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ЗмістMethods of examination in gynecology
Additional methods of examination
Smear on gonorrhea presence.
Smear on "hormonal mirror".
Methods of functional diagnostics
The "pupil symptom".
Cytological examination of vaginal smears
Such indexes are determined
Endoscopic methods of examination
Indications for making hysteroscopy
Contra-indications to culdoscopy
Instrumental methods of examination
Contra-indications to this operation
DOCTOR'S ROUND IN GYNECOLOGICAL DEPARTMENT
Doctor's work in gynecological department begins from the round. It is desirable, that a nurse would be present on doctor's round telling him about changes in patient's state during previous day, noting doctor's prescriptions into the form. Going on the round, a doctor must show interest what temperature has each patient, what changes are in analyses, done the day before. One should begin doctor's round from interrogating and examination of such patients, whose state is the most severe, and to finish it by examination of convalescent ones, however it is necessary to pay sufficient attention to every patient, because a woman can think, that her health state is underestimated. It's necessary to remember, that not every question can be put to woman in the ward, in presence of other patients, because they can touch intimate things and woman can give a doctor incomplete information, that will influence on diagnostics and treatment.
A volume of everyday inspection depends on pathology, because of which a patient stays in a hospital. Outside that, all patients are obligatorily inquired about complaints, whether their state of health has changed during previous day, what changes took place. After this a doctor examines a patient, estimating a state of skin, mucous membranes, pulse description, measures of arterial blood pressure. This is very important during examination of postoperative patients. One should look at abdomen (its participation in breathing act), to perform its palpation (painfullness, presence or lack of peritoneum rebound tenderness symptoms), at necessity performs auscultation (available or absent peristalsis, its description). In postoperative patients a bandage state (dry, wet through), operation wound, drainages function, amount of discharge from them are obligatorily estimated. It is necessary to estimate the amount and character of vaginal discharge. The character of urination, defecation, gases passing are checked up too. Gynecological examination is performed once in 3-5 days, depending on the pathology. (Detailed examinations at each pathology are described in suitable chapters).
All data, got during examination of patient, are estimated comparing with previous day and written into the "Medical card of stationary patient".
One should inform a patient about some prescriptions and results of analyses, especially about examination of vaginal smears, not in the ward, in presence of other patients, but in the examining room.
Each patient, that is hospitalized into permanent establishment, must be examined by the head of the department together with her doctor-curator during first three days. Each week he must make the round, to make correctives in examination and treatment of patients at necessity.
In clinical hospitals and maternity hospitals professors and assistant professors make regular doctors' rounds. On these rounds the Head doctor, doctor-curator and all the doctors of the department are present. A doctor-curator tells professor or assistant professor about the diagnosis of each patient, the treatment, that she receives, changes in disease course, that took place during treatment. If there are no doubts in diagnosis, at positive cure results a professor contents with doctor's information, that's why it must be full and objective.
Patients with the most complicated pathology, incomprehensible diagnosis, and those who have no expectative results of the treatment, are examined by professor in detail, including gynecological examination. After examination a professor or assistant professor gives recommendations for additional methods of examination, further treatment. During examination the questions about necessity, volume and time of surgical intervention are decided. Such rounds are a very good school for doctors, especially for beginners.
Examination of gynecological patient consists of history taking, objective (general and special) and additional methods of examination. The examination begins with obtaining the history in accordance with a certain plan.
First of all, the passport data is required: surname, name, patronymic, and also birth date (woman's age). This is done because each phenomenon in different age of women lifecycle can have different meaning, for example, absence of menses in young women and women in menopause.
History taking. History has extraordinary value in gynecology. Sometimes it deals with the intimate life problems, that's why it is necessary to ask a patient delicately and accurately for obtaining sufficiently full and exact information. Carefully taken history sometimes is sufficient for making the previous diagnosis. At first patient should be asked about complaints, development of the disease (anamnesis morbi), life conditions and the previous diseases (anamnesis vitae). Gynecological history should be taken in such a way.
Patient Complaints. Most often patients complain of pain, pathological secretions from vagina, bleeding and also of the adjacent organs' dysfunction. The character of pain may point out the disease: the dull pain arises due to abnormal uterine position and chronic inflammatory processes of ovaries. Colicky pain appears in case of uterine or tube contraction (tube or uterine abortion, protruding myoma). Pain has stabbing and stinging character in case of inflammation. Its intensity becomes more severe that is followed by peritoneal irritation. Such pain appears at blood presence in abdominal cavity. Pain has an acute, cutting character at uterine tube and pyosalpinx rupture. Permanent pain is typical for chronic inflammatory diseases and malignant tumors. Pain appeares in sacrum and dorsal lumbar region in dorsal uterine dislocations (retropositio uteri), parametritis and perimetritis. In adnexal diseases pain is present in lateral regions of the lower parts of abdomen. In the diseases of external genital organs pain is situated in place of lesion. Pain irradiation into sacrum, thigh, supraclavicular region (phrenicus-symptom) is typical for some gynecological diseases.
Leucorrhea is a discharge from vagina, that is common at inflammatory processes, uterine disposition and tumors. It is important to pay attention to amount, colour and smell of the discharge. For instance, at trichomoniasis it has "foamy" character, in case of candidiasis it is cheese-like, at cervix erosions it has mucous character, and in case of malignant tumors it looks like "meat slops".
Bleeding can be the manifestation of irregular menstrual cycle, malignant processes and pregnancy.
The physician should inquire about disorders of adjacent organs such as the character and frequency of urination (pain, urine incompetence, extremely frequent urination), defecation (constipation presence, pain at defecation act) and also about the general disorders (hot flushes, palpitation, dizziness, loss of weight or, to the contrary the obesity).
Gynecologic History (anamnesis morbi). The following questions are typical for gynecologic history:
Correct taking of gynecological history gives a possibility to make a previous diagnosis with sufficient exactness. However, doctor can perform definitive conclusion about disease only after carrying out an objective examination.
^ (anamnesis vitae) should define, in which conditions woman has grown up and was formed and also in which conditions she lives at present. Conditions, in which girl lived from early age can have effect on the development of the whole organism. Important value has a full-valued rational feeding, especially in the period of puberty. Excessive or, on the contrary, insufficient feeding can cause wrong forming of the genital system, menstrual and regenerative dysfunction. Material-domestic and job conditions have also a great effect on woman's health state.
Professional and work conditions. There are many professional factors, that have negative effect on woman's health. First of all this is weight lifting, that can contribute to genital organs prolapse, long standing on feet can cause blood stagnation in lower extremities and in pelvic organs causing hypersecretion of mucous membranes. Salts of heavy metals, aniline paints, varnishes and some other chemical substances and radiation have harmful effect on woman's health. Most frequently their action causes menstrual and regenerative dysfunction. Mental overloads can also cause various disorders.
Previous diseases. It is important to find out whether the patient was ill with tuberculosis and sexually transmitted diseases. It is important to know whether the operative interventions on abdominal cavity organs took place. Appendectomy in the past can provoke ovarian inflammation and lately performed appendectomy should be a cause of adhesion process.
Special importance has allergic history, for instance, presence of allergic reactions on some medicines. The physician should inquire patient about harmful habits (smoking, alcoholism and drug abuse).
^ includes data about menstrual, sexual, generative and woman's secretory functions.
Menstrual history reflects the state of sexual system and organism in a whole. It is important to establish the patient's age at first menstruation (menar-che), the interval from the first day of one menstrual period to the first day of the next menstrual period (cycle length), the duration of the menstrual flow, the estimated amount of flow (number of pads) and pain presence.
Late appearing of menses can point to infantilism. Normal amount of blood loss is about 150 ml. If there is an excessive blood loss, myoma or endometriosis should be suspected. Menses duration is also increased in these diseases. Painful menses are present if inflammatory processes, endometriosis is present. It is important to know whether menses character has changed with the beginning of sexual life, after delivery and abortions. Interrogating is finished by asking about the character and date of the last menses.
If a patient has menopause it is necessary to specify, at what age it has begun, how the transitional period passed, whether she has bloody secretions from vagina (this thing can testify about endometrial cancer).
Sexual history. Special tact should be while inquiring woman about this function. It is important to know whether the woman is married or not, about the presence of sexual partners, whether there appeared any signs of disease beginning of sexual life or with partner change. Patient's contraceptive history should include the contraceptive method currently used, when it was firstly used, any problems or complications connected with the method and her partner's satisfaction with the method. It is necessary to ask about the main compounds of sexual function: sexual appetite, orgasms. In case of sexual dysfunction it is important to know whether there where any factors that could negatively affect woman's sexual function (trauma, rape etc.). Some peculiarities of sexual function can give information about presence of concomitant disease. If there is contact bleeding one can suppose cervical diseases such as erosion, endometriosis and sometimes cervical cancer. Painful sexual act can point to the inflammatory processes of peritoneum, ovaries, nearby uterine cellular space and vaginism.
Generative (childbearing) function. Childbirth is the women's basic function. In this part one ought to find out, in what time after the beginning of sexual life the first pregnancy had happened without contraception, how many pregnancies were in the past, what was the duration of each one and how they have finished (with delivery or abortion), whether there were premature births or, stillborn children. One should know about babies death in early neonatal period, about the character of the complications during and after delivery, about the operative interventions during delivery. In case of performed abortions the patient should be inquired about whether were they artificial (at woman's desire), spontaneous, or criminal, in what terms pregnancy was interrupted, were there any complications during and after abortions. If abortions were spontaneous what were their causes.
Absence of pregnancy for a year of sexual life testifies sterility, that can be a concern of woman's genital organs abnormality, ovarian dysfunction or result of the inflammatory process. Rare pregnancy and its frequent loss indicates on hormonal insufficiency. One should obligatorily find out whether the woman uses contraceptives, which ones and during what time.
Secretory history. Much discharge from genital organs is an indication of the gynecological diseases presence. It is necessary to know about amount, smell, appearance, discharge periodicity, because at different gynecological diseases their character differs (due to trichomonal vaginitis they have "foamy" character, in candidiasis — cheese-like character, in malignant tumors — the appearance of "meat slops").
It starts from general examination. It is important to pay attention to the colour of skin: pallor can indicate anemia, ground colour characterizes malignant neoplasm presence.
Excessive hairiness, the lipids dysmetabolism can indicate presence of endocrine diseases.
Dry, coated tongue can indicate to the inflammatory process, "raspberry" one points to candidiasis.
Attention should be paid to the form of the abdomen (tumors of abdominal cavity, ascitis). It is importnt to determine whether the abdomen takes part in breathing act. Palpation gives a possibility to find presence or absence of abdominal wall muscles tensity that is common for ovarian inflammation, torsion of the pedunculated cystoma. Extension of inflammatory process from ovaries to peritoneum or blood presence in abdomen causes positive symptoms of peritoneal irritation. Deep abdominal palpation reveals tumors or infiltrates in pelvis.
Special attention in examination of gynecological patient belongs to breasts palpation. It is important to find presence or absence of consolidations in breasts, character of discharge from nipples. Patient needs additional examination in case of sanious discharge from nipples. The axillary and inguinal lymphatic nodes should be also examined.
Auscultation of abdomen can be useful to determine of bowels peristalsis (at pelvioperitonitis it is languid, at peritonitis it is languid or absent). Auscultation is used for differential diagnostics of pregnancy and tumor.
Each symptom that is found during physical examination should be estimated in complex with the others.
Gynecologic examination. All the methods of gynecological examination are divided into basic which are obligatory, and additional those are performed according to certain indications.
To basic methods belong:
Following methods belong to additional ones:
Basic methods of examination
Gynecological examination is performed on the examination table. Woman lays on back, with half-flexed legs in femoral and knee joints. It is obligatory to empty the urinary bladder before examination, in some cases vacuant enema is indicated. Examination is made in sterile gloves.
Pelvic examination begins with the inspection of external genital organs. Attention should be paid to pubic hair type (masculinizing, feminizing or mixed type), presence or absence of hair on theinternal thigh surfaces. Skin irritation in the same places can occur at excessive discharge. Doctor should examine the labia major and labia minor, their size, pigmentation, presence or absence of edema, ulcers, condylomatous nodes and varicose veins. The degree of pudendal cleft closing is marked. The labia are spread laterally to examine the outer of vagina, pigmentation, colour, presence or absence of ulcers. Estimation of hymen (intact, torn, fresh ruptures) is obligatory. Making examination of clitoris an attention should be paid to its size. The urethral orifice, the areas of the urethra and Skene's glands should be examined. Doctor examines whether there are any secretions, polyps vegetation or hyperemia in this area. The region of the Barto-line's glands should be inspected. Estimation of their excretive ducts (discharge character, hyperemia, edema around orifices) is performed. Perineum state, old ruptures presence, scars, hemorrhoid nodes in anus region, condylomas, fissures, ulcers and mucous membrane are also inspected. Offering a woman to push doctor should determine the presence or absence of prolapse of vagina or uterus.
After finishing of external genitals inspection vaginal speculum examination is performed. For this purpose single-blade Sims' speculum with vaginal retractor or bivalve Cuskoe 's speculum. Recently single-use bivalve specula were used.
Bivalve speculum is introduced into vagina with closed values. With thumb and index fingers of the left hand labia are drawn and speculum is inserted into vagina, placing blades parallel to pudendal cleft. After insertion speculum is turned on 90°. The speculum is inserted as far as it goes which in most women means insertion of the entire speculum length. The speculum is then opened in a smooth delicate way with slight tilting of the speculum, the cervix slides into space between the blades of the speculum. The speculum is then locked into the opened position using the thumb screw.
Sims speculum is inserted into vagina in such a way: with left hand labia major and minor are drawn laterally and with right one the speculum turned, slantwise to pudendal cleft is inserted into vagina, slightly pressing on perineum. Flat anterior speculum (lateral) should be inserted parallely, lifting up anterior wall of vagina. Flat speculum should be inserted additionally in case if vagina is wide and its lateral walls are hanging.
Uterine cervix, its size, shape (cylindrical, conic), shape of external os (round in nonparous women, fissured in parous ones) must be inspected. Character of the cervical mucous membrane (cyanosis, hyperemia), erosions, ruptures, inversions, condylomas presence, hyperemia around external cervical orifice, secretions character may be marked.
After cervical examination speculum is gradually withdrawn, inspecting vaginal walls. Attention should be paid to the state of mucous membrane (hyperemia, edema), discharge character.
During inspection by Sims speculum at first the elevator, and then the speculum are withdrawn.
After finishing speculum examination, bimanual vaginal-abdominal and rectal-abdominal examination should be performed.
^ (vaginal-abdominal) examination. With thumb and index fingers of the left hand labia minor are spread. The middle and index fingers of the right hand are inserted into vagina, nameless and little fingers are pressed to palm, and thumb finger is facing the pubis. An examination is made by one finger if vagina is narrow. Fingers during insertion into vagina should be gently pushed downwards to avoid unpleasant feelings of irritation of the most sensible areas such as anterior wall, clitoris, region of urethra. During introducing fingers into vagina following signs are estimated: presence or absence of pain, outer width (in women, which live sexual life, two fingers enter easily). Determination of the muscles tone and perineum state is performed with pressing on the muscles of the pelvic floor. During gradual moving of fingers into vagina its length, width, ability to tension, rugosity, humidity degree, septums presence, tumors, scars, constrictions are determined. An attention to vaults depth, presence or absence of pain, hanging, shortening should be paid. After palpation cervical form (cylindrical, conic, deformed), its size (underdeveloped, normal size or hypertrophied), presence or absence of ruptures, state of external os (opened, closed, deformed), consistence (dense, sclerosed, softened, of heterogeneous consistence), tumors presence are determined. Cervical attitude to pelvis axis is also estimated. Then fingers are placed into anterior vault and cervix is pushed to back. With abdominal hand one should cautiously press on the front abdominal wall towards fingers those are inserted into vagina. So, uterus is found between fingers of the abdominal and vaginal hands. If uterus is retroflected, then vaginal fingers are placed into the posterior fornix.
Uterus is situated in pelvis in such a way that its body and cervix form an angle, opened frontally (anteflexio), and the whole uterus is flexed forward (ante-versio). It is sufficiently mobile at displacement attempt. Overmobility of the uterus is observed at its descent and prolapses due to incompetence of ligament system. Limited movability is common at adhesions and infiltrates presence in true pelvis.
During uterus examination its size (in nonparous women it is smaller than in parous ones) is determined. Diminish of the uterus size is observed at genital infantilism and menopause. Enlarged uterus can be found at pregnancy and tumors presence. Uterine shape normally is pear-like, flattened in front-back direction, at pregnancy it can be asymmetric due to protrusion of implantation place, at subserous fibromyoma it is tuberous. Uterine consistency is tightly-elastic and painless.
Bimanual examination of the adnexa begins with placing the vaginal fingers to the side of the cervix deep in the lateral fornix. It is important to note that the fallopian tubes are not palpable. Ovaries can be palpated as elastic painless structures. They are mobile and rather sensitive. Normal uterine and ovarian ligaments could not determined. Normally there is no pain and infiltration in paramethrium.
^ In girls, or in case of athresia or stenosis of vagina recto-abdominal examination is made. This method should be used for more detailed inspection of pelvic organs tumors. The examination is made by introducing index finger into rectum. As at previous examination external hand is placed on the anterior abdominal wall over pubis. Vaginal part of cervix which directly adjoins to the anterior wall of rectum is palpated. Its size, mobility, uterine and adnexa sizes, sacral-uterine ligaments and parametriums are palpated.
They are: bacterioscopy examination (smear for purity degree), cytologic investigation of vaginal smears, bacteriological checkup, methods of functional diagnostics, colposcopy, biopsy, uterine sounding, fractional diagnostic curettage of cervical canal and uterine cavity with the following histological research, culdocentesis, pertubation and hydrotubation. X-ray examination methods such as hysterosalpingography, pelviography and bicontrast pelviography are also used. Colposcopy, hysteroscopy, laparoscopy and culdoscopy are endoscopic methods in gynecology. Ultrasonic examination is wide-spreaded nowadays. These methods are used for verification of the diagnosis. Cytologic investigation is obligatory for women who undergo monitoring.
Nurse or midwife prepares the woman and necessary instruments (specula, sets for abrasion, spoons or brushes for smear taking) for carrying out additional examinations. Nurse must prepare a bottle with 10 % formalin solution for tissual fixation of the biopsy tissue after curettage. Proper assignment registration on research is of great importance.
Smears from vagina are taken for purity degree, gonorrhea, oncocytologic investigation, "hormonal mirror".
Following instruments are necessary for material taking:
Patient's preparation :
Bacterioscopic investigation of vaginal discharge gives possibility to determine vaginal purity degree, bacterial flora, presence of contraindications to different diagnostic manipulations. This method gives possibility to diagnose inflammatory process.
Technique of smear taking for examination on vaginal purity degree:
Laboratory assistant quantifies epithelium cells, leukocyte number, microflora character (Doderlein's bacillus, pathogenic flora — gram-negative bacillus, cocci, fungi, trichomonades, gonococci) and also reaction of vaginal discharge.
There are 4 stages of vaginal discharge purity.
^ Material for research is taken just from the cervical canal, urethra (before urination after light massage of the posterior urethra wall) and rectum drift on a glass slide as separate strokes.
Bacteriological research is taken to find the pathogene and its sensitiveness to antibiotics. Material for research is a content of cervical canal, vagina, urethra and puncture material. This material should be sent into bacteriological laboratory. It is necessary to indicate the date and time when the material was taken.
Oncocytologic research (Pap smear) is made for the early diagnostics of oncologic diseases.
Smear taking technique for oncocytologic research:
Cytological investigation gives a possibility to reveal women who need more detailed examination (biopsy, diagnostic curretage, etc).
There are 5 Pap smear types:
I type — unaltered epithelium
Il-a type — inflammatory process
Il-b type — proliferation, metaplasia, hyperkeratosis (at corresponding clinical picture they are interpreted as polyp, simple leukoplakia, endocervicosis
Ill-a type — light, moderate, dysplasia on the background of benign processes on unaltered epithelium
Ill-b type — severe dysplasia of squamous epithelium on the background of benign processes and on unaltered epithelium
IV type — suspicion on malignisation, intraepithelial cancer should be possible
V type — cancer
VI type — smear is non-informative (material has been taken in a wrong way)
^ Material is taken by light touch of instrument from the upper one-third of lateral vaults not earlier than in 2 days after cessation of any manipulations in vagina. The taken material is thinly smeared on a glass slide. Woman's age, pregnancy term or day of menstrual cycle is indicated.
This method can be used for diagnostics of pregnancy loss, menstrual cycle disordes and also as a control for hormone therapy results.
Properties of cervical mucus. Properties of cervical mucus are changing due to estrogen and progesterone action during menstrual cycle. Maximum quantity is secreted during ovulation, the minimum is secreted before menses.
The mucus tension symptom. In case, when you place some mucus from cervical canal between forceps legs and carefully move them apart, then you'll get a mucus string, the length of which depends on the mucus viscosity. Maximum length of the string will be in ovulation period when mucus viscosity is maximal. String's length is measured in centimeters (the greater estrogen production the longer is the string) and is estimated for 3-point system: 1 point (+) at string length up to 6 cm (early follicular phase), 2 point (++) — 8-10 cm (medium follicular phase, moderate estrogen saturation), and 3 point (+++) when string length is 15 cm and more (maximum estrogen saturation). Tension symptom diminishes and then disappears in luteal phase of menstrual cycle.
^ Cervical tone and its external os diameter are changing during menstrual cycle under the influence of estrogen hormones. Dilatation of external cervical os and mucus appearance in it starts from the 8-9th cycle day and up to the 14th day it is maximally dilated (up to 3-6 mm in diameter). Mucus drop, that comes forward from external os seems to be dark and looks like a pupil at illumination on the background of pink cervix. This is a positive "pupil" symptom. Amount of mucus begins to decrease during the next days and up to 18th-20th day of the cycle this symptom disappears and cervix becomes "dry". Such changes are typical for normal menstrual cycle. In case of follicle persistence, the "pupil" symptom does not disappear up to the time when bleeding occurs. This indicates on hyperestrogenemia and absence of luteal phase in ovaries. The "pupil" symptom is slightly positive or absent at amenorrhea. This symptom is also absent during pregnancy. The "pupil" symptom is estimated on the 3-point system: presence of small dark dot means 1 point (+), early follicular phase; 2,0-2,5 mm — 2 points (++), medium follicle phase; and 3,5 mm — 3 points (+++), ovulation. If cervix is strained by postnatal ruptures, erosion or endocervicitis test is unreliable.
The "fern symptom ". The "fern test" is used to distinguish the ovaries functional state. It is named from the pattern of absorbtion that occurs when discharge is placed on a slide and is allowed to be dried in the room air. Arborisation intensity depends on the menstrual cycle phase i.e. on the ovarian estrogenic effect. Mucus is taken by forceps, which are inserted into cervical canal to depth of 5 mm. Then it is drifted on a glass slide, dried up and examined under the microscope. Such varieties of "ferm symptom" are distinguished as:
This test like the previous one is used for ovulation determination. Presence of "fern symptom" during the whole menstrual cycle indicates on high estrogen saturation (persistation of the follicle) and absence of the luteal phase; absence of this symptom can testify about estrogen insufficiency. Diagnostic value of all the described above tests is considerably increased in their complex using.
Basal temperature. Basal temperature (BT) changing is based on the hyperthermic influence of progesterone on hypothalamus. BT is measured in rectum in the morning regularly by the same thermometer with the empty stomach, without getting up. In first phase of menstrual cycle temperature is below 37 °C (0,2-0,3° lower), after ovulation it rises and holds on between 37,1-37,4 °C. Basal temperature change indicates on presence or absence of ovulation, follicle persistence, threatened abortion and some other states. This test is simple, easily available and sufficiently objective, however one should remember, that any causes of non-hormonal character (diseases, that are accompanied with temperature reaction) can affect it. It is necessary to carry out measuring during 2-3 cycles. Only in this case this method has the diagnostic value.
During examining degree of estrogen saturation determines the morphology of vaginal epithelium, which is changing during menstrual cycle. Basal, parabasal, intermediate, superficial layers are distinguished in the stratified squamous epithelium of vagina. Vaginal epithelium is exposed to rhythmic changes during menstrual cycle, that is characterized by different stages of mucous membrane proliferation. According to degree of organism saturation by estrogens, superficial, intermediate and basal cells in different ratio are differed. Method of colpocytodiagnostics is based on the determination of quantity and morphological peculiarities of epithelial cells.
Cells' disposition (layers presence) and amount of the "rolled up" cells should be determined for revealing of progesterone effect on vaginal epithelium. Progesterone stimulation degree is estimated for 3-point system too: the plenty of the "rolled up cells" makes 3 points (+++), moderate amount makes 2 points (++), low quantity makes 1 point (+), undetermined cells makes 0 (-).
Due to functional diagnostics tests and cytological research data normal menogram may be represented.
Colposcopy, cervicoscopy, hysteroscopy, laparoscopy and culdoscopy are used in gynecology. Endoscopes are necessary for all these methods. Some of them have manipulators, with the help of which some medical operations in abdominal cavity could be performed.
Colposcopy is the first endoscopic method that is wide spread in gynecology.
Colposcopy. A colposcope is a fixed stereomicroscope with a source of internal light and magnification in 10-30 times used to facilitate the detailed examination of the cervical surface, vagina and vulva when malignacy is suspected. It is used to make direct biopsies of suspecious area and to control the process of healing during the treatment. Diagnostic value of this method is extraordinarily great. There are simple and broadened colposcopies. During simple colposcopy cervix is visualized without the previous processing with chemical substances. During broadened colposcopy cervix is examined after application of 3% solution of acetic acid with 3% Lugol solution.
Some models of colposcope allow to make research by method of fluorescent analysis thanks to revealing of secondary gleaming in ultraviolet rays.
^ has preliminary character and gives possibility to define the cervix and its external os, colour, relief of mucous membrane and squamo-columnar junction.
After the simple colposcopy cervix is processed by 3% solution of acetic acid, which causes temporary (up to 3 min) epithelium edema, constriction of the subepithelial vessels and decreasing of blood supply. This method is called broadened colposcopy. It gives a possibility to distinguish distinctly flat epithelium from the columnar One, to find the epithelium transformation, state of glands ducts etc. After this cervix is processed with 3% Lugol solution (Shiller's test). Iodine has ability to paint the cells, rich with glycogen into brown color. Pathologically altered cells (at dysplasias), and also atrophic cells are poor with glycogen, that's why they are not painted with iodine and look like white blots. In such a way the areas that undergo biopsy are revealed. , One of the modifications of broadened colposcopy is cervical chromocolpo-scopy. It is performed after application of some paints: hematoxylin, toluidin blue or methylviolet. The last one paints tissues into the violet colour (only the squamous epithelium). Vsage of these dye-stuffs allows to fmd borders of lesion and to choose the area for biopsy.
Colpomicroscopy is a histological examination of vaginal part of cervix without making a biopsy. This research is made with contrasting luminescent colpomicroscope, the tubes of which are directly enclosed to cervix. Before examination cervix is processed with 0,1% hematoxylin solution. Then nuclei acquire violet colour, cytoplasm is sky-blue; cells of the squamous epithelium have polygonal form and distinct borders. Subepithelial vessels have proper, not expanded bifurcations. This method has high accuracy. Its results in 97-98 % of cases correlate with histological research data.
Hysteroscopy is the method by which uterine mucous state, presence of polyps, cancer, synechias and submucous fibromyoma of uterus may be diagnosed, polypectomy should be controlled, and place of sighting biopsy is chosen. Modern hysteroscopes make magnification in 5 times (fig. 31).
After dilation of cervical canal hysteroscope is inserted into the uterine cavity. Hysteroscopy is performed introducing into its cavity carbonic gas (gaseous hysteroscopy) or liquid (liquid hysteroscopy). Preference is given to liquid hysteroscopy (inserting of the isotonic Sodium chloride solution, Polyglucin etc.), because it gives a possibility to make control after diagnostic curettage. It is also performed at uterine bleeding. Liquid washing the walls improves examination pos-ibility.
^ cyclic and acyclic uterine bleedings, suspicion on intrauterine pathology, and especially continuation of bleeding after fractional diagnostic curettage. This method is also of a great value to control treatment of hyperplastic processes.
Contra-indications for hysteroscopy: acute inflammatory diseases of genital organs, III-IV stages of vaginal cleaning, and also extragenital pathology such as thrombophlebitis, acute pyelonephritis, serious cardiac-vascular pathology. Special hysteroscopes with manipulators are introduced recently. They are able to perform polypectomy, submucous myomatous nodes enucleation, intrauterine contraceptives insertion.
Laparoscopy gives a possibility to visualize internal organs of the abdominal cavity, including the organs of true pelvis (fig. 32-34). Ovarian and uterine tumors, extragenital tumors, ectopic pregnancy, polycystic ovaries and ovarian inflammatory processes may be diagnosed with laparoscopy. Except that, this method can specify the cause of the "acute abdomen".
Recently laparoscopy is used not only as a diagnostic method. Laparoscopy becomes a necessary method for taking of ovum with aim of the extracorporal insemination.
New models of laparoscopes are created. They are used for ovarian biopsy, cystectomy, dissection of adhesions and other operations.
Indications for laparoscopy in planned order:
In urgent cases laparoscopy is performed for diagnostics of:
Contra-indications to laparoscopy: decompensed heart failure, essential hypertension, kidneys' and liver insufficiency and other severe diseases.
Culdoscopy is made for ovaries examination in case of obesity. This method is rarely used. It is almost displaced by laparoscopy. Intervention is made under the local anesthesia with 0,25% Novocain solution. Examination is made in knee-elbow position of the woman. Under specula control a needle is introduced into posterior fornix, air penetrates through it into abdominal cavity independently. Bowels then move to diaphragm. Cut of 3-5 mm length at posterior fornix is made to introduce the laparoscope optical system. Accessible for examination area done with this method is considerably less than at laparoscopy — one can see posterior uterine surface, ovaries, tubes.
^ : presence of adhesions in small pelvis, tumors of small pelvis, and also extragenital pathology, that is contraindication to laparoscopy.
This method is based on tissual ability to absorb or to reflect ultrasonic waves in different ways. It is used for diagnostics of tumors, differential diagnostics between tumor and pregnancy. The examination is made while urinary bladder is filled that makes some discomfort for women. The day before it is necessary to make the evacuant enema.
Vaginal sonography and dopplerometry are widely used for recent years. Last models are so perfect that they'are used for follicle growth control, ovulation observing, endometrial thickness, hyperplasia and polyps determination. Vaginal sonography allows to diagnose a pathology without fiiiing urinary bladder. Obesity and adhesion process do not affect on this examination. This method gives a possibility to diagnose retrocervical endometriosis and ovarian inflammation that is impossible to diagnose by the abdominal sonography.
Examination by tenaculum gives a possibility to specify uterine and ovarian tumors origin.
Necessary instruments: Sims speculum with retractor, pincers and tenaculum.
Cervix is opened by specula, then it is processed with disinfective solution and gripped by the anterior lip with tenaculum. Specula are taken out after that. The tumor is displaced upwards during the bimanual examination. If tumor is connected with uterus, then another method should be used. The doctor displaces tumor upwards, and assistant pushes the tenaculum downwards. During this tumor's pedicle stretches and "becomes accessible for examination.
^ This method allows to determine cervical canal permeability, length and configuration of uterine cavity, neoplasm presence in uterus. Sounding is used not only as a single diagnostic method, but it is a stage of some operations (dilation and curettage).
Necessary instruments: specula, pincers, tenaculum and uterine sound. Manipulation is made in extraordinarily sterile conditions. Sound is an incurved metallic instrument 20-30 cm long, with transversal centimeter points. There is a bulbous nodule on the probe end.
Operation technique. After speculum examination and disinfection the cervix is gripped for the anterior lip with tenaculum. Retractor is taken out dragging the cervix introitus of vagina, a little posteriorly (at anteflexio uterine position), straightening the cervical canal. Sound is carefully pulled through the external os into the canal and beyond the borders of internal os, which is felt as nonsignificant resistance, then into uterine cavity. At anteflexio uterine position, sound is directed forward, in retroflexio — backwards. Sound insertion allows to measure uterine length, then to determine the form of its cavity by sliding on anterior, posterior and lateral uterine walls, presence of tumors, membranes and polyps in it. Sounding is made exceptionally in stabile patients condition, because sometimes such complications as bleeding and uterine perforation may develop.
^ : III-IV stages of vagina purity, vaginitis, endometritis, cervical neoplasia, suspicion on pregnancy.
Biopsy is a tissue taking for histological research. Most frequently biopsy is taken from the cervix at erosions, dysplasias, papillomas presence. It is performed under control of colposcopy. Sometimes tissue for research is taken from female external genitalia such as vulva, vaginal walls, and from the other places depending on the lesion localization.
Sims speculum with retractor, forceps, tenaculum, scalpel or conchotom are necessary for biopsy. Cervix is examined with specula, then it is disinfected and gripped with two tenaculums on both sides of biopsy place. A slice of tissue should be cut out in such a way, that there must be not only altered, but also non-altered tissue. Material can be taken also by conchotom. The tissue is poured over with 10 % formalin solution and then sent to histological laboratory.
Diagnostic fractional dilatation and curettage. This method is one of the biopsy modifications. It is made if polyps, dysfunctional uterine bleeding, suspicion on polyposis of mucous membrane, malignant tumors are present. Before the operation pubic hair should be shaved and urinary bladder emptied. The following instruments are necessary: Sims speculum with retractor, pincers, tenaculum, uterine sound, Hegars dilators and curettes.
The operation is performed under the general (intravenous) or local (para-cervical) anesthesia. Novocain anesthesia must be done in sterile conditions. Cervix is disclosed by specula and desinfected. The anterior lip is gripped with tenaculum, then it is pulled a little posteriorly (at anteflexio uterine position) or to symphisis (at retroflexio uterine position). Uterine sound for its length determination is used. Hegars dilators are inserted into the cervical canal. Each one is 0,5 mm wider, than previous one. Dilation is made up to 9-10 number of dilator. After dilation the curette is inserted..One should watch whether its curve coincides with the uterine curve. Then insert the curette into the cervical canal and scrape off its walls. The material is collected into the separate bottle with 10% formalin solution. Curette end reaches the uterine fundus and then gradually scrape off mucous from all the uterine walls by motions from fundus to cervix. The obtained material is inundated with 10 % formalin solution and send to histological research.
^ III-IV stages of vaginal purity, acute inflammation of uterus and its adnexa, infectious diseases, rising temperature (except of the cases when abrasion is made for cure purpose and according to vital indications).
Culdocentesis. Puncture of abdominal cavity is made through the posterior fornix . This method gives a possibility to diagnose (or to exclude) ectopic pregnancy or pelvioperitonitis by receiving blood or exudation of inflammatory character (serous, purulent) from abdominal cavity. Puncture of abdominal cavity is made through the anterior vaginal wall at ascitis presence.
Sims speculum with retractor, tenaculum, syringe with long needle and forceps are necessary for culdocentesis. Preparing is the same as for uterine dilation and curretage.
^ involves needle puncture of the posterior vaginal cuff to identify free fluid in the posterior fornix
Cervix is disclosed by specula and disinfected. The posterior lip is gripped with globular forceps, cervix is pulled forward making posterior fornix visible. Puncture is made by needle in the middle of sacro-uterine ligaments on the depth of 1 -2 cm. After that the syringe piston is weight down at simultaneous slow moving out the needle. If pus is present during the punction, it is send into laboratory for bacteriological investigation. Antibiotics are injected into abdominal cavity.
Determination of uterine tubes' permeability. For examination of uterine tubes' permeability insertion of air (pertubation) or liquid (hydrotubation) is performed. For this method speculum with retractor, tenaculum, special apparatus which consists of tubes system with balloon for pumping air or with devicp for insertion of liquid are required. This system is connected with pressure-gauge showing the pressure, under which air or liquid is pumped. Manipulation is made in sterile condition.
Contraindications: III-IV stages of vaginal purity degree, vaginitis, cervicitis, acute and subacute inflammatory processes in uterus and its adnexa. Non-keeping of these demands can cause complications up to peritonitis.
^ . Woman lays on the table. Cervix is disclosed in spe-culums and disinfected. The anterior lip is gripped with globular forceps, and a device's tip is inserted into the cervical canal. Air or liquid pumped by balloon pass through the uterus into the tubes. Kymograph record of tubes' contractions should be used during pertubation. It is necessary to perform hydrotubation and pertubation during the first week after menses. Air or liquid is pumped up to 100 mm.Hg pressure, then a short pause should be made and then pressure is raised up to 150 mm.Hg. Maximal pressure to which air or liquid can be pumped is 180 mm.Hg.
At uterine tubes occlusion the following signs are present:
Permeability of the uterine tubes can also be defined in a retrograde way. During laparotomy a special cannula is inserted into tube's ampula, then it is snuggled with fingers and by syringe the liquid is injected into the tube. A t tubes' occlusion they are stretched by liquid in the obstructed place.
Hysterosalpingography (metrosalpingography) gives a possibility to research tubes' permeability, defects of internal genitalia,uterine abnormalities, endometriosis, presence of submucous fibrous nodes, synechias.
Contraindications for this method: inflammatory processes of woman's genitalia, suspicion on pregnancy, III-IV stages of vaginal purity degree. Instruments, necessary for hysterosalpingography: Sims speculum with retractor, tenaculum, Brown's syringe and contrasting substance.
^ : The cervix is opened by specula and disinfected. The anterior lip is gripped with tenaculum, contrasting substance is inserted into uterus by Brown's syringe and then X-ray examination is made. The internal contours of uterus are clearly visible on the film, its cavity has triangle form. Contrasting substance outpours into abdominal cavity through the permeable tubes.
Rhoentgenopelviography. Through a special device carbon gas is inserted into the abdominal cavity (through puncture of frontal abdominal wall, or posterior fornix). Roentgenogram should be made after this. The configuration of uterus, ligaments and ovaries are perfectly visible. This method is used at suspicion on uterine abnormality, polycystosis.
^ is a combination of metrosalpingography and pelviography. This method gives a possibility to perform detailed examination of the internal genitalia condition.
Rhoentgenological examination-of the adrenal glands on the background of pneumoperitoneum and rhoentgenogram of turkish saddle in some cases is required.
For diagnostics in gynecology axial computered tomography is rarely used in everyday practice. It is expensive method.
This method includes medical-genetic counseling and cytological research.
Cytogenetic analysis is performed by genetics specialists. One of the basic methods of cytogenetic investigation is the sexual chromatin determination. This method plays an important role in diagnostics of congenital defects of genital glands. Determination of sexual chromatin is made in nucleus of superficial epithelial cells, which are received by abrasion from mucous membrane of internal cheek surface by spatula.
One of X-chromosomes makes sexual chromatin. Normally its quantity is 16-28% (quantity of nuclei that possess a corpuscle of sexual chromatin per 100 counted nuclei). Changing of quantity and structure of sexual chromosomes leads to changing of percent of sexual chromatin containing.
Determination of sexual chromatin can be used as a screening-test. Analysis of caryotype in connection with its complicity is made only for some indications, namely: deviation in sexual chromatin amount, presence of short height in patients, plural, frequently effaced anomalies of somatic development, dysplasias, and also in plural mutations or spontaneous abortions in early terms of pregnancy.
Determination of caryotype is obligatory in patients with gonad dysgenesia, because presence of Y-chromosome indicates on the high risk of malignant growth possibility.
|Department of nervous diseases, psychiatry and medical psychology|
«syndrome of burning out». Ways of his warning. Communication in a medical environment. Observance of ethical requirements. Types...
|Department of nervous diseases, psychiatry and medical psychology|
«syndrome of burning out». Ways of his warning. Communication in a medical environment. Observance of ethical requirements. Types...
|Of conferences, round able discussion, seminars and other scientific events for academic year 2012-2013||M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Rickets|
|M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Diarrhea||M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Anomalies of constitution|
|M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Acute bronchitis in children||M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Respiratory failure in children|
|M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Malabsorption syndromes in children||M. Gorky Donetsk National Medical University Department No. 2 of Pediatrics Head of the Department Dr. Churilina A. V., Ph. D. Cystic Fibrosis in children|