovirin mass or tuberovirin abscess which may be the features and later on because of the fibrosis and obstruction and destruction there may be this it can result in infertility. Tuberculosis of the ovaries is less 20% it again the pathology is cation adnexal mass and Tu abscess. Destruction of the entire ovarian tissue can result in premature ovarian failure which will result in premature menopause or infertility. So there is a wet type of tuberculosis of the female tract with involvement of the peritoneum where you will see ositis as seen here and peritoneal thickening and you will see septae incomplete septae due to 5 billion strands and the echogenic particles and the fallopian tubes may be thickened as seen here both the fallopian tubes are thickened as seen in the transverse scan and another case where you see ositis and you see the marked thickening of the fallopian tube you see the ovary here that is the fallopian tube markedly thickened and another case of wet type of tuberculosis you see ositis and you see the femurilin end of the fallopian tubes on both sides markedly thickened varying appearance I am showing different cases another case you see the right fallopian tube thickened, left fallopian tube thickened and there is ositis and there is peritoneal thickening on the fallopian tube itself I can here see the fallopian tuboclosis nodules and the thick fallopian tube you can see also see 5 billion strands in the ositic fluid very characteristic of the wet type of tuberculosis this is the video showing the markedly thickened right fallopian tube left fallopian tube and that is the fallopian tube and you see the 5 billion strands in the ositic fluid that is the 5 billion strands very typical of tuberculosis now another case where you see the sagittal skin of the uterus and you see the obliteration of peritoneal recesses due to peritoneal thickening as you hear this is the bladder this is the uterus so vesico uterine recess is obliterated and you see the peritoneal thickening ositis that is the peritoneal thickening obliterating the recess and peritoneal thickening here in the pelvis and you see the thick fallopian tube so that is tuberculosis of the fallopian tube this is the video showing the obliteration of the vesico uterine recess by a dynamic scan there is no sliding of the bladder wall due to adhesion and the tuberculosis pyosulfins you see the markedly thickened fallopian tube and you see ositis by the side and in cross section also you see markedly thickened fallopian tube with internal distention of the lumen with debris and when you do color Doppler you see intense hyperemia of the walls so this is tuberculosis pyosulfins patient will not be having any acute symptoms and you can see the real-time dynamic movement of the debris in the fallopian tube indicating that it is pus pyosulfins there is dry type of tuberculosis of the female genital tract where there is no ositis but there is peritoneal thickening as shown here this is the ovary and you may see fallopian tube the thick walls or you may see hydro salfings now here you see the markedly thickened fallopian tube or you may see the mother is again markedly thickened fallopian tube and color Doppler there is hyperemia so there is no ositis so this is called frozen pelvis so when they open up they may not be able to enter the pelvis because of dense additions that is frozen pelvis in dry type of tuberculosis of the female genital tract and peritoneal another case of dry type of tuberculosis you see the markedly thickened fallopian right fallopian tube while on the left side there is some hydro salfings you can see the hydro salfings of the markedly thickened fallopian tube so this is the varying appearance now this is the video of the same patient you see the markedly thickened fallopian tube on right side and the equal tube with hydro salfings on the left side so that is the thickened tube here on the right side and when you come to the left side there is hydro salfings these are the varying appearances so here in the dry type there is no ositis and this is in a girl young girl abdominal scan you see the hydro salfings with thickened fallopian tube or you may see a mass involving the hydro salfings and the ovary peritoneal thickening so it can be a tube ovary mass or a tube ovary abscess now with healing with fibrosis there may be sequelae of tuberculosis of the fallopian tube resulting in a hydro salfings or in a tubal block so when there is tubal block there will be infertility to assess tubal block we do saline infusion sonography the cis which shows normal spill on the right side indicating patent tube whereas on the left side there is no spill indicating that there is the left fallopian tube is blocked. Indomitri tuberculosis is seen in 50 to 80 percent of cases which shows there the pathology will be irregular contour of the endometrium due to the granulomas and the ulcerations and results in a polypoid endometrium on ultrasound it can lead to synaecae with healing scarred cavity of osherman syndrome as a result of tuberculosis and rarely there may be endometrial calcification because of the scarring of the endometrium it can result in secondary amenorrhea and infertility so here you see the saline infusion sonography in a patient with infertility you see the thin distinction of the uterine cavity with polypoid irregular contour of the endometrium and the synaecae formation 3d construction exists you see the addition in the uterine cavity in the form of synaecae or there may be extensive scarring of the cavity which may result in failure of distinction of the uterine cavity with cis and there may be endometrial calcification as seen here you see the endometritine punctate calcifications in the endometrium which is again a non-specific with other things you come to a conclusion but it will result in amenorrhea. So, in differential diagnosis of female genital tag tuberculosis is non-specific when we can inflammatory disease and endometriosis and the diagnosis when you suspect tuberculosis diagnosis achieved by culture of menstrual blood or endometrial biopsy or culture for tuberculosis and laparoscopy and biopsy. Thank you very much.