(produced by a doctor!!!)
Indications:
· Suspicion of the presence of fluid in the pelvic cavity
· Suspicion of ectopic pregnancy with unclear clinical picture;
· Suspicion of ovarian cancer with ascites;
· To determine the location of the incision for colpotomy;
· In cases of difficult differential diagnosis of “fluid” formations in the pelvis.
Equipment:
· Sterile gloves;
· Forceps – 2 pcs.
· Water solution alcohol or iodonate;
· Sterile gauze balls;
· Bullet pliers;
· Syringe with a long puncture needle (No. 13 – 14);
· Novocaine solution 0,25% - 10,0;
· Clean tray;
· Capacity for collecting puncture material (for culture and cytology).
Technique:
The patient is placed on a gynecological chair. The external genitalia, vagina and cervix are treated with an antiseptic. Using a spoon-shaped speculum and a lift, the vaginal part of the cervix is exposed, the rear lip is grabbed with bullet forceps, the lift is removed, and the mirror is handed over to an assistant. The cervix is pulled towards you and anteriorly using bullet forceps, at the same time the mirror is pressed on back wall vagina and thus stretch the posterior arch as much as possible. Under the cervix strictly midline, retreating 1 cm from the place of transition of the posterior fornix into the vaginal part of the cervix, insert the needle through the fornix to a depth of 2-3 cm. When piercing the fornix, there should be a feeling of the needle “falling” into the void. After this, you need to pull the syringe plunger towards you. If liquid does not flow into the syringe, you can carefully push the needle deeper or, conversely, slowly remove it while simultaneously pulling the syringe plunger towards you. The resulting punctate is examined, its character, color, and smell are determined. According to indications, bacteriological, cytological, oncocytological or biochemical studies are carried out. When interrupted ectopic pregnancy punctate with small clots.
Ultrasound of the pelvic organs – diagnostic method volumetric formations in the small pelvis, is performed by a special apparatus with a sensor.
Preparation:
1. 3 days before the test, exclude gas-forming foods from the diet.
2. 3 days before the study, prescribe Activated carbon: 1 tablet 3 times a day.
3. On the day of the examination, empty in the morning bladder.
4. Come to the examination with complete bladder(do not urinate 2-3 hours before the examination or give 500 - 700 ml of water to drink 30 - 60 minutes before the examination).
Colposcopy (performed by a doctor) – examination of the vaginal part of the cervix, the junction of sections of stratified squamous and columnar epithelium of the surface of the endocervix, vagina and external genitalia optical device(colposcope) with an illuminator at a magnification of 4 - 30 times. There are simple and extended colposcopy. During permanent colposcopy the examination is carried out after removing mucus from the vagina and without treating the cervix with any substance. With extended - the cervix is treated with a 3% solution acetic acid, and then with Lugol's solution.
Colposcopy is performed before bimanual examination without anesthesia.
Preparation and equipment:
· Sterile gloves;
· Vaginal speculum;
· Kornang;
· Sterile beads;
· 3% vinegar solution acid solution Lugol;
· Slides for oncocytology.
If there is an indication for a biopsy, additionally prepare instruments for taking a piece of tissue (see above).
Hysterosalpingography (performed by a doctor) – This contrast study uterine cavity and fallopian tubes using only aqueous X-ray contrast solutions. Iodlipol cannot be used in gynecology, because it promotes the formation of intratubal adhesions, fatty tumors (oleomas), and also, with fragile vessels in the uterine cavity, can cause fat embolism.
Indications: the presence of various pathological processes that cause changes in the shape and size of the uterus, as well as for diagnosing the patency of the fallopian tubes. Cervicography makes it possible to identify the state of the relief of the mucous membrane of the cervical canal, detect polyposis, deformation, and ectropion of the cervix.
Metrosalpingography (MSG) is carried out 7–10 days after the end of menstruation and no later than 7–10 days before the start of it.
Equipment:
· Sterile gloves;
· Forceps – 2 pcs.
· Spoon-shaped mirror with lift;
· Bullet pliers;
· Uterine probe;
· Syringe – 10g with a uterine tip;
· Contrast agent (verografin, urografin, urotrast, etc.)
· Gauze balls;
· Alcohol 70 0 .
Technique and methodology: A cleansing enema is recommended the night before and the morning of the test. Before starting the MSG procedure, you must empty your bladder. The patient is placed on the edge of the x-ray table, as for vaginal surgery. The external genitalia, vagina and cervix are treated with an antiseptic. Apply bullet forceps to the anterior lip of the cervix when the uterine body is positioned anteriorly or behind the posterior lip when the uterine body is positioned posteriorly. Slowly, over 15–20 seconds, 4–5 ml of contrast liquid, heated to body temperature, is injected into the uterine cavity using a Brown syringe or a device for MSG. The tip is inserted so that it does not reach the fundus of the uterus, and its narrow part extends beyond the internal os. After slowly introducing the contrast agent into the uterine cavity, the tip is removed and bullet forceps are applied to the cervix, closing the external os. The contrast agent is removed from the vagina with a swab (to avoid shadowing the image of the genital organs). Immediately after the administration of the contrast agent, the first image is taken. If the contrast agent does not enter the fallopian tubes, then after 5 - 10 minutes. take a second photo.
Examination and palpation of the mammary glands – carried out in a standing position, then lying down in the first phase menstrual cycle(from the 6th to the 25th day) with arms raised and lowered. Pay attention to the degree of formation of the mammary glands, their shape, size, condition skin and nipple, the presence of skin scars, retractions, bulging, pigmentation.
Palpation first carried out superficially, by easy stroking both glands from the periphery to the center, then deeply, to feel the presence of nodular formations, assess their size, quantity, density, homogeneity, mobility, connection with the underlying tissues, skin. The outer and inner quadrants of the mammary gland and regional zones of lymphatic drainage (lymph nodes) are sequentially palpated. The absence or presence of discharge from the nipples, its color, consistency and character are determined by pressing on the isola.
Cytological examination discharge from the nipples. When the discharge is received, it is sent to cytological examination. Lightly press on the base of the nipple. A clean glass slide is applied to the protruding drop. Carefully smear the drop with another glass slide. In this way, at least three smears are prepared in order to obtain maximum information about the various parts of the milky passage system. Strokes in laboratory conditions stained according to Romanovsky-Giemsa.
Mammography – X-ray of the mammary glands without use contrast agents. Allows you to exclude anatomical changes in them, the presence of a tumor, and also assess the condition of glandular and fibrous tissue. Mammography is the best (informativeness - 95 - 97%) and inexpensive method of visualizing the mammary glands.
Indications: suspicion of a breast tumor, according to physical examination and clinic data, screening of women once every two years after the age of 35 years and once a year during pregnancy after 50 years, breast cancer.
There are no contraindications.
If necessary, use a lead apron.
Diagnostic methods in gynecology are often associated with invasive intervention in the pelvic area. Bimanual examination and ultrasound do not always provide an idea of the pathology. Culdocentesis is often used as an emergency diagnostic method.
Introduction to the methodology
Culdocentesis is puncture of the retrouterine recess in order to obtain the accumulated there biological fluid: blood, pus or exudate.
The possibility of fluid accumulation is explained anatomical structure Douglas spaces. The peritoneum covers the pelvic organs in a special way. It completely covers sigmoid colon, descends to the middle of the rectum. There, only the front and sides are covered. The peritoneum then passes to the posterior vaginal fornix and uterus.
Semilunar folds form on the sides, which help secure the uterus and bladder. The uterorectal pouch turns out to be the lowest place in the abdominal cavity, where, according to the law of physics, all fluids rush. During an ultrasound, you can see it, but it is impossible to understand the nature of the effusion. And further treatment tactics depend on this.
Emergency gynecological pathology requires immediate diagnosis. It is culdocentesis that allows you to quickly differential diagnosis between various diseases, many of which require surgical treatment.
Objectives of the study
The procedure has one goal - to obtain fluid accumulated in the retrouterine space. Its composition allows us to confirm various diseases and pathological conditions.
Indications for culdocentesis are an assumption of the presence of the following diseases:
- interrupted with rupture of the fallopian tube;
- ovarian cancer;
- ovarian apoplexy;
- any unclear clinical picture of an acute abdomen.
Some of these conditions can be diagnosed by ultrasound, but in conditions where ultrasound is not possible, culdocentesis is performed.
To conduct the study, certain conditions are required:
- Pushing of the posterior fornix into the vagina during examination in the speculum.
- The symptom of uterine fluctuation is positive.
The study is carried out only in a hospital in a small operating room, subject to the requirements of asepsis and antiseptics.
Contraindications to the procedure include conditions such as obliteration of the vagina, severe bleeding, massive bleeding that does not stop. abdominal cavity. During pregnancy, culdocentesis is also not performed. With uterine cancer there is a high risk of contact metastasis, and with inflammatory diseases vagina - infection may occur during the procedure, so it is not performed for these diseases.
Intervention steps
Preparation for culdocentesis does not last long. The woman must urinate and have bowel movements. Otherwise, they give an enema and release urine with a catheter.
Tools required for the procedure:
- spoon-shaped mirrors;
- bullet tongs;
- puncture needle 10-12 cm;
- disposable syringe 10 ml.
Is it painful to puncture the retrouterine space?
Painful sensations different intensity will be bothersome in the absence of anesthesia. Anesthesia is selected based on medical tactics and hospital conditions. In some cases, an anesthesiologist is called, who gives a short-term mask or intravenous anesthesia. If there is a contraindication to general anesthesia or if the woman has recently eaten, perform a paracervical blockade with a 1% lidocaine solution. To do this, they are infiltrated back cervix. Some doctors use lidocaine gel for pain relief. It is applied to a cotton swab and pressed against the overhanging vaginal vault.
The technique has remained the same for many years. The woman is on the gynecological chair in the dorsal lithotomy position - standard for intravaginal interventions. Anesthesia is given if the decision is made to use general anesthesia. I treat the perineum and the entrance to the vagina with an antiseptic solution - tincture of iodine, chlorhexidine, alcohol.
Speculums are carefully inserted into the vagina and the cervix is exposed. It is also treated with an antiseptic. At this stage they carry out local anesthesia, if such intervention tactics are chosen.
Use bullet forceps to take the posterior lip of the cervix and pull it forward slightly upward. The needle on the syringe is inserted along the midline into the pouch of Douglas until a sensation of failure is felt. Usually it is 1-2 cm. They pull the syringe plunger and get the contents of the pocket. The needle is carefully removed, the vagina is treated with an antiseptic, and the instruments are removed. The resulting liquid is sent for testing.
Interpretation of results
Further tactics depend on the results of the puncture. If the presence of an abscess in the retrouterine cavity was suspected and pus was obtained in the syringe, drainage of the pouch of Douglas can be performed simultaneously. To do this, an incision is made at the puncture site with a scalpel. The edges of the wound are spread apart with a Kelly forceps and the pus is released. The abscess cavity is washed with an antiseptic. IN further treatment involves prescribing a course of antibiotics wide range actions.
Serous exudate can appear with inflammatory diseases of the appendages or ovaries. In such cases, culdocentesis is carried out for the purpose of bacteriological examination. The resulting liquid is sent to the laboratory for culture and determination of the sensitivity of pathogens to antibiotics. Pus from an abscess is also sent for bacterial culture.
The absence of pus or serous effusion when an infectious-inflammatory disease is suspected does not refute the diagnosis. Sometimes when chronic diseases develops in the small pelvis, which prevents fluid from draining into the utero-rectal space.
A common result of culdocentesis is blood in the syringe. Dark, with clots indicates an interrupted ectopic pregnancy. Sometimes there may be little or no blood drawn into the syringe. This is possible with adhesions in the pelvis and accumulation of blood in the abdominal cavity. Sometimes the clot blocks the needle cut, and it is impossible to draw liquid into it. To restore patency, it is blown with air into a sterile napkin. In some cases, the injection of 1-2 ml of saline or novocaine into the retrouterine cavity helps. They dilute the contents of the pocket, which must be quickly aspirated.
If serous fluid with hemorrhagic impurities is obtained, this does not exclude tubal pregnancy. False positive result if an ectopic pregnancy is suspected, it appears with ovarian apoplexy, blood loss after rupture of the spleen. Carrying out manipulation after or during menstruation can also lead to blood impurities in the syringe.
Culdocentesis is accompanied by the appearance of serous effusion - the contents of a burst cyst. This helps differentiate cyst rupture from ectopic pregnancy and apoplexy.
Serous effusion can appear with tumors of the pelvic organs. Analysis of the resulting fluid will determine the degree of cellular atypia.
Possible complications
Complications during the procedure rarely occur. It can be:
- needle injury to the uterus;
- entry into the vessel of the parametrium;
- intestinal injury.
After puncturing the vessel, the parametrium will appear in the needle. liquid blood, which soon collapses. Bleeding after culdocentesis is uncommon. When bloody discharge you need to see a doctor. They may be a consequence of the underlying pathology (ectopic pregnancy) or injury to the vessel.
Long-term consequences of frequently performed manipulation can manifest themselves in the form of adhesive process in the pelvic area. But we should not forget that diseases that serve as indications for intervention themselves become the cause of the formation of adhesions. Therefore, the root cause of this complication is the underlying pathology.
Special rehabilitation after. The recovery period corresponds to the diagnosed disease. In most cases, sexual rest, antibiotic therapy, basic hygiene and at least a year are required. In a month you need an examination by a gynecologist to find out general condition after treatment.
Indications: the need to determine the nature of the contents of the rectouterine cavity. Evacuation of exudate, pus, injection of liquid or gas into the abdominal cavity.
Rice. 20. Puncture of the uterorectal recess through the posterior vaginal fornix
Patient position: on the back. The limbs are fixed in a “gynecological” position.
Anesthesia: local anesthesia, anesthesia
Technique. Puncture of the fornix for fixation of the cervix. Speculums are inserted into the vagina. The posterior lip of the cervix is fixed with bullet forceps and pulled towards the pubic symphysis. The posterior fornix is exposed.
A long needle is used to puncture the posterior fornix at the cervix. The needle is advanced 10-20 mm parallel to the pelvic axis. Use the plunger of the syringe to suck out the contents. The needle is moved depending on the presence and volume of contents in the pelvic cavity.
Rear arch puncture on mirrors
Two lateral and one long lift are inserted into the vagina, with which the cervix is lifted upward. A spoon-shaped speculum is inserted into the posterior vaginal fornix. When the vagina is dilated, the sacrouterine ligaments are stretched with mirrors, the posterior fornix is punctured between them, directing the needle parallel to the cervix. By traction of the syringe piston, the contents of the pelvic cavity are sucked out.Errors and dangers. The needle may damage the body of the uterus and intestines. To prevent this complication, it is necessary before the puncture to perform a manual examination through the vagina, to determine the degree of overhang of the posterior fornix and the position of the uterus (anteversio, retroversio). These data are important for choosing the direction of movement of the needle and the depth of its immersion (usually no more than 15-30 mm) into the pelvic cavity. Before puncture, the rectum must be emptied.
V. D. Ivanova, A. V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova
A biopsy and histological examination of the obtained tissue make it possible to clarify the nature pathological process cervix, vagina and external genitalia. Preparation for surgery is the same as for diagnostic curettage. Compliance with asepsis and antiseptics is mandatory.
Set of necessary tools: spoon-shaped mirrors, forceps, tweezers, bullet forceps (2), scalpel, scissors, needle with needle holder, catgut. Sterile material, alcohol, and tincture of iodine are also needed.
The resulting piece of tissue is placed in a formalin solution and sent for histological examination with the appropriate direction.
If cervical cancer is suspected, in addition to excision of a piece of tissue, the mucous membrane of the cervical canal is scraped.
To obtain material from the uterine cavity, you can use aspiration biopsy. For this purpose, a special Brown syringe is used, equipped with a long tip with a smooth rounded end. In addition to the Brown syringe, glass slides are required, onto which the aspirate is applied, air dried, and transported to the laboratory.
Abdominal puncture. Puncture of the abdominal cavity is performed through the posterior vaginal fornix and the anterior abdominal wall. A puncture is performed through the posterior fornix if a tubal pregnancy is suspected, sometimes with acute inflammatory processes of the uterine appendages and pelvic peritoneum to detect blood, serous or purulent effusion in the abdominal cavity.
Puncture through the anterior abdominal wall is performed in the presence of ascites. Ascitic fluid is examined for the content of atypical cells to exclude malignant tumor. The absence of atypical cells in ascitic fluid may indicate a connection between ascites and some kind of heart disease, cirrhosis of the liver.
A set of necessary instruments for puncture through the posterior vaginal fornix: spoon-shaped mirrors, forceps (2), bullet forceps, syringe with a long needle (12-15 cm) with side holes. Sterile material, alcohol, and tincture of iodine are also needed.
Preparing the patient, as for diagnostic curettage. Asepsis is mandatory. In case of tubal pregnancy receive dark blood with small clots. If you receive a serous or purulent effusion, you must perform bacteriological examination(the punctate for inoculation is collected in a sterile tube with a stopper).
After the operation, the patient is transported to the ward on a gurney.
End of work -
This topic belongs to the section:
Gynecology. Complaints: leucorrhoea, pain, bleeding, dysfunction of adjacent organs, sexual dysfunction, itching of the external genitalia
Any gynecological pathology has very similar symptoms, so no matter what pathology a woman comes with, her complaints are... complaints of leucorrhoea, pain, bleeding, dysfunction of adjacent organs.. there are many other complaints, but these complaints are the main ones..
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All topics in this section:
Research methods
1. Anamnesis collection. Great attention is paid to it, since, for example, errors in ectopic pregnancy are often associated with a poorly collected anamnesis. During collection, the main functions are clarified
Additional research methods
To clarify the diagnosis, resort to additional methods research. Of these methods, it is necessary to highlight those that are currently used by all gynecological patients, as well as healthy women.
Bacterial research
It is used to diagnose inflammatory processes and allows you to determine the type of microbial factor. Bacterioscopy vaginal discharge helps determine the degree of vaginal cleanliness, which
Examination with bullet forceps
This study helps clarify the connection of the tumor with the genital organs. It is used when it is unclear whether the tumor comes from the uterus, appendages or intestines. A set of necessary tools
Diagnostic curettage of the mucous membrane of the cervix and uterine body
Curettage of the uterine mucosa and histological examination of the scraping have diagnostic value and give an idea of the cyclic changes in the endometrium, the presence of pathological conditions in it
X-ray methods
Hysterosalpinography is performed to determine the patency of the fallopian tubes and is most often used in women suffering from infertility. Indications: according to
Endoscopic methods
The most widely used endoscopic methods in gynecological practice are hysteroscopy, culdoscopy and laparoscopy. For all endoscopic methods instruments are used
Study of the functions of the fallopian tubes
To check patency and functional ability fallopian tubes, the method of introducing air (perturbation) or liquid (gendrotubation) into the tubes is used. Indications: infertility
Ovarian function test
Ovarian function is judged by tests functional diagnostics(cytological picture of a vaginal smear, the phenomenon of the pupil, the phenomenon of arborization of cervical mucus (fern symptom), rectal (basal
Puncture of the posterior vaginal vault is surgical intervention and is carried out in a hospital.
The procedure is carried out in cases of determining the presence or absence of blood, pus, serous fluid in the pelvic cavity. The resulting liquid for diagnostics inflammatory process in the pelvic cavity or early diagnosis ovarian cancer is sent for cytological and bacteriological examination.
Puncture of the posterior vaginal fornix also used to confirm or exclude diagnoses of diseases internal organs, including:
- rupture of the uterus or other internal organs;
- ectopic pregnancy, pelvioperitonitis or general peritonitis;
- to determine the nature of the exudate of saccular tumors of the fallopian tubes and ovaries of non-malignant origin.
The procedure is carried out in therapeutic purposes: for introduction antibacterial drugs or suction of inflammatory exudate; preliminary operation before colpotomy or before colpoceliotomy.
Puncture of the posterior vaginal fornix is a very painful operation. Preoperative preparation is that first of all it is necessary to empty the rectum and bladder.
70% are processed before surgery ethyl alcohol and iodine on the external genitalia and vagina.
Method of manipulation during surgery
Without grasping with forceps, the cervix is exposed and retracted with a lift to the pubic symphysis.
This allows the back of the vaginal vault to stretch between the speculum and the lift. Before the puncture, the puncture site is numbed with lidocaine solution. Some time after the anesthesia has taken effect, using a long injection needle, with a light but decisive push, strictly along the midline, the back part of the vaginal vault is pierced and the liquid present in the rectal uterine cavity is sucked out. The needle is inserted to a depth of up to two centimeters.
During the puncture, the needle should be directed horizontally or slightly upward so as not to damage the rectum. The reverse movement of the piston, simultaneously with the slow withdrawal of the needle, removes the liquid, then conducts its bacteriological and cytological examination.
To confirm the diagnosis ectopic pregnancy defibrinated blood is sucked out. But this does not always work out, since this blood quickly clots and the needle is thrombosed by a blood clot. This clot is pushed out with a syringe onto a gauze pad and tested in the same way as with blood, since this is enough to confirm an ectopic pregnancy. If the blood that gets into the syringe is thick and dark with clots, this is also an indicator of an ectopic pregnancy.
Blood is also detected when the spleen ruptures, ovarian apoplexy, and also after curettage of the uterus.
Puncture of the posterior vaginal vault is also used if an abscess of the uterine appendages is suspected. In this case, when the pus is sucked out, antibiotics are injected into the cavity of the purulent tumor.
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