Modern gynecology: diagnostic methods. Methods of objective examination General obligatory special methods of gynecological examination

After collecting an anamnesis, they begin an objective study of the patient. A general objective study is carried out to obtain a complete picture of the state of all organs and systems of the female body.

General objective examination

An objective examination begins with a general examination. At the same time, it is important to pay attention to the color of the skin and mucous membranes (pallor, cyanosis, jaundice, pigmentation), the presence of edema, forced position, the general appearance of the patient according to the age, excessive or insufficient hair growth, height and body weight, constitutional features, obesity or malnutrition. . Paleness of the skin is characteristic of diseases accompanied by blood loss (myoma, tubal pregnancy). Emaciation and sallow complexion are typical of malignant neoplasms. Excessive hair growth, obesity are possible with disorders of the menstrual function of endocrine etiology. Attention should be paid to pathological rashes on the skin, hemorrhages. Growth and physique characterize the constitution of the patient. In gynecological patients, infantile, intersex and asthenic types should be distinguished, the presence of which may be associated with a violation of sexual development and sexual differentiation.

The infantile type is characterized by small or, conversely, high growth, underdevelopment of the mammary glands and external genitalia, weak hair growth, and a narrow pelvis. With infantilism, there is an underdevelopment of the entire reproductive system, with which violations of menstrual and reproductive functions are associated.

The asthenic type is characterized by high growth, a narrow chest, a decrease in muscle tone, weakness of the connective tissue system, in particular the ligamentous apparatus. Therefore, such women often have an incorrect position of the uterus (bends, omissions), painful menstruation, constipation, and decreased ability to work.

The intersex type occurs with insufficient sexual differentiation, is characterized by a powerful physique resembling a man's, and excessive male-type hair in combination with hypoplasia (underdevelopment) of the genital organs, which is manifested by infertility, menstrual dysfunction.

Examination of the mammary glands (examination, palpation) is performed to identify pathological processes in them. This study is also mandatory when conducting preventive examinations of healthy women. It is important to establish the presence and nature of discharge from the nipples, the relationship of this symptom with a previous pregnancy, menstrual irregularities, etc. The sanious fluid secreted from the nipples may indicate a tumor process in the mammary gland. Such a patient needs additional examination.

The area of ​​accessible lymph nodes (inguinal, axillary) is also examined. Their increase can sometimes be associated with metastasis of a malignant tumor of the female genital organs, mammary glands.

In the study of the respiratory, circulatory, digestive and urinary systems, examination, percussion, palpation, and auscultation are performed. Detection of common diseases will help clarify the etiology of a gynecological disease. For example, with pulmonary tuberculosis or its other localization, tuberculosis of the uterine appendages can be suspected. A change in frequency, pulse tension, and a decrease in blood pressure may accompany gynecological diseases accompanied by acute blood loss and shock.

Examination of the abdominal organs often helps to identify a gynecological disease. Dryness and furry tongue can be signs of intoxication in inflammatory processes of the uterine appendages. When examining the abdomen, attention is paid to the presence of postoperative scars, the size and shape of the abdomen, and its participation in the act of breathing. An increase in the abdomen is possible as a result of obesity, flatulence (with inflammation of the peritoneum, interrupted tubal pregnancy), ascites (with tumors). With ascites, the abdomen is flattened (“frog belly”), and with a tumor, its shape is ovoid, spherical, or irregular in accordance with the shape of the tumor.

With superficial palpation of the abdomen, muscle tension of the abdominal wall is established (with inflammation of the uterine appendages), diffuse or local pain (with inflammation of the uterine appendages, torsion of the cyst leg, tubal pregnancy).

A positive Shchetkin-Blumberg symptom is characteristic of the spread of inflammation of the uterine appendages to the peritoneum, and is also observed when blood is poured into the abdominal cavity during a disturbed tubal pregnancy. With deep palpation, the presence of tumors or infiltrates, their localization, size, consistency, mobility and soreness are determined. Infiltrates (inflammatory, malignant) usually do not have clear boundaries, are inactive. Benign tumors and cysts are clearly contoured, mobile. It is important to establish where the tumor comes from. If it has developed from the pelvic organs, its lower pole is located in the small pelvis and is inaccessible to palpation, and the free curvature of the tumor is directed upwards. In a tumor originating from the upper abdomen, the lower pole is located above the womb, the curvature is directed downward. The surface of the tumor can be smooth (single-chamber ovarian tumor, single fibroid nodule) or bumpy (cancer, multiple fibroids). Percussion of the abdomen establishes the presence of flatulence (high tympanitis), fluid in the abdominal cavity with dullness in sloping places with displacement of the boundaries with a change in body position. If a tumor or infiltrate is detected, their boundaries are determined percussion. In case of tumors or inflammation of the pelvic tissue, palpation and percussion borders should coincide, and with inflammatory infiltrates in the abdominal cavity, the palpatory boundaries are usually wider than the percussion ones.

Auscultation of the abdomen is also important in the diagnosis of gynecological diseases, especially in the differential diagnosis of a tumor and pregnancy (fetal heartbeat is heard). With pelvioperitonitis, peritonitis, postoperative intestinal paresis, intestinal motility is sluggish or absent. Violent peristalsis is possible with intestinal volvulus. The study of the nervous system is limited to determining the adequacy of the patient's behavior, its orientation in time and space. The presence of increased irritability, tearfulness, sleep disorders is important, which often accompanies gynecological diseases, especially with a chronic course. If necessary, they resort to consulting a neurologist who conducts a special neurological examination.

Each identified symptom should be evaluated in conjunction with the others.

After a general objective examination of the patient, a conclusion is made about her general condition, a diagnosis of a concomitant disease is made and a presumptive gynecological diagnosis is clarified.

Gynecological examination

Gynecological examination is a set of methods for studying the female reproductive system. Methods of gynecological examination can be divided into basic, used in the examination of all patients without fail, and additional, which are used according to indications, depending on the presumptive diagnosis.

The main methods include: 1) examination of the external genitalia; 2) examination with the help of mirrors; 3) vaginal examination: one-handed and two-handed (vaginal-abdominal), with indications - rectal and rectovaginal.

To clarify the diagnosis (if indicated), additional research methods are used.

These include:

1. colposcopy;
2. cytological examination;
3. bacterioscopic examination;
4. probing the uterus;
5. examination with bullet forceps;
6. separate diagnostic curettage of the mucous membrane of the cervix and the mucous membrane of the body of the uterus;
7. biopsy, including aspiration;
8. puncture of the abdominal cavity;
9. X-ray methods (hysterosalpingography, gas and bicontrast X-ray pelvigraphy, lymphography, phlebography);
10. endoscopic methods (culdoscopy, laparoscopy, hysteroscopy);
11. study of the function of the tubes (pertubation, hydrotubation);
12. study of ovarian function (functional diagnostic tests, study of hormone levels, hormonal tests), including diagnostic curettage of the mucous membrane of the body of the uterus;
13. ultrasound procedure;
14. examination of adjacent organs (bladder catheterization, chromocystoscopy, sigmoidoscopy, colonoscopy, irrigoscopy, fluoroscopy of the stomach and intestines).

Examination of the external genitalia. A gynecological examination of the patient is carried out after emptying the bladder (if it is impossible to urinate independently, urine is removed by a catheter) and preferably after defecation in the position of the patient on the gynecological chair on the back with legs half-bent at the knees and hip joints. The study is performed in sterile rubber gloves, preferably disposable.

When examining the external genital organs, pay attention to the nature and degree of hair growth, the development of the labia minora and labia majora. Male pattern hair (up to the navel) may indicate a tumor or dysfunction of the ovaries. Hypoplasia of the labia is typical for the underdevelopment of the reproductive system. The gaping of the genital slit is characteristic of the prolapse and prolapse of the walls of the vagina and uterus, and when straining it is more pronounced. On examination, the presence of pathological processes is established: ulcers (cancer, syphilis), swelling and hyperemia, condylomas, fistulas, scars, varicose veins, cracks in the anus, discharge from the vagina or rectum, spreading the labia minora with the fingers of the left hand, examine the vestibule of the vagina and the external opening of the urethra and paraurethral passages located here, the hymen and the excretory ducts of the large vestibular glands. The presence of pathological whites (pus), hyperemic areas of the mucous membrane are characteristic of gonorrhea or nonspecific inflammatory processes. Establish the state of the hymen (its integrity, the shape of the hole).

Viewing with mirrors. An examination should be carried out before a vaginal examination, since the latter may change the picture of the pathological process (destruction of a tumor or polyp of the cervix, etc.). In addition, during the study, smears are taken with the help of mirrors for bacterioscopic and cytological examination, which is advisable to do before the vaginal examination. Patients who have not lived sexually are usually not examined with mirrors, with the exception of special indications, for example, the need to examine the cervix in girls with juvenile bleeding (children's gynecological mirrors are used in pediatric practice). There are several models of vaginal mirrors: cylindrical, folding and spoon-shaped.

Mirrors are sterilized in accordance with the rules for the preparation of metal instruments. Used mirrors are washed with a brush under running water, and then sterilized in a dry oven, autoclave or by boiling in a 1% sodium bicarbonate solution for 12-15 minutes. Spoon-shaped mirrors are carefully inserted along the posterior wall of the vagina, having previously parted the labia minora with the left hand, and brought to the posterior fornix of the vagina. Then, with the other hand, a lift is inserted, which lifts the anterior wall of the vagina (Fig. 11)

Having exposed the cervix, they examine it, characterizing the shape, the presence of scars, ulcers, polyps, fistulas, traces of bullet forceps, etc. The cervix of the uterus is conical in shape with a pinpoint pharynx found in nulliparous women. Cicatricial deformity indicates breaks in childbirth. Hypertrophy of the cervix may indicate chronic inflammation of it.

The slit-like form of the pharynx is observed in women who have given birth. Pay attention to the location of the pharynx. Finding it on the side (eccentric) may indicate a tumor of the cervix with growth in its thickness (cancer), and also be a sign of cervical pregnancy. Pregnancy is characterized by cyanosis of the cervix.

In the external pharynx there may be polyps, tumors (cancer, submucosal fibroids). It is necessary to note the nature of the discharge (purulent, bloody). When removing the mirror, it is necessary to examine the walls of the vagina in order to exclude pathological changes (fistulas, hyperemia).

Internal research. The internal examination is divided into one-handed vaginal, two-handed vaginal (vaginal-abdominal), rectal and rectovaginal. Vaginal examination is performed with the II and III fingers of the right hand, which are inserted into the vagina sequentially (first III, then II), having previously parted the labia minora with the left hand. During the study, the region of the large vestibular glands (I and II fingers), the urethra (II finger through the front wall of the vagina) is palpated and the condition of the pelvic floor muscles is determined. Find out the condition of the vagina: volume, folding and "extensibility, the presence of pathological processes (tumors, scars, narrowing). Examine the vaginal vaults. The posterior fornix is ​​usually the deepest; the lateral fornixes are normally symmetrical. Overhanging, flattening of the arches may indicate the presence of blood, infiltrates or tumors in the abdominal cavity or pelvic tissue. When examining the vaginal part of the cervix, its shape, consistency, degree of mobility and sensitivity during displacement, the shape of the external os, the patency of the cervical canal, the presence of pathological formations (tumors) in it are determined.

Softening of the cervix may be characteristic of pregnancy, compaction - for inflammation, swelling. The immobility of the cervix is ​​noted when the tissue surrounding it is damaged by a tumor or inflammatory infiltrate, excessive mobility of the cervix - with prolapse of the uterus. Soreness during displacement of the cervix is ​​characteristic of inflammation of the uterine appendages and pelvic peritoneum, for interrupted tubal pregnancy. The external pharynx can be ajar with cicatricial deformity of the cervix, as well as with an incipient or incomplete abortion.

Consistently produce palpation of the uterus, while determining its position (inclination, inflection, displacement along the horizontal and vertical axes), size (normal, more or less than normal), shape (normal, spherical, irregular), consistency (normal, softened, dense) , mobility (normal, limited, absent, excessive). Inflections and displacements of the uterus are most often caused by pathological processes outside it, namely, tumors of the ovaries, adjacent organs, adhesions. The shape and size of the uterus change due to pregnancy, tumors of the uterus, accumulation of blood and pus in its cavity. The reduced size of the uterus indicates its underdevelopment. The bumpy surface of the uterus, a dense consistency are characteristic of uterine fibroids. The mobility of the uterus may be limited due to tumor or inflammatory infiltrates in the periuterine tissue, adhesions in the pelvis. Excessive uterine mobility is most often associated with the presence of fluid in the abdominal cavity (blood, ascites, exudate).

Then the uterine appendages are palpated, for which the fingers of the inner (right) hand are moved to the left, and then to the right lateral fornix, and the outer (left) hand to the corresponding inguinal-iliac region. Normally, the tubes and ovaries are not palpable.

If tumor-like formations are determined in the region of the appendages, it is necessary to characterize their size, shape, consistency, size, surface, mobility and sensitivity. When determining clearly limited, rounded tumor-like formations, the presence of a cyst, a tumor can be assumed. Tuberosity, dense consistency, limited mobility are characteristic of malignant tumors.

The doughy consistency of a tumor-like formation is characteristic of a tubal pregnancy, especially if there is a hematoma in or around the fallopian tube.

Pathological processes in the cellular tissue of the small pelvis are determined in the form of dense immobile infiltrates, often displacing the uterus in the opposite direction.

With a two-handed examination, it is possible to palpate the sacro-uterine ligaments, especially with their endometrioid lesion.

Rectal and rectovaginal examinations are used in girls, in patients with stenosis or atresia of the vagina, or to clarify the diagnosis in order to obtain additional information, for example, in cervical cancer to determine the prevalence of the process on the pelvic tissue or rectal wall, with endometriosis and inflammatory processes. A rectal examination is performed if a disease of the rectum is suspected in case of pus or blood.

Rectal examination is carried out with one finger, while determining the condition of the ampoule of the rectum, cervix, sacro-uterine ligaments, pelvic tissue.

During a rectovaginal examination, the second finger is inserted into the vagina, and the third finger is inserted into the rectum in the presence of a pathological process in the rectovaginal septum, vaginal wall, intestine (endometriosis, uterine cancer). With the help of the outer hand (recto-abdominal examination), the body of the uterus and appendages are palpated (Fig. 13).

Gynecological examination is an objective assessment of the health of a woman of any age. The meaning of the survey is invested in visual inspection, sampling for analysis, and instrumental research. Each patient should undergo preventive examination 1-2 times a year. If the patient's history contains any chronic diseases of the pelvic organs, suspicions of STIs, then visits to the gynecologist should be made at least 1 time in 3 months. This will quickly prevent the development of exacerbations and identify other pathologies at the very beginning of development.

Types of diagnostic examination

The tactics of examining a patient completely depends on her age, status, and the final goal of the study. All research methods in gynecology are classified in several areas and ways to achieve diagnostic goals. There are rectal, rectovaginal, vaginal (bimanual) examination with and without a mirror.

Usually gynecologists use several types of examinations at once for more reliable information. An examination of the genital organs is performed using an examination with gynecological instruments and is necessary to compile a holistic clinical picture. The color of the skin and mucous membranes, the condition of the skin, the presence of rashes or irritation, hair growth, the nature of the discharge, and the smell are taken into account.

Examine the contours of the anatomical structures, exclude the presence of pathologies or tumor-like formations by palpation of the outer walls of the vagina from the side of the peritoneum and from the inside with a finger. The gynecologist takes into account the condition of the perineum, perianal region and urethral canal. Some types of inspections include:

The smaller size of the uterus may indicate its infantility or the course of menopause. An increase in the size of the uterus is possible during pregnancy or tumors. The shape of the uterus during pregnancy has a spherical appearance, and with neoplasms - pathologically altered contours.

It is important to support a gynecological examination with laboratory results and instrumental examination data.

It is important to correctly convey the goals that are achieved during the study, for example, the exclusion of diseases, preparation for pregnancy, routine preventive examination, and so on.

Indications for examination and necessary tests

It is not always necessary to look for special reasons to visit a gynecologist, but many women usually neglect preventive examinations and go to the doctor already upon the discovery of symptoms of a disease or upon ascertaining the fact of pregnancy. The following conditions may serve as additional indications for examination:

Before the examination, the doctor visually assesses the patient's figure, the amount of hair in intimate places, and the hormonal status. It is important to remember that you need to answer the doctor's questions honestly, because this is part of the diagnostic measures and will provide an opportunity to get a more accurate clinical picture. For example, it is necessary to answer questions about sexual life, the nature of menstruation, about a partner, about the presence of serious diseases in history (for example, STIs).

During the examination, the following methods of examination of gynecological patients can be applied:

If serious pathologies are detected, minimally invasive research methods and surgical intervention can be prescribed:

Only one analysis or procedure is not enough to make a diagnosis. To identify gynecological diseases or pathological pregnancy, a comprehensive examination is carried out, the general clinical history of the patient is carefully studied.

Features of the diagnosis of STIs and bacteriological examination

A gynecological examination for STIs has some peculiarities, so it is very important to seek help immediately after questionable sexual intercourse. STIs are sexually transmitted infections, that is, infection occurs during sexual intercourse.

All sexually transmitted infections are classified into:

• infections caused by microbes(syphilis or gonorrhea);
• infections caused by protozoan microorganisms(trichomoniasis);
• hepatitis (B, C) or HIV.

Scabies, pubic pediculosis are common diseases transmitted through sexual contact.

A timely visit to the doctor will allow you to diagnose the disease and prevent its progression. The smear examination will be more effective when the infection has just joined. As other research methods, tests for sowing, a detailed biochemical blood test are used. For the diagnosis of STIs, it is important to apply all diagnostic methods in combination. Treatment for STIs should be given to both partners. Only a comprehensive gynecological examination can accurately predict the course and success of the entire therapeutic treatment.

Bacteriological research involves growing bacteria in special conditions to study their resistance to certain drugs. The most common method of bacteriological research is bacterioscopy. To study the non-fixed bacterial microflora, two methods are used:

• flattened drop(finding of bacteria between glasses);
• hanging drop.

It is important to remember that unfixed bacteria are extremely contagious. A smear is used for bacterioscopy of fixed bacteria. The most common method of fixing the drug is heating it with a gas burner or using fixing compounds. In the laboratory, fixed bacteria are always stained.

Preparing for the inspection: rules and regulations

Before visiting a gynecologist, it is important to follow all the necessary measures and conduct proper preparation. All these simple rules will allow you to determine the gynecological problem as accurately as possible, get full information from the test results, and help the doctor prescribe adequate treatment. Before preparing for the visit, it is important to do the following:

A complete gynecological examination includes the disclosure of complete information about the status of one's life, about the number of sexual partners. During the reception, you should not hide facts that may be important for making a diagnosis. You need to trust the doctor in order to fully discuss the existing problem, establish an accurate diagnosis, and exclude relapses of the disease. Removing the psychological barrier should also become the rule for visiting the gynecological office.

Communication with patients is an integral part of the work of a doctor. The ability to conduct a dialogue, listen carefully and answer questions truthfully helps the doctor understand the patient, understand the causes of her illness and choose the best method of treatment.

In order to obtain sufficiently accurate and complete information, the doctor must inspire confidence in the patient, win over the patient with his attentive and serious attitude. The patient's reaction depends not only on what the doctor said, but also on how he said it, how he looked at it and what gestures he accompanied his speech.

The idea of ​​cooperation between the patient and the doctor is gaining more and more recognition. The patient can participate in making decisions concerning her health. Written consent should be obtained from the patient for various manipulations and operations.

Examination of gynecological patients should be considered as a dynamic process that begins with an initial survey and examination, continues with the necessary additional research methods, both to clarify the diagnosis and to assess the course of the disease in dynamics, and ends with recovery.

17

Anamnesis

History taking scheme

1. Complaints: main, accompanying.

2. History of present illness.

3. Anamnesis of life.

4. Special anamnesis: menstrual function; sexual function; reproductive function; secretory function.

5. Gynecological diseases, operations on the genitals.

6. Features of contraception.

7. Past diseases, operations, blood transfusions, allergic reactions to medications, injuries.

8. Lifestyle, nutrition, bad habits, working and rest conditions.

Objective examination

On examination, determine body type:

The hypersthenic type is characterized by low (medium) height, the length of the legs is insignificant compared to the length of the body. The kyphosis of the back is slightly pronounced, the lumbar lordosis is located high, the shoulder girdle is relatively narrow. The subcutaneous fat layer is well developed. The specific functions of the female body in most cases are not changed.

With the infantile type, both general (universal) infantilism and sexual (genital) infantilism can occur without general signs of underdevelopment. The infantile type is characterized by small stature, underdevelopment of the mammary glands, and a generally uniformly narrowed pelvis. Menarche often comes later than usual, and menstruation is characterized by irregularity and soreness.

The asthenic type is characterized by anatomical and functional weakness of the entire muscular and connective tissue

18 Practical gynecology

systems. In women of the asthenic type, relaxation of the muscular and connective tissue apparatus of the pelvic floor and perineum is noted, often intensification, lengthening and pain of menstruation.

The intersex type is characterized by insufficient differentiation of sex, especially secondary sexual characteristics. This type of women has physical and mental characteristics that are characteristic of the male body. In women of the intersex type, the hairline is highly developed, often according to the male type, facial features resemble those of men, and the genitals are often hypoplastic.

Between these main types of constitution, there are various transitional options that are characterized by combinations of individual features characteristic of different types of physique.

Pay attention to excessive hair growth, color and condition of the skin (increased greasiness and porosity, acne, follicles), the presence of stretch marks.

The state of the mammary glands:

Ma 0 - the mammary gland is not enlarged, the nipple is small, not pigmented;

Ma 1 - swelling of the areola, an increase in its diameter, pigmentation of the nipple is not pronounced;

Ma 2 - the mammary gland is conical in shape, the areola is pigmented, the nipple rises;

Ma 3 - mature breasts are rounded.

The mammary gland (MF) is part of the reproductive system, a hormone-dependent organ, a target for the action of sex hormones, prolactin, and indirectly hormones of other endocrine glands (thyroid and adrenal glands).

Inspection of the breast is carried out in a standing and lying position, followed by palpation of the outer and inner quadrants of the gland. On examination, attention is paid to a change in the volume and shape of the breast, as well as a change in the color of the skin, nipple and areola, the presence or absence of discharge from the nipples, their color, texture, character. Brown discharge from the nipples or an admixture of blood indicate a possible malignant process or papillary lesions.

Chapter 1. Methods of examination of gynecological patients 19

melting in the ducts of the breast; liquid transparent or greenish discharge is characteristic of cystic changes in the gland. The presence of milk or colostrum allows the diagnosis of galactorrhea.

Palpation of the breast allows you to establish the diagnosis of fibrocystic mastopathy or determine its form: glandular, cystic, mixed. With mastopathy, ultrasound of the mammary glands and mammography are performed. Patients with this form of mastopathy are referred to an oncologist to perform special research methods (puncture and aspiration biopsy of cystic formation, etc.).

Assessment of body weight, height, proportionality of physique.

Body mass index (BMI) is the ratio of body mass to the square of body length.

Normal BMI = 20-26

BMI 26-30 - low probability of metabolic disorders;

BMI 30-40 - the average degree of probability of their development (obesity III st);

BMI 40 - a high degree of probability of developing metabolic disorders, corresponds to IV Art. obesity.

With overweight, they find out when obesity began: from childhood, at puberty, after the onset of sexual activity, after abortion or childbirth.

Examination of the abdomen carried out in the position of the patient lying on his back. Pay attention to its configuration, swelling, symmetry, participation in the act of breathing, the presence of free fluid in the abdominal cavity.

On palpation, the sizes of individual organs are determined, ascites, flatulence, and volumetric formations are excluded. Determine the size of the liver. Then the rest of the abdominal organs are palpated.

Examination of the abdomen provides valuable information. For example, if a patient with a pelvic tumor has a mass in the epigastric or umbilical region, ovarian cancer with metastases to the greater omentum should be ruled out.

20 Practical gynecology

Gynecological examination carried out on a gynecological chair.

Examination of the external genitalia

Examine the pubis, large and small labia, perineum, anus. The condition of the skin, the nature of hair growth, the presence of volumetric formations are noted. Palpate all suspicious areas.

With the index and middle fingers of a gloved hand, the labia majora are parted and the anatomical structures are examined in order: the labia minora, the clitoris, the external opening of the urethra, the entrance to the vagina, the hymen, the perineum, the anus.

If a disease of the small glands of the vestibule is suspected, they are palpated by pressing on the lower part of the urethra through the anterior wall of the vagina. In the presence of secretions, smear microscopy and culture are indicated. Palpate the large glands of the vestibule. To do this, the thumb is placed on the outside of the labia majora closer to the posterior commissure, and the index finger is inserted into the vagina. On palpation of the labia minora, epidermal cysts can be detected.

The labia minora is spread with the index and middle fingers, then the patient is offered to push. In the presence of a cystocele, the anterior wall of the vagina appears at the entrance, with a rectocele - the posterior one, with prolapse of the vagina - both walls. The condition of the pelvic floor is assessed during a bimanual examination.

Examination of the vagina and cervix in the mirrors

Examining the vagina, note the presence of blood, the nature of the discharge, anatomical changes (congenital and acquired); condition of the mucous membrane; pay attention to the presence of inflammation, mass formations, vascular pathology, injuries, endometriosis. Examining the cervix, pay attention to the same changes as when examining the vagina. But at the same time, the following must be borne in mind: with bloody discharge from the external uterine os outside of menstruation, a malignant tumor of the cervix or body of the uterus is excluded; with cervicitis, mucopurulent discharge from

Chapter 1. Methods of examination of gynecological patients 21

external uterine os, hyperemia and sometimes erosion of the cervix; cervical cancer is not always possible to distinguish from cervicitis or dysplasia, therefore, at the slightest suspicion of a malignant tumor, a biopsy is indicated.

Vaginal (one-handed) examination carried out after removing the mirrors.

Palpate the walls of the vagina, its vaults. On palpation of the cervix, its position, shape, texture, pain and mobility are assessed. Note the presence of volumetric formations and anatomical changes.

Bimanual (two-handed vaginal-abdominal) examination. When palpation of the uterus, its position, size, shape, symmetry, consistency, presence of volumetric formations, pain, mobility are determined. If volumetric formations are found, their number, shape, localization, consistency, pain are determined. Next, the uterine appendages are palpated. Normally, the fallopian tubes are not palpable. It is not always possible to palpate unchanged ovaries. If a volumetric formation of the uterine appendages is determined, its position relative to the body and cervix, pelvic walls, dimensions, mobility, and pain are assessed.

Modern methods of objective examination of gynecological patients include,

Examination methods in gynecology

Modern methods of objective examination of gynecological patients include, along with traditional ones, a number of new methods that allow you to have the most complete picture of the nature of the disease, the phase and degree of the pathological process.

Examination of the patient begins with a survey, then they proceed to her examination, after which they draw up a plan for the laboratory examination of the patient. After that, according to indications, instrumental methods of examination and special diagnostic techniques can be applied. Despite the fact that the schemes for examining gynecological patients are well known and described in textbooks and manuals, it makes sense to once again give an approximate plan and procedure for examining a patient so as not to miss any significant point that is crucial in diagnosis.

The most complete and comprehensive examination can only be carried out by professionals. If you need one of the procedures described below - do not hesitate to visit the doctors of the medical center Your Clinic and get a 10% discount!

Anamnesis

When taking an anamnesis, the age of the patient is of great importance. For example, at the age of pre- and postmenopause, as well as in young girls who do not live sexually, diseases associated with pregnancy can be immediately excluded. In addition to the main complaint, there are accompanying ones, which the woman reports after additional, leading questions. Important information can be obtained by finding out the lifestyle, diet, bad habits. When collecting an anamnesis, it is necessary to be interested in the nature of work, living conditions.

Taking into account the hereditary conditionality of many diseases, one should obtain information about mental illness, endocrine disorders (diabetes, hyper- or hypothyroidism, etc.), the presence of tumors (myoma, cancer, etc.), pathology of the cardiovascular system in relatives of the first and second generations. In addition to the usual questions regarding family history, in women with menstrual irregularities, infertility, excessive hairiness, it is necessary to find out if the next of kin has obesity, hirsutism, and whether there have been cases of miscarriage.

Information about past somatic diseases, their course, and surgical interventions is important for clarifying the nature of gynecological diseases. Particular attention is paid to infectious diseases.

For the recognition of gynecological diseases, data on menstrual, reproductive, secretory and sexual functions are of paramount importance.

Disorders of menstruation occur most often in violation of the functions of the nerve centers that regulate the activity of the endocrine glands. The functional instability of this system can be congenital or acquired as a result of damaging factors (diseases, stressful situations, malnutrition, etc.) in childhood and during puberty.

It is necessary to find out how many pregnancies the patient had, how they proceeded and how they ended. Gynecological diseases can be both the cause of reproductive dysfunction (infertility, spontaneous abortions, anomalies of birth forces, etc.), and their consequence (inflammation, neuroendocrine disorders, consequences of obstetric injuries). For the recognition of gynecological pathology, information about postpartum (post-abortion) diseases of infectious etiology is of great importance.

Pathological secretion (leucorrhea) can be a manifestation of the disease of different parts of the genital organs. There are tubal leucorrhea (emptying hydrosalpinx), uterine leucorrhea (endometritis, polyps), cervical leucorrhea (endocervicitis, polyps, erosion).

The most common are vaginal leucorrhoea. Normally, the processes of formation and resorption of the vaginal contents are completely balanced, and the symptom of the appearance of leucorrhoea, as a rule, indicates an inflammatory process.

Data on sexual function deserve attention because its disorders are observed in a number of gynecological diseases. It is known that sexual feeling and sexual desire characterize the maturity of a woman's sexual function. The absence of these indicators is observed in gonadal dysgenesis and other endocrine disorders, as well as a number of gynecological diseases.

After a correctly collected anamnesis, a diagnosis can be made in 50-60% of patients and determine the direction of further examination (the choice of diagnostic methods and the sequence of their application).

General condition assessment

Assessment of the general condition begins with an external examination. Pay attention to the height and weight of the body, physique, the development of adipose tissue, especially its distribution. Particular attention is paid to the condition of the skin. It is necessary to pay attention to the color of the skin, the nature of hair growth, acne, increased porosity, etc.

It is necessary to examine the area of ​​lymph nodes accessible for palpation. Blood pressure, pulse rate, auscultation of the lungs, percussion and palpation of the abdomen are measured. The mammary glands are carefully examined, a visual examination is performed in a standing position, then in the supine position, successive palpation of the armpits, external and internal quadrants of the gland is performed.

Gynecological examination

Gynecological examination involves a whole range of methods to study the state of the female reproductive system. Research methods can be divided into basic, used to examine all patients without fail, and additional, which are used according to indications, depending on the alleged diagnosis. This study is carried out on a gynecological chair after emptying the bladder and, preferably, after defecation. The study is carried out in sterile gloves.

Examination of the external genitalia.

Pay attention to the nature and degree of hair growth, the development of small and large labia, the gaping of the genital gap. On examination, the presence of inflammatory pathological processes, ulcers, tumors, varicose veins, discharge from the vagina or rectum is noted. The woman is offered to push, while determining whether there is a prolapse or prolapse of the walls of the vagina and uterus.

Inspection with a mirrorcal.

The study is carried out before the vaginal bimanual (two-handed) study, since the latter can change the picture of the pathological process. Folding or spoon-shaped mirrors are used. The folding mirror is carefully inserted in a closed state for the entire length of the vagina, having previously parted the labia minora with the left hand. If a spoon-shaped mirror is used, then an elevator is additionally introduced to lift the anterior wall of the vagina. Having exposed the cervix, they examine it, noting the color of the mucosa, the nature of the secret, the shape of the cervix, the presence of ulcers, scars, polyps, tumors, fistulas, etc. After a visual examination, swabs are taken for bacterioscopic and cytological examination.

Vaginal (bimanual) examination.

Conducting this study provides valuable data on the state of the internal genital organs. It should be carried out in compliance with all the requirements of asepsis and antisepsis. During the study, the fingers of the right hand should be in the vagina, and the left hand is located on the anterior abdominal wall, palm down. Consistently produce palpation of the uterus, while determining its position, displacement along the horizontal and vertical axes, consistency and size. Then the uterine appendages are palpated, for which the fingers of the right hand located in the vagina are moved to the left and then to the right fornix, and the outer hand to the corresponding inguinal-iliac region. The uterus on palpation has a pear-shaped shape, a smooth surface, is easily displaced in all directions, and is painless on palpation. Normally, the tubes and ovaries are not detected; when determining formations in this area, it is necessary to identify them as inflammatory, tumor-like, which often requires additional or special research methods.

The data of the vaginal examination allow diagnosing the presence of tumors of the uterus, formations of the fallopian tubes and tumors of the ovaries. We must not forget that for the correct diagnosis, it is important not so much the presence of individual symptoms as their detection in combination with other signs of the disease.

After questioning, examination and two-handed gynecological examination, a preliminary diagnosis is established. This allows you to draw up a plan for further in-depth examination using laboratory diagnostics, instrumental methods of examination and various diagnostic techniques. The provisional diagnosis gives the right, along with ongoing examination, to start drug treatment, depending on the nosological form of the gynecological disease.

bacterioscopic examination.

It is used to diagnose inflammatory diseases, and its results allow you to establish the type of pathogen. Bacterioscopy makes it possible to determine the degree of purity of the vagina, which is necessary before any diagnostic manipulations and gynecological operations. Material for bacterioscopic examination is taken with a Volkmann spoon from the urethra, cervical canal, posterior vaginal fornix. Before the study, it is impossible to treat the walls of the vagina with disinfectants, douche or inject drugs. It is better to take a smear before urinating. A swab is taken from the urethra with a Volkmann spoon with a narrow end or a grooved probe after preliminary massage of the urethra from back to front, pressing the urethra against the womb until a drop of discharge is obtained, which is applied to a glass slide with a thin layer marking. A smear from the cervical canal is taken after the cervix is ​​exposed in the mirrors with a Volkmann spoon with a wide end or a probe. Each smear is taken with a separate instrument, applying a thin layer on two glass slides. In accordance with the nature of the smear, there are four degrees of purity of the vaginal contents:

Idegree of purity. In the smear, single leukocytes (no more than 5 per field of view), vaginal bacilli (Dederlein sticks) and squamous epithelium are determined. The reaction is acidic.

II degree of purity. In the smear, leukocytes are determined (no more than 10-15 in the field of view), along with Dederlein sticks, single cocci and epithelial cells are determined. The reaction is acidic.

III degree of purity. There are 30-40 leukocytes in a smear, vaginal bacilli are not detected, various cocci predominate. The reaction is weakly alkaline.

IV degree of purity. There are no vaginal bacilli, there are many pathogenic microbes up to specific ones - gonococci, Trichomonas, etc. The reaction is alkaline.

I-II degrees of purity are considered the norm. All types of surgical and instrumental interventions in gynecology should be carried out in the presence of such smears. III and IV degree of purity accompany the pathological process and require treatment.

Cytological study.

Produced for the early detection of cancer. Smears are taken from the surface of the cervix or from the cervical canal. Cytological examination is also subjected to material obtained by puncture from volumetric formations, or aspirate from the uterine cavity. The material is applied to a glass slide and dried in air. A mass cytological examination, carried out during preventive examinations, makes it possible to identify a contingent of women (who have atypical cells) who need a more detailed examination to exclude or confirm cancer of the female genital organs.

Colposcopy.

The first endoscopic method that has found wide application in gynecological practice. The diagnostic value of the method is very high. This method provides an opportunity to examine the vulva, the walls of the vagina and the vaginal part of the cervix using a colposcope, which gives an increase in the object in question by 30-50 times. allows you to identify early forms of precancerous conditions, choose a site for a biopsy, and also control healing during treatment.

• Simple colposcopy. It makes it possible to determine the shape, size of the cervix, external os, color, relief of the mucosa, the border of the squamous epithelium covering the cervix and the condition of the cylindrical epithelium.
• Extended colposcopy. It differs from simple colposcopy in that before examination, the cervix is ​​treated with a 3% solution of acetic acid, which causes short-term swelling of the epithelium, a decrease in blood supply. The action lasts 4 minutes. After studying the obtained colposcopic picture, a Schiller test is performed - lubricating the neck with a cotton swab with 3% Lugol's solution. The iodine contained in the solution stains glycogen in healthy epithelial cells in a dark brown color. Pathologically altered cells in various dysplasias of the cervical epithelium are poor in glycogen and do not stain with iodine solution. Thus, zones of pathologically altered epithelium are identified and areas for cervical biopsy are indicated.

Probing of the uterus.

The method is used for diagnostic purposes to determine the patency of the cervical canal, the length of the uterine cavity, its direction, the shape of the uterine cavity, the presence and location of submucosal tumors of the uterus, the bicornuate uterus or the presence of a septum in its cavity.

Curettage of the uterine cavity.

Produced for diagnostic purposes to determine the cause of uterine bleeding, if malignant tumors of the uterus are suspected, as well as for the collection of histological material from the uterus according to indications.

Biopsy of the cervix.

It is a diagnostic method that allows timely diagnosis if there is a suspicion of a tumor process of the cervix.

Puncture through the posterior fornix of the vagina.

This is a widely used and effective research method, with the help of which it is possible to confirm the presence of intra-abdominal bleeding with a high degree of certainty, as well as to analyze the discharge obtained by puncture.

Ultrasound examination (ultrasound).

Ultrasound is a non-invasive research method and can be performed in almost any patient, regardless of her condition. The safety of the method has made it one of the main ones in monitoring the condition of the fetus. In gynecological practice, it is used to diagnose diseases and tumors of the uterus, appendages, to detect abnormalities in the development of internal genital organs. With the help of ultrasound, it is possible to control the growth of the follicle, diagnose ovulation, register the thickness of the endometrium, identify its hyperplasia and polyps. The diagnostic capabilities of ultrasound have been significantly expanded after the introduction of vaginal sensors, which improves the diagnosis of retrocervical endometriosis, adenomyosis, inflammatory formations in the uterine appendages and various forms of the tumor process.

Hysteroscopy (HS).

The main advantage of the method is the ability to detect intrauterine pathology using the optical system of the hysteroscope. Apply gas and liquid hysteroscopy. With gas HS, the uterine cavity is examined in a gaseous environment (carbon dioxide). The most commonly used liquid GS using various solutions, most often isotonic sodium chloride solution. The great advantage of this method is the ability to perform not only an examination of the uterine cavity, but also surgical manipulations with subsequent control (diagnostic curettage, polypectomy, "unscrewing" the myomatous node, separation of synechia, etc.). Expansion of the cervical canal up to № 8-9 Hegar dilators guarantees free outflow of the washing fluid and prevents endometrial pieces from entering the abdominal cavity. Indications for hysteroscopy:

• uterine bleeding in women of any age of a cyclic and acyclic nature;
• control over the therapy of hyperplastic conditions;
• suspicion of intrauterine synechia;
• suspicion of a malformation of the endometrium;
• multiple endometrial polyps, etc.

Hysterosalpingography (HSG).

HSG has long been used in gynecology to establish the patency of the fallopian tubes, to detect anatomical changes in the uterine cavity, and adhesions in the pelvic cavity. HSG is carried out in an X-ray operating room. The study is performed with water, contrast preparations (verografin - 76%, urographin - 76%, urotrast - 76%). The solution is introduced into the uterine cavity under aseptic conditions using a special conductor with a tip, after which an X-ray image is taken.

Laparoscopy.

A technique that allows you to examine the organs of the small pelvis and abdominal cavity against the background of pneumoperitoneum. The optics of the laparoscope is introduced into the abdominal cavity through a small incision, which makes it possible to directly examine the pelvic organs or, by connecting a video camera, transmit the image to the monitor. It is difficult to overestimate the diagnostic possibilities that practical gynecology has received with the introduction of laparoscopy into everyday practice. The widespread introduction of operative laparoscopy has truly revolutionized gynecology, significantly expanding the possibilities of providing highly qualified care to all groups of gynecological patients. Thanks to laparoscopy, for the first time, small forms of external endometriosis were identified, and it became possible to find out the causes of chronic pelvic pain. Using this technique, it is possible to differentiate inflammatory processes in the appendages, appendix, in a matter of minutes to diagnose an ectopic pregnancy, etc. The method is indispensable in the diagnosis and treatment of various forms of infertility, ovarian tumors, malformations of the internal genital organs, etc.

Computed tomography (CT).

The essence of the method is as follows. A thin beam of X-ray radiation falls on the investigated area of ​​the body from different directions, and the emitter moves around the object under study. When passing through tissues of different density, the intensity of the beam is weakened, which is recorded by highly sensitive detectors in each direction. The information obtained in this way is entered into the computer, which makes it possible to determine the value of local absorption at each point of the layer under study. Since different human organs and tissues have different values ​​of the absorption coefficient, the ratio of these coefficients for normal and pathological tissues can be used to judge the presence of a pathological process. With the help of CT, it is possible to obtain longitudinal images of the area under study, reconstruct sections and, as a result, obtain a section in the sagittal, frontal, or any given plane, which gives a complete picture of the organ under study and the nature of the pathological process.

Magnetic resonance imaging (MRI).

The method is based on the phenomenon of magnetic resonance, which occurs when exposed to constant magnetic fields and electromagnetic pulses of the radio frequency range. To obtain an image in MRI, the effect of absorption of electromagnetic field energy by hydrogen atoms of a human body placed in a strong magnetic field is used. Next, the received signals are processed, which makes it possible to obtain an image of the object under study in different planes.

The method is harmless, since magnetic resonance signals do not damage cellular structures and do not stimulate pathological processes at the molecular level.

To clarify the diagnosis resort to additional research methods. Of these methods, it is necessary to single out those that are currently used by all gynecological patients, as well as healthy women who apply for preventive examinations. Such additional methods include cytological, bacterioscopic studies and colposcopy.

Cytological study. Produced for the purpose of early detection of cancer of the uterus and fallopian tubes. From the surface of the cervix, the material is obtained using smears-imprints (glass taken with tweezers is applied to the surface of the cervix, or Eyre's spatula is carried out along the cervix with a rotational movement). Material is taken from the cervical canal with a special spoon or a grooved probe.

The material is applied to a glass slide and dried in air. After special staining, smears are examined. A mass cytological examination during preventive examinations makes it possible to identify a contingent of women (if atypical cells are detected) who need a more detailed examination (biopsy, diagnostic curettage, etc.) to exclude or confirm cancer of the female genital organs.

Colposcopy. This method allows you to examine the cervix and vaginal walls using a colposcope, which gives an increase in the object in question by 10-30 times or more. Colposcopy allows you to identify early forms of precancerous conditions, choose the site most suitable for a biopsy, and monitor healing during treatment.

There are various types of colposcopes, including those with a photo attachment, which makes it possible to photograph and document the detected changes (Fig. 14).

bacterioscopic examination. It is used to diagnose inflammatory processes and allows you to establish a type of microbial factor. Bacterioscopy of vaginal discharge helps to determine the degree of purity of the vagina, which is necessary before gynecological operations and diagnostic manipulations.

Bacterioscopic examination in some cases makes it possible to identify a venereal disease with its low-symptomatic course.

Material for bacterioscopic examination is taken from the urethra, cervical canal and the upper third of the vagina. Before taking a smear, douching and medical procedures associated with the introduction of medicinal substances into the vagina should not be performed. The swab should be taken before urination. A smear from the urethra is taken with a Volkmann spoon or a grooved probe after a light massage of the posterior wall of the urethra by moving the index finger from top to bottom and applied to a glass slide with a thin layer. each smear is taken with a separate instrument).

In accordance with the nature of the smear, there are 4 degrees of purity of the vagina: I degree of purity - in the smear, squamous epithelium and vaginal bacilli (normal flora) are determined; the reaction is acidic;

II degree of purity - there are fewer vaginal bacilli than with I degree; epithelial cells, single cocci and leukocytes are found; the reaction is acidic (I and II degrees of purity are considered the norm);

III degree of purity - there are few vaginal bacilli, other types of bacteria predominate, there are a lot of leukocytes; the reaction is weakly alkaline;

IV degree of purity - no vaginal bacilli, many pathogenic microbes, up to gonococci and Trichomonas, many leukocytes; the reaction is slightly alkaline (III and IV degrees of purity accompany pathological processes).

Probing of the uterus. Probing is used to measure the length and determine the configuration of the uterine cavity, the relief of the walls, the length and patency of the cervical canal. For this purpose, a metal uterine probe is used.

A set of necessary tools: spoon-shaped mirrors, bullet forceps (2), forceps and uterine probe. All instruments are used sterile. To treat the vagina, alcohol, tincture of iodine and gauze balls are needed. Probing of the uterus is performed in a hospital, observing the rules of asepsis and antisepsis. The doctor performs manipulation only at I-II degree of purity of the vagina after emptying the diseased bladder.

Contraindications: the presence of purulent discharge (III and IV degree of purity of the vagina), signs of acute or subacute inflammation of the uterus and appendages, pregnancy.

Examination with bullet forceps. This study helps to clarify the relationship of the tumor with the genitals. It is used when it is unclear whether the tumor comes from the uterus, appendages or intestines.

A set of necessary tools: spoon-shaped mirrors, forceps, bullet tongs. All instruments are used sterile.

After exposing the cervix with the help of mirrors, it is treated with alcohol and grasped by the front lip with bullet forceps.

The mirrors are removed, and the handles of the bullet tongs are handed over to the assistant. The fingers of the right hand are inserted into the vagina or rectum, the tumor is pushed upward with the left hand. In this case, the stem of the tumor is stretched, palpated more clearly and it becomes possible to determine the relationship of the tumor with the uterus or appendages. Another technique using bullet tongs is as follows. Bullet forceps applied to the cervix hang freely from the vagina, and the examiner moves the tumor up through the abdominal wall. In this case, the tumor of the uterus carries along the forceps, which are drawn into the vagina. Displacement of an ovarian or intestinal tumor is usually not transferred to bullet forceps.

Contraindications: III-IV degree of purity of the vagina, suspicion of pregnancy, acute or subacute inflammation of the internal genital organs. Diagnostic curettage of the mucous membrane of the cervix and body of the uterus. Curettage of the uterine mucosa and histological examination of the scraping are of diagnostic value and give an idea of ​​the cyclic changes in the endometrium, the presence of pathological processes in it (cancer, chorionepithelioma, polyposis), and the remains of the fetal egg. Diagnostic curettage of the mucous membrane of the body of the uterus is performed with acyclic (sometimes cyclic) bleeding and other signs indicating pathology of the endometrium (the presence of atypical cells in the vaginal smear).

A set of necessary tools: spoon-shaped vaginal mirrors, forceps (2), bullet forceps (2), uterine probe, sets of dilators and curettes. Alcohol, tincture of iodine, sterile dressings (balls, napkins, etc.), vials with a formalin solution are also needed to preserve the material obtained for histological examination. The vials should be labeled with the name of the patient, the date of the manipulation, the place where the material was taken from (cervix, uterine cavity), clinical diagnosis.

Contraindications: III-IV degree of purity of the vagina, the presence of signs of acute and subacute inflammation in the uterus and appendages, infectious diseases, fever. This applies to a planned operation and does not apply to cases of curettage for health reasons (massive uterine bleeding), when it is performed not only for diagnostic, but also for therapeutic purposes. Compliance with the rules of asepsis and antisepsis is mandatory. To prepare the patient, it is necessary to shave the hair in the area of ​​​​the external genitalia, and offer to empty the bladder. The operation is performed under aseptic and antiseptic conditions on a gynecological chair.

Curettage of the mucous membrane of the cervix and the body of the uterus is often performed separately, which provides a more accurate diagnosis (in this case, the resulting material is collected in two different vials). Biopsy. Biopsy and histological examination of the obtained tissue allow us to clarify the nature of the pathological process of the cervix, vagina and external genitalia (Fig. 16). Preparation for surgery is the same as for diagnostic curettage. Compliance with asepsis and antisepsis is mandatory.

A set of necessary tools: spoon-shaped mirrors, forceps, tweezers, bullet forceps (2), scalpel, scissors, needle with a needle holder, catgut. Sterile material, alcohol, 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 referral.

If cervical cancer is suspected, in addition to excising a piece of tissue, the mucous membrane of the cervical canal is scraped (see above).

An aspiration biopsy can be used to obtain material from the uterine cavity. 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 needed, on which the aspirate is applied, dried in air and delivered to the laboratory.

Abdominal puncture. The puncture of the abdominal cavity is performed through the posterior fornix of the vagina and the anterior abdominal wall. Through the posterior fornix, a puncture is done if a tubal pregnancy is suspected, sometimes with acute inflammatory processes of the uterine appendages and pelvic peritoneum in order to detect blood, serous or purulent effusion in the abdominal cavity (Fig. 17).

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 a malignant tumor. The absence of atypical cells in the ascitic fluid may indicate an association of ascites with some kind of heart disease, cirrhosis of the liver.

A set of necessary tools for puncture through the posterior vaginal fornix: spoon-shaped mirrors, forceps (2), bullet forceps, a syringe with a long needle (12-15 cm) with side holes. Sterile material, alcohol, tincture of iodine are also needed.

Prepare the patient as for diagnostic curettage. Asepsis is mandatory. During tubal pregnancy, dark blood with small clots is obtained. Upon receipt of a serous or purulent effusion, it is necessary to perform a bacteriological examination (the puncture for sowing is collected in a sterile tube with a stopper).

After the operation, the patient is transported to the ward on a stretcher.

X-ray methods. Hysterosalpingography is performed to determine the patency of the fallopian tubes and is most often used in women suffering from infertility. Indications: suspicion of submucosal uterine fibroids, endometriosis, underdevelopment and malformations of the uterus, synechia in the uterine cavity, infertility.

2-5 ml of a radiopaque substance (iodolipol, verografin, cardiotrast, etc.) is injected into the uterine cavity, and then an x-ray is taken.

Contraindications: III-IV degree of purity of the vagina, acute and subacute forms of inflammatory processes, pregnancy.

A set of tools necessary for hysterosalpingography: Brown syringe, radiopaque "substance, cylindrical or folding mirror, bullet forceps (2), forceps.

Compliance with the rules of asepsis and antisepsis is mandatory. After the introduction of a contrast agent into the uterine cavity, the patient is taken to the X-ray room in a horizontal position (on a stretcher). In the picture, the normal uterine cavity has a triangular shape with clear contours. With passable tubes, the contrast agent is poured into the abdominal cavity.

Gas X-ray pelvigraphy (pneumopelvigraphy) consists in the fact that carbon dioxide is injected into the abdominal cavity (pneumoperitoneum is created), and then x-rays are taken (the outlines of the uterus, ligaments, appendages are clearly visible in the image).

Indications: suspicion of anomalies in the development of the uterus and its appendages, tumors (when a two-handed examination does not give a clear idea of ​​the nature of the pathological process). Contraindications: CNS diseases, cardiovascular insufficiency, bronchial asthma, pulmonary emphysema, tuberculosis, acute inflammatory diseases of the genital organs, extensive tumors in the abdominal cavity.

The preparation of the patient is as follows: on the eve and on the day of the study, a cleansing enema is made, and immediately before the procedure, the bladder should be emptied. After the study, the patient may be disturbed by bloating, a feeling of fullness, while it is necessary to create an inclined position with her head down and a raised pelvis.

Bicontrast X-ray pelvigraphy consists in creating double contrasting of the genital organs: with carbon dioxide and X-ray contrast agents, that is, it is a combination of gas X-ray pelvigraphy with hysterosalpingography, which allows a more detailed examination of the state of the internal genital organs.

Endoscopic methods. The most widespread in gynecological practice are such endoscopic methods as hysteroscopy, culdoscopy and laparoscopy. For all endoscopic methods, devices with an optical system and illumination are used. Modern devices are equipped with manipulators that allow you to perform some diagnostic and therapeutic manipulations in the abdominal cavity and in the uterine cavity under visual control. All endoscopic examinations should be carried out in compliance with the rules of asepsis and antisepsis. Hysteroscopy is a method that allows you to examine the uterine mucosa and detect pathological processes: polyps, hyperplasia, cancer, adhesions, as well as submucosal uterine myoma, adenomyosis.

Hysteroscopy is performed to clarify the diagnosis, targeted biopsy, as well as to control the curettage of the uterine mucosa, removal of polyps.

Laparoscopy and culdoscopy allow you to examine the internal organs of the abdominal cavity, including the organs of the small pelvis.

Culdoscopy is performed through the posterior fornix of the vagina. During laparoscopy, abdominal access is used.

Indications: the need or difficulty in the differential diagnosis of tumors of the ovaries and uterus, extragenital tumors, ectopic pregnancy, sclerocystic ovary syndrome, inflammatory formations of the uterine appendages, acute appendicitis. Culdoscopy is preferred for obesity of the abdominal wall, if necessary, examination of the ovaries. Laparoscopy is performed in nulliparous women, as well as, if necessary, examination of the appendix or tumors located in front of the uterus.

Contraindications: decompensated heart disease, hypertension and other severe general diseases.

Preparation of the patient for culdoscopy or laparoscopy is as follows: on the eve and on the day of the study, a cleansing enema is given. The hair in the vulva is shaved. The study is carried out in a hospital. Local anesthesia is used (0.5% novocaine solution is injected into the posterior vaginal fornix or the anterior abdominal wall).

Study of the functions of the fallopian tubes. To check the patency and functional ability of the fallopian tubes, the method of introducing air (pertubation) or liquid (hydrotubation) into the tubes is used. Indications: infertility due to a previous inflammatory process in the uterine appendages. For carrying out pertubation and hydrotubation, there is a special apparatus consisting of a tip connected by a system of tubes to a cylinder for injecting air (or a device for introducing liquid) and with a pressure gauge showing the pressure of air or liquid. With pertubation, simultaneous kymographic recording of contractile movements of the tubes is possible. When carrying out pertubation and hydrotubation, it is imperative to follow the rules of asepsis and antisepsis.

Contraindications: III-IV degree of purity of the vagina, colpitis, cervicitis, acute and subacute inflammation of the uterus and its appendages. Failure to comply with the above conditions can lead to infection of the uterus, tubes, abdominal cavity and serious complications.

The procedure is performed in the usual position of the patient on the gynecological chair. The patient must first empty the bladder.

A set of necessary tools: vaginal mirrors, bullet forceps, forceps, sterile material, alcohol, tincture of iodine.

Hydrotubation is used not only for diagnostic, but also for therapeutic purposes. Study of ovarian function. Ovarian function is judged by functional diagnostic tests [cytological picture of the vaginal smear, pupil phenomenon, cervical mucus arborization phenomenon (fern symptom), rectal (basal) temperature, endometrial biopsy], as well as by the content of hormones in blood plasma, urine and hormonal tests.

To study the cytological picture of the vaginal smear, the discharge of the posterior fornix of the vagina is applied to a glass slide with a thin layer, dried in air, fixed in a mixture of alcohol and ether, and then stained with hematoxylin and eosin or fuchsin.

Under the influence of estrogen in the stratified squamous epithelium of the vagina, the process of keratinization occurs, which is all the more pronounced, the higher the estrogen content. The predominance of keratinizing cells in the smear indicates a high content of estrogens (hyperestrogenism). With a moderate content of estrogens, the so-called intermediate cells are sloughed off from the vaginal wall. With a low content of estrogens (hypoestrogenism with hypofunction of the ovaries or postmenopause), basal cells from deeper layers are exfoliated and predominate in the smear. Depending on the ratio of types of epithelial cells, 4 types (or reactions) of the vaginal smear are distinguished:

Type I - a smear consists of basal (atrophic) cells and leukocytes, which is characteristic of a pronounced estrogen deficiency. It is observed in postmenopausal women, and in young women - with ovarian hypofunction, amenorrhea;

Type II - in the smear basal and intermediate cells with a predominance of basal cells and leukocytes. It is observed with significant estrogen deficiency (ovarian hypofunction, postmenopause);

Type III - intermediate cells predominate in the smear. Observed with moderate estrogen deficiency;

Type IV - the smear consists of keratinized cells. It is observed with sufficient estrogen saturation.

In a normal menstrual cycle, III and IV types are noted (depending on the phase of the cycle). It is also possible to quantify the cytological picture, in which the percentage of surface cells with pycnotic nuclei to the total number of surface cells is determined - the karyopyknotic index (K.PI).

The symptom, or phenomenon, of the pupil is as follows. In the folliculin phase of the cycle, the cervical glands produce a mucous secretion, the largest amount of which accumulates by the middle of the cycle. The external opening of the cervical canal is expanded by this secret and resembles a pupil, which is visible when viewed with the help of mirrors. This symptom is observed from the 10th to the 17th day of the cycle, and its greatest severity is noted on the 14th-15th day of the cycle. With estrogen deficiency, the pupil symptom is mild or absent, and with excessive estrogen production, this symptom may be expressed for a longer time.

The phenomenon of cervical mucus arborization (fern symptom) is that the cervical mucus, applied to a glass slide and air-dried, forms crystals in the form of a fern leaf. The fern symptom is observed in parallel with the pupil symptom (2-3 drops of mucus are taken with tweezers and applied to a glass slide, dried in air for 10-15 minutes, a drop of isotonic sodium chloride solution is added and examined under a microscope).

Rectal (basal) temperature (Rt) is measured in the rectum in the morning after sleep, at rest. In a normal cycle, the temperature changes throughout the cycle: in the follicular phase Rt = = 36.2 - 36.7 ° C, in the luteal phase it rises by 0.4 - 0.5 ° C, and with the onset of menstruation it decreases again . Rt fluctuations depend on the ratio of estrogen and progesterone. Usually, a two-phase temperature curve indicates ovulation (ovulatory, or two-phase, menstrual cycle). In the absence of ovulation, the temperature curve will be monotonous, single-phase (anovulatory, or monophasic, menstrual cycle).

The presence of ovulation and the luteal phase confirms the histological examination of the endometrium, namely its secretory transformation. Scraping should be done in the second half of the menstrual cycle (on the 22-24th day of the cycle). The absence or insufficiency of the secretory transformation of the endometrium indicates a violation of the function of the corpus luteum.

The function of the ovaries is also assessed by the content of hormones in the blood plasma and urine. To clarify the level of the disorder (hypothalamus, pituitary gland, ovaries, adrenal cortex), the causes of damage to the endocrine system, various functional tests are used (Test with releasing hormone, LH, FSH, CG, ACTH, synthetic progestins, progesterone, cyclic, with glucocorticoids, etc.). Ultrasound procedure. It is used to diagnose tumors of the internal genital organs, as well as for the purpose of differential diagnosis of tumors and pregnancy. The method is based on the ability of tissues of different density to absorb ultrasonic energy differently.

Examination of neighboring organs. An examination of the pelvic organs is performed by a gynecologist due to the need in some cases to distinguish tumors of the female genital organs from tumors of the intestines, prolapse of the kidney, etc. In addition, with malignant neoplasms of the ovaries, uterus, it becomes necessary to establish the degree of spread of the process to the intestines, bladder. For the study of the pelvic organs, catheterization of the bladder, cystoscopy, chromocystoscopy, X-ray methods of investigation (irrigoscopy, excretory urography) are used.

Bladder catheterization is performed not only for diagnostic purposes, but also for therapeutic purposes (in preparation for surgery, urinary retention, to remove residual urine, etc.). Emptying the bladder can sometimes avoid the misdiagnosis of an ovarian cyst or tumor.

Cystoscopy allows you to determine the condition of the mucous membrane of the bladder and identify its pathology, tumor growth, etc.

Chromium cystoscopy is based on the introduction of indigo carmine into a vein and subsequent examination with a cystoscope of the mouths of the ureter, from which, with normal kidney function, indigo carmine is poured out in an intense stream 4-5 minutes after its introduction. Lack of release of indigo carmine indicates obstruction of the ureter (the presence of a stone, compression by the tumor).

Excretory urography (intravenous administration of a radiopaque substance) allows you to see the renal pelvis, ureters and bladder on x-rays and makes it possible to differentiate kidney prolapse and ovarian tumors, etc.

Sigmoidoscopy allows you to determine the condition of the mucous membrane of the rectum, sigmoid colon, identify the pathology of these sections of the intestine and, if indicated, perform a biopsy.

Irrigoscopy is a study of the large intestine. A comprehensive examination of the patient allows you to diagnose a gynecological disease (as well as concomitant diseases) and outline a treatment plan.