Examination of the external genitalia description in ib. Examination of the female external genitalia
Chapter 1. METHODS OF EXAMINATION OF GYNECOLOGICAL PATIENTS
Chapter 1. METHODS OF EXAMINATION OF GYNECOLOGICAL PATIENTS
1.1. History and examination
At history taking in gynecological patients pay attention to:
Age;
Complaints;
Family history;
lifestyle, food, bad habits, working and living conditions;
Past illnesses;
Menstrual and reproductive functions, the nature of contraception;
Gynecological diseases and operations on the genitals;
History of present illness.
Communication with patients is an integral part of the work of a doctor. His ability to conduct a dialogue, listen carefully and answer questions truthfully helps to understand the patient, understand the causes of her illness and choose the best method of treatment. The patient should feel that the doctor is ready to listen to her and keep everything she says secret, as required by the Hippocratic oath.
Previously, the doctor has always acted as a mentor, giving the patient a guide to action. Now patients prefer more equal relations, they do not expect commands, but advice, they demand respect for their own, albeit unprofessional, opinion. The patient should take an active part in the choice of treatment method, as well as be aware of possible consequences and complications of either method. The doctor needs to obtain written consent from the patient for various manipulations and operations.
When taking the history, one should Special attention on the patient's complaints. The main complaints in gynecological patients are pain, leucorrhoea, bleeding from the genital tract, infertility and miscarriage. First, they find out the time of the appearance of the first menstruation (menarche), menstruation was established immediately or after some time, what is their duration and amount of blood loss, the rhythm of the appearance of menstruation. Then they clarify whether menstruation has changed after the onset of sexual activity (coitarche), childbirth, abortion, how menstruation occurs during a real illness, when was the last menstruation and what are its features.
All numerous violations of menstrual function can be divided into amenorrhea and hypomenstrual syndrome, menorrhagia, metrorrhagia and algomenorrhea.
Amenorrhea - lack of menstruation; observed before puberty, during pregnancy and lactation. These types of amenorrhea are a physiological phenomenon. Pathological amenorrhea occurs after the establishment of the menstrual cycle due to general and gynecological diseases of various origins.
Hypomenstrual syndrome It is expressed in a decrease (hypomenorrhea), shortening (oligomenorrhea) and a decrease (opsomenorrhea) of menstruation. Usually this syndrome occurs in the same diseases as pathological amenorrhea.
menorrhagia - bleeding associated with the menstrual cycle. Menorrhagia occurs cyclically and is manifested by an increase in blood loss during menstruation (hypermenorrhea), a longer duration of menstrual bleeding (polymenorrhea) and disturbances in their rhythm (proyomenorrhea). Relatively often, these violations are combined. The occurrence of menorrhagia may depend both on a decrease in uterine contractility due to the development of inflammatory processes (endo- and myometritis), tumors (uterine fibroids), and on ovarian dysfunction associated with improper maturation of follicles, corpus luteum or lack of ovulation.
metrorrhagia - acyclic uterine bleeding that is not associated with the menstrual cycle and usually occurs with various disorders of ovarian function due to impaired ovulation processes (dysfunctional uterine bleeding), with submucosal uterine myoma, cancer of the body and cervix, hormonally active ovarian tumors and some other diseases.
Menometrorrhagia - bleeding in the form heavy menstruation continuing into the intermenstrual period.
Algodysmenorrhea - painful menstruation. Pain usually accompanies the onset of menstrual bleeding and is less common throughout menstruation. Painful menstruation is the result of underdevelopment of the genital organs (infantilism), incorrect position of the uterus, the presence of endometriosis, inflammatory diseases of the internal genital organs, etc.
Pathological discharge from the genitals is called whiter. Beli can be both a symptom of gynecological diseases and a manifestation of pathological processes not related to the reproductive system. Beli can be scarce, moderate, plentiful. They can be milky, yellowish, green, yellow-green, gray, "dirty" (with an admixture of blood) color. The consistency of whiter is thick, viscous, creamy, foamy, curdled. It is important to pay attention to the smell of secretions: it may be absent, it can be pronounced, sharp, unpleasant. The patient is asked if the amount of discharge increases during certain periods of the menstrual cycle (especially in connection with menstruation), whether the discharge is associated with sexual intercourse or a change of partner, does not appear
whether contact bleeding after intercourse, as well as under the influence of provoking factors (after stool, weight lifting).
Grade reproductive (childbearing) function the patient allows you to get data about her gynecological well-being or trouble.
It is important to find out:
At what year of sexual life and at what age did the first pregnancy occur;
How many pregnancies there were and how they proceeded, whether there was a cystic drift, ectopic pregnancy and other complications;
How many births there were and when, were there any complications during childbirth and in the postpartum period, if so, which ones, was there an operational benefit;
How many abortions were there (artificial in the hospital, for medical reasons, out-of-hospital, spontaneous) and when, were there any complications during the abortion or in the post-abortion period, what treatment was carried out;
When was the last pregnancy, at what age, how did it proceed and how did it end: urgent or premature birth, artificial or spontaneous abortion, were there any complications during childbirth (abortion) or in the postpartum (post-abortion) period, if any, then what, than and how the patient was treated.
During inspection, the following characteristics are determined.
Body type: female, male (tall, long torso, broad shoulders, narrow pelvis), eunuchoid (tall, narrow shoulders, narrow pelvis, long legs, short torso).
Phenotypic features: retrognathia, arched palate, wide flat nose bridge, low auricles, short stature, short neck with skin folds, barrel-shaped rib cage and etc.
Hair growth and condition of the skin.
Condition of the mammary glands. Assessment of the mammary glands is an obligatory component in the work of an obstetrician-gynecologist. Examination of the mammary glands is carried out in two positions: 1st - the woman is standing, her arms hang down along the body; 2nd - raises his hands and puts them on his head. On examination, the following are evaluated: the size of the mammary glands, their contours, symmetry, the condition of the skin (color, presence of edema, ulceration), the condition of the nipple and areola (size, location, shape, discharge from the nipple or ulceration). Discharge from the nipple can be watery, serous, hemorrhagic, purulent, milky. Hemorrhagic discharge is characteristic of intraductal papilloma, purulent - for mastitis, milky - for hyperprolactinemia of various origins. In the presence of secretions, it is necessary to make a smear-imprint on a glass slide.
X-ray mammography is the most common and highly informative method for examining the mammary glands. Plain mammography is advisable in the 1st phase of the menstrual cycle. Application-
This method is contraindicated in women under 35 years of age, as well as during pregnancy and lactation.
For differential diagnosis a number of diseases of the mammary glands also use artificial contrast - ductography. This method is used to diagnose intraductal changes. An indication for ductography is the presence of bloody discharge from the nipple.
For the study of young women, the most informative is ultrasound (ultrasound). Its promising addition is dopplerometry. Ultrasound in combination with color Doppler mapping (CDC) allows you to identify tumor vessels. Currently, computed tomography (CT) and magnetic resonance imaging (MRI) are also used to diagnose diseases of the mammary glands.
Determination of body length and weight needed to calculate body mass index (BMI).
BMI \u003d Body weight (kg) / Body length (m 2).
Normally, the BMI of a woman of reproductive age is 20-26 kg / m 2. An index of more than 40 kg/m 2 (corresponds to IV degree of obesity) indicates a high probability of metabolic disorders.
With overweight, it is necessary to find out when obesity began: from childhood, at puberty, after the onset of sexual activity, after abortion or childbirth.
Abdominal examination can provide very valuable information. It is carried out in the position of the patient lying on his back. When examining the abdomen, pay attention to its size, configuration, swelling, symmetry, participation in the act of breathing. If necessary, the circumference of the abdomen is measured with a centimeter tape.
Palpation of the abdominal wall is of great practical importance, especially for the establishment of pathological neoplasms. Tension of the anterior abdominal wall is an important symptom of peritoneal irritation; observed in acute inflammation of the uterine appendages, pelvic and diffuse peritonitis.
Percussion complements palpation and helps to determine the boundaries of individual organs, the contours of tumors, the presence of free fluid in abdominal cavity.
Auscultation of the abdomen is of great diagnostic value after cerebrosection (diagnosis of intestinal paresis).
Gynecological examination carried out on a gynecological chair. The patient's legs lie on supports, buttocks - on the edge of the chair. In this position, you can examine the vulva and easily insert the mirror into the vagina.
The normal (typical) position of the genital organs is considered to be their position in a healthy sexually mature non-pregnant and non-nursing woman, who is in an upright position, with emptied bladder and rectum. Normally, the bottom of the uterus is turned upward and does not protrude above the plane of the entrance to the small pelvis, the area of the external uterine os is located at the level of the spinal plane, the vaginal part of the neck
uterus is located downwards and backwards. The body and cervix form an obtuse angle, open anteriorly (position anteverzio and anteflexio). The bottom of the bladder is adjacent to the anterior wall of the uterus in the isthmus, the urethra is in contact with the anterior wall of the vagina in its middle and lower thirds. The rectum is located behind the vagina and is connected with it by loose fiber. The upper part of the posterior wall of the vagina (posterior fornix) is covered by the peritoneum of the recto-uterine space.
The normal position of the female genital organs is ensured by:
Own tone of the genital organs;
Relationships between internal organs and coordinated activity of the diaphragm, abdominal wall and pelvic floor;
The ligamentous apparatus of the uterus (suspension, fixation and support).
Own tone of the genital organs depends on the proper functioning of all body systems. A decrease in tone may be associated with a decrease in the level of sex hormones, a violation of the functional state nervous system, age-related changes.
Relationships between internal organs(intestine, omentum, parenchymal and genital organs) form a single complex as a result of their direct contact with each other. Intra-abdominal pressure is regulated by the friendly function of the diaphragm, the anterior abdominal wall and the pelvic floor.
Suspension apparatus make up round and wide ligaments of the uterus, own ligament and suspensory ligament of the ovary. The ligaments provide the median position of the uterine fundus and its physiological inclination anteriorly.
To fixing apparatus include sacro-uterine, utero-vesical and vesico-pubic ligaments. The fixing device ensures the central position of the uterus and makes it almost impossible to move it to the sides, backwards and forwards. Since the ligamentous apparatus departs from the uterus in its lower section, physiological inclinations of the uterus in different directions are possible (lying position, overfilled bladder, etc.).
Support apparatus it is represented mainly by the muscles of the pelvic floor (lower, middle and upper layers), as well as by the vesico-vaginal, rectovaginal septa and dense connective tissue located at the side walls of the vagina. The lower layer of the pelvic floor muscles consists of the external sphincter of the rectum, bulbous-cavernous, ischiocavernosus, and superficial transverse perineal muscles. The middle layer of muscles is represented by the urogenital diaphragm, the external urethral sphincter and the deep transverse muscle that lifts the anus.
Examination of the external genitalia: condition and size of small and large labia; the condition of the mucous membranes ("juiciness", dryness, color, condition of the cervical mucus); the size of the clitoris; the degree and nature of the development of the hairline; condition of the perineum; pathological processes (inflammation, tumors, ulcerations, warts, fistulas, scars).
They also pay attention to the gaping of the genital slit; inviting the woman to push, determine if there is any prolapse or prolapse of the walls of the vagina and uterus.
Examination of the vagina and cervix in the mirrors(Fig. 1.1) is carried out by women who are sexually active. Timely recognition of diseases of the cervix, erosions, polyps and other pathologies is possible only with the help of mirrors. When viewed in mirrors, swabs are taken for microflora, for cytological examination, a biopsy of pathological formations of the cervix and vagina is also possible.
Bimanual (two-handed vaginal-abdominal) examination carried out after removing the mirrors. Index and middle fingers one hand (usually right), dressed in a glove, is inserted into the vagina. The other hand (usually the left) is placed on the front abdominal wall. With the right hand, the walls of the vagina, its vaults and the cervix are palpated, volumetric formations and anatomical changes are determined. Then, carefully inserting fingers into the posterior fornix of the vagina, the uterus is displaced forward and upward and palpated with the other hand through the anterior abdominal wall. They note the position, size, shape, consistency, sensitivity and mobility of the uterus, pay attention to volumetric formations (Fig. 1.2).
Rectovaginal examination necessarily in postmenopause, and also if it is necessary to clarify the condition of the uterine appendages. Some authors suggest that it be performed for all women over 40 years of age to exclude concomitant diseases of the rectum. Rectal examination determines the tone of the sphincters anus and the condition of the pelvic floor muscles, volumetric formations (internal hemorrhoids, tumor).
Rice. 1.1. Inspection of the vagina and cervix in the mirrors. Artist A.V. Evseev
Rice. 1.2. Bimanual (two-handed vaginal-abdominal) examination. Artist A.V. Evseev
1.2. Special Methods research
Functional diagnostic tests
Functional diagnostic tests used to determine functional status reproductive system have not yet lost their value. According to the tests of functional diagnostics, one can indirectly judge the nature of the menstrual cycle.
The symptom of the "pupil" reflects the secretion of mucus by the glands of the cervix under the influence of estrogens. On pre-ovulatory days, mucus secretion increases, the external opening of the cervical canal opens slightly and, when viewed in mirrors, resembles a pupil. In accordance with the diameter of the mucus visible in the neck (1-2-3 mm), the severity of the "pupil" symptom is determined as +, ++, +++. During the period of ovulation, the "pupil" symptom is +++, under the influence of progesterone to last day the menstrual cycle, it is +, and then disappears.
The symptom of stretching of the cervical mucus is associated with its character, which changes under the influence of estrogens. The extensibility of the mucus is determined with the help of forceps, which take a drop of mucus from the cervical canal and, pushing the branches apart, look at how many millimeters the mucus is stretched. The maximum stretching of the thread - by 12 mm - occurs during the period of the highest concentration of estrogens, corresponding to ovulation.
Karyopyknotic index (KPI) - the ratio of keratinizing and intermediate cells in a microscopic examination of a smear from the posterior fornix of the vagina. During the ovulatory menstrual cycle, CPI fluctuations are observed: in the 1st phase - 25-30%, during ovulation - 60-80%, in the middle of the 2nd phase - 25-30%.
Basal temperature - the test is based on the hyperthermic effect of progesterone on the thermoregulatory center of the hypothalamus. In the ovulatory cycle, the temperature curve has two phases. With full-fledged 1st and 2nd phases, the basal temperature rises by 0.5 ° C immediately after ovulation and stays at this level for 12-14 days. In case of insufficiency of the 2nd phase of the cycle, the hyperthermic phase is less than 10-8 days, the temperature rises in steps or periodically drops below 37 °C. At various types anovulation, the temperature curve remains monophasic (Fig. 1.3, 1.4).
Indicators of tests of functional diagnostics during the ovulatory cycle are given in table. 1.1.
Table 1.1. Indicators of functional diagnostic tests during the ovulatory menstrual cycle
An accurate method for assessing ovarian function is a histological examination of endometrial scrapings. Secretory changes in the endometrium, removed during curettage of the uterine mucosa 2-3 days before start of menstruation, with an accuracy of 90% indicate ovulation has occurred.
Laboratory diagnostics of causative agents of inflammatory diseases of the genital organs
This diagnosis is represented by bacterioscopic, bacteriological, cultural, serological, molecular biological methods. Bacterioscopic (microscopic) examination based on microscopy of stained or native smears taken from the posterior fornix of the vagina, cervical canal, urethra, according to indications - from the straight line
Rice. one.3. Basal (rectal) temperature during a normal 2-phase menstrual cycle
Rice. 1.4. Basal (rectal) temperature during 1-phase (anovulatory) menstrual cycle
intestines. Before taking a smear, it is not recommended to douche, inject drugs into the vagina. The material for research is taken with the help of a Volkmann spoon, applying it in a thin uniform layer on two glass slides. After drying, one smear is stained with methylthioninium chloride (methylene blue ♠), the other with Gram stain. Microscopy of a native smear is performed before it dries. Evaluate the presence of epithelium in the preparations, the number of leukocytes, erythrocytes, the morphotype of bacteria (cocci, coccobacilli, lactobacilli), the presence of diplococci located extra- and intracellularly.
In accordance with the results of the study, four degrees of purity of the smear are distinguished:
I degree - single leukocytes are determined in the field of view, rod flora (lactobacilli);
II degree - 10-15 leukocytes in the field of view, against the background of rod flora there are single cocci;
III degree - leukocytes 30-40 in the field of view, few lactobacilli, cocci predominate;
IV degree - a large number of leukocytes, lactobacilli are absent, the microflora is represented by various microorganisms; may be gonococci, Trichomonas.
Pathological smears are considered III and IV degrees of purity.
Serological studies are based on the antigen-antibody reaction and give indirect indications of infection. To serological methods diagnostics include the determination of the level of specific immunoglobulins of various classes (IgA, IgG, IgM) in the blood serum by enzyme immunoassay(IFA). The reaction of direct (PIF) and indirect (NPIF) immunofluorescence is used to identify the pathogen with fluorescent microscopy. In practice, serological methods are used to diagnose infections such as toxoplasmosis, measles, rubella, parotitis, genital herpes, syphilis, hepatitis B and C, urogenital and chlamydial infections.
Molecular biological methods allow identification of a microorganism by the presence of specific DNA segments. Of the various variants of DNA diagnostics, the polymerase method is the most widely used. chain reaction(PCR), which allows you to identify various infectious agents.
Bacteriological diagnostics is based on the identification of microorganisms grown on artificial nutrient media. Material for research is taken from the pathological focus (cervical canal, urethra, abdominal cavity, wound surface) with a bacteriological loop or a sterile swab and transferred to a nutrient medium. After the formation of colonies, microorganisms are determined and their sensitivity to antibiotics and antibacterial drugs is assessed.
Tissue biopsy and cytology
Biopsy- intravital taking of a small amount of tissue for microscopic examination for the purpose of diagnosis. In gynecology, excisional biopsy (excision of a piece of tissue) is used (Fig. 1.5), targeted biopsy - under the visual control of an extended colposcopy or hysteroscope, and puncture biopsy.
Most often, a biopsy is performed when there is a suspicion of malignant tumor cervix, vulva, vagina, etc.
cytological diagnosis. Cells are subjected to cytological examination in smears from the cervix, in punctate (volumetric formations of the small pelvis, fluid from the retrouterine space) or aspirate from the uterine cavity. The pathological process is recognized by the morphological features of cells, the quantitative ratio of individual cell groups, the location of cellular elements in the preparation.
Cytological examination is a screening method for mass preventive examinations of women in high-risk groups for the development of cancer.
Cytological examination of cervical smears under a microscope is used as a screening method, but has insufficient sensitivity (60-70%). There are various systems for evaluating its results.
In Russia, a descriptive conclusion is often used. The most commonly used system is the Papanico-Lau (Pap test). The following classes of cytological changes are distinguished:
I - normal cytological picture;
II - inflammatory, reactive changes in epithelial cells;
III - atypia of individual epithelial cells (suspicion of dysplasia);
IV - single cells with signs of malignancy (suspicion of cancer);
V - complexes of cells with signs of malignancy (cervical cancer).
Rice. 1.5. Excisional biopsy of the cervix. Artist A.V. Evseev
Determination of hormones and their metabolites
In gynecological practice, protein hormones are determined in blood plasma: lutropin (luteinizing hormone - LH), follitropin (follicle-stimulating hormone - FSH), prolactin (Prl), etc .; steroid hormones (estradiol, progesterone, testosterone, cortisol, etc.); in the urine - excretion of androgen metabolites (17-ketosteroids - 17-KS) and pregnane-diol - a metabolite of the corpus luteum hormone progesterone.
AT last years when examining women with manifestations of hyperandrogenism, the levels of androgens, adrenal hormones are examined; their precursors in blood plasma and metabolites in urine - testosterone, cortisol, dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S), 17-hydroxyprogesterone (17-OPN), 17-KS. The determination of pregnandiol has given way to a study of the level of progesterone in the blood.
Functional trials
A single determination in the blood and urine of hormones and their metabolites is uninformative; these studies are combined with functional tests, which allows you to clarify the interaction of various parts of the reproductive system and find out the reserve capabilities of the hypothalamus, pituitary gland, adrenal glands, ovaries and endometrium.
Test with estrogens and gestagens is carried out in order to exclude (confirm) a disease or damage to the endometrium (uterine form of amenorrhea) and to determine the degree of estrogen deficiency. Intramuscular injections of ethinyl estradiol (Microfollin ♠) are administered at a dose of 0.1 mg (2 tablets of 0.05 mg) daily for 7 days. Then progesterone is administered in the doses indicated for the test with gestagens. 2-4 or 10-14 days after the administration of progesterone or HPA, respectively, a menstrual-like reaction should begin. A negative result (lack of reaction) indicates deep organic changes in the endometrium (damages, diseases); positive (onset of a menstrual-like reaction) - for a pronounced deficiency of endogenous estrogens.
Dexamethasone test is carried out to determine the cause of hyperandrogenism in women with clinical manifestations of virilization. With signs of virilization, it is first necessary to exclude an ovarian tumor.
The test with dexamethasone is based on its ability (like all glucocorticosteroid drugs) to suppress the release of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland, as a result of which the formation and release of androgens by the adrenal glands are inhibited.
Small dexamethasone test: dexamethasone 0.5 mg every 6 hours (2 mg / day) for 3 days, the total dose is 6 mg. 2 days before taking the drug and the next day after its withdrawal, the content of testosterone, 17-OHP and DHEA in the blood plasma is determined. If this is not possible, the content of 17-KS in the daily urine is determined. With a decrease in these indicators compared to the original by more than 50-75%, the test is considered positive, which indicates an adrenal origin
androgens; a decrease after the test of less than 30-25% indicates the ovarian origin of androgens.
In case of a negative test, a large dexamethasone test: taking 2 mg of dexamethasone (4 tablets of 0.05 mg) every 6 hours (8 mg / day) for 3 days (total dose - 24 mg). The control is the same as for the small dexamethasone test. A negative test result - the absence of a decrease in androgens in the blood or urine - indicates a virilizing tumor of the adrenal glands.
Functional tests to determine the level of impairment of the hypothalamic-pituitary system. Tests are carried out at normal or reduced content gonadotropins in the blood.
Test with clomiphene used for diseases accompanied by chronic anovulation on the background of oligomenorrhea or amenorrhea. The test begins after a menstrual-like reaction caused by the intake of estrogens and progesterone. From the 5th to the 9th day from the onset of a menstrual-like reaction, clomiphene is prescribed at a dose of 100 mg / day (2 tablets of 50 mg). The information content of the test is controlled by determining the level of gonadotropins and estradiol in the blood plasma before the test and on the 5-6th day after the end of the drug, or by basal temperature and the appearance or absence of a menstrual-like reaction 25-30 days after taking clomiphene.
A positive test (increased levels of gonadotropins and estradiol, two-phase basal temperature) indicates the preserved functional activity of the hypothalamus, pituitary gland and ovaries. A negative test (no increase in the concentration of estradiol, gonadotropins in the blood plasma, monophasic basal temperature) indicates a violation of the functional activity of the pituitary zone of the hypothalamus and pituitary gland.
Determination of chorionic gonadotropin (CG) used in the diagnosis of both uterine and ectopic pregnancy.
The quantitative method consists in determining the level of β-CHG subunit in blood serum using enzyme immunoassay. The level of β-CHG increases most intensively before the 6th week of pregnancy, reaching 6,000-10,000 IU/l; subsequently, the growth rate of the indicator decreases and becomes unstable. If the level of β-CHG exceeds 2000 IU / l, and the fetal egg in the uterus is not detected by ultrasound, one should think about an ectopic pregnancy.
A widely available screening method is the qualitative determination of CG using disposable test systems. They are strips impregnated with a reagent, upon interaction with which the HCG contained in the urine of pregnant women changes the color of the strip (a colored strip appears).
1.3. Instrumental Methods research
Endoscopic methods
Colposcopy - examination of the vaginal part of the cervix with a tenfold increase using a colposcope; can be simple (survey colposcopy) and advanced (using additional tests and dyes). At simple colposcopy determine the shape, size of the vaginal part of the cervix, the area of the external os of the cervical canal, the color, the relief of the mucous membrane, the border of the squamous and cylindrical epithelium, the features of the vascular pattern.
At extended colposcopy treatment of the cervix with a 3% solution acetic acid* or 0.5% solution salicylic acid, Lugol's solution *, methylthioninium chloride (methylene blue *), hematoxylin, which differently stain normal and altered areas, allows you to evaluate the characteristics of the blood supply to pathological areas. Normally, the vessels of the underlying stroma react to the action of acid with a spasm and become empty, temporarily disappearing from the field of view of the researcher. Pathologically dilated vessels with a morphologically altered wall (absence of smooth muscle elements, collagen, elastic fibers) remain gaping and look blood-filled. The test allows you to assess the condition of the epithelium, which swells and becomes opaque, acquiring a whitish color due to acid coagulation of proteins. The thicker the white staining of the spots on the cervix, the more pronounced the damage to the epithelium. After a detailed inspection, Schiller test: the cervix is lubricated with a cotton swab with 3% Lugol's solution *. Iodine stains the cells of a healthy squamous epithelium of the cervix in a dark brown color; thinned (atrophic) and pathologically altered cells of the cervical epithelium do not stain. Thus, zones of pathologically altered epithelium are identified and areas for cervical biopsy are indicated.
Colpomicroscopy - examination of the vaginal part of the cervix with an optical system (contrast luminescent colpomicroscope or Hamo colpomicroscope - a type of hysteroscope), giving an increase of hundreds of times.
Hysterocervicoscopy - examination using optical systems of the inner surface of the uterus and cervical canal.
Hysteroscopy can be diagnostic or operative. Diagnostic hysteroscopy is currently the best method for diagnosing all types of intrauterine pathology.
Indications for diagnostic hysteroscopy
Menstrual irregularities in various periods of a woman's life (juvenile, reproductive, perimenopausal).
Bleeding in postmenopausal women.
Suspicion for:
Intrauterine pathology;
Anomalies in the development of the uterus;
Intrauterine synechia;
Remains of the fetal egg;
Foreign body in the uterine cavity;
Perforation of the uterine wall.
Clarification of the location of the intrauterine contraceptive (its fragments) before its removal.
Infertility.
Habitual miscarriage.
Control examination of the uterine cavity after surgery on the uterus, hydatidiform mole, chorionepithelioma.
Evaluation of the effectiveness and control of hormone therapy.
Complicated postpartum period.
Contraindications for hysteroscopy the same as for any intrauterine intervention: common infectious diseases (flu, tonsillitis, pneumonia, acute thrombophlebitis, pyelonephritis, etc.); acute inflammatory diseases of the genital organs; III-IV degree of purity of vaginal smears; severe condition of the patient with diseases of cardio-vascular system and parenchymal organs (liver, kidneys); pregnancy (desired); cervical stenosis; widespread cervical cancer.
After a visual determination of the nature of the intrauterine pathology, diagnostic hysteroscopy can be transferred to the operating room - immediately or delayed (if preliminary preparation is necessary).
Hysteroscopic operations are divided into simple and complex.
Simple operations: removal of small polyps, separation of thin synechiae, removal of an intrauterine contraceptive loosely lying in the uterine cavity, small submucous myomatous nodes on a stalk, thin intrauterine septum, removal of hyperplastic uterine mucosa, remnants of placental tissue and fetal egg.
Complex hysteroscopic operations: removal of large parietal fibrous polyps of the endometrium, dissection of dense fibrous and fibromuscular synechia, dissection of a wide intrauterine septum, myomectomy, resection (ablation) of the endometrium, removal of foreign bodies embedded in the uterine wall, falloscopy.
Complications during diagnostic and operative hysteroscopy include complications of anesthesia, complications caused by the environment for expanding the uterine cavity (fluid overload of the vascular bed, cardiac arrhythmia due to metabolic acidosis, gas embolism), air embolism, surgical complications (uterine perforation, bleeding).
Complications of hysteroscopy can be minimized by observing all the rules for working with equipment and apparatus, as well as the technique of manipulations and operations.
Laparoscopy - examination of the abdominal organs using an endoscope inserted through the anterior abdominal wall against the background of the creation of pneumoperitoneum. Laparoscopy in gynecology is used both for diagnostic purposes and for surgical intervention.
Indications for elective laparoscopy:
Infertility (tubal-peritoneal);
polycystic ovary syndrome;
Tumors and tumor-like formations of the ovaries;
uterine fibroids;
Genital endometriosis;
Malformations of the internal genital organs;
Pain in the lower abdomen of unknown etiology;
Prolapse and prolapse of the uterus and vagina;
stress urinary incontinence;
Sterilization.
Indications for emergency laparoscopy:
Ectopic pregnancy;
Apoplexy of the ovary;
Acute inflammatory diseases of the uterine appendages;
Suspicion of torsion of the leg or rupture of a tumor-like formation or ovarian tumor, as well as torsion of a subserous fibroid;
Differential diagnosis of acute surgical and gynecological pathology.
Absolute contraindications for laparoscopy:
hemorrhagic shock;
Diseases of the cardiovascular and respiratory system in the stage of decompensation;
Uncorrected coagulopathy;
Diseases in which the Trendelenburg position is unacceptable (consequences of brain injury, damage to cerebral vessels, etc.);
Acute and chronic hepatic and renal insufficiency.
Relative contraindications to laparoscopy:
polyvalent allergy;
Diffuse peritonitis;
Pronounced adhesive process after previous operations on the organs of the abdominal cavity and small pelvis;
Late pregnancy (more than 16-18 weeks);
Large uterine fibroids (more than 16 weeks of pregnancy). Contraindications for implementation planned laparoscopic interventions include existing or transferred less than 4 weeks ago acute infectious and catarrhal diseases.
Complications of laparoscopy may be associated with anesthesia and the performance of the manipulation itself (injury main vessels, trauma of the gastrointestinal tract and urinary system, gas embolism, mediastinal emphysema).
The frequency and structure of complications depend on the qualifications of the surgeon and the nature of the interventions performed.
Prevention of complications in laparoscopic gynecology includes careful selection of patients for laparoscopic surgery, taking into account absolute and relative contraindications; the experience of the endoscopist surgeon, corresponding to the complexity of the surgical intervention.
Ultrasound procedure
ultrasound internal genitalia is one of the most informative additional research methods in gynecology.
An echogram (visual picture) is an image of the object under study in a certain section. The image is registered in a gray-white scale. For the correct interpretation of echograms, you need to know some acoustic terms. The main concepts necessary for interpreting the results of ultrasound are echogenicity and sound conduction.
Echogenicity - is the ability of the object under study to reflect ultrasound. Formations can be anechoic, reduced, medium and increased echogenicity, as well as hyperechoic. For the average echogenicity take the echogenicity of the myometrium. anechoic call objects that freely transmit an ultrasonic wave (fluid in the bladder, cysts). An obstacle to conducting an ultrasonic wave in liquid media is called hypoechoic(cysts with suspension, blood, pus). Dense structures - such as bone, calcifications, and gas - hyperechoic; on the monitor screen they have an echo-positive image (white). Anechoic and hypoechoic structures are echo-negative (black, grey). Sound conductivity reflects the ability of ultrasound to propagate to depth. Liquid formations have the highest sound conductivity, they greatly facilitate the visualization of the anatomical structures located behind them. This acoustic effect is used in abdominal scanning of the pelvic organs with filled bladder. In addition to abdominal, vaginal sensors are used. They have a higher resolution and are as close as possible to the object of study, however, full-fledged visualization of some formations is not always possible. In pediatric gynecology, in addition to abdominal sensors, rectal sensors are used.
The ultrasound technique involves assessing the location of the uterus, its size, external contour and internal structure. The size of the uterus is subject to individual fluctuations and is determined by a number of factors (age, number of previous pregnancies, phase of the menstrual cycle). The size of the uterus is determined by longitudinal scanning (length and thickness), the width is measured by transverse scanning. In healthy women of childbearing age, the average length of the uterus is 52 mm (40-59 mm), thickness 38 mm (30-42 mm), width of the uterine body 51 mm (46-62 mm). The length of the cervix ranges from 20 to 35 mm. In postmenopause, there is a decrease in the size of the uterus. The echogenicity of the myometrium is average, the structure is fine-grained. Median uterine structure corresponds to two combined layers of the endometrium, with longitudinal scanning it is designated as a median uterine echo (M-echo). To clarify the state of the endometrium, the thickness of the M-echo, shape, echogenicity, sound conductivity, and additional echo signals in the structure matter. Normally, with a two-phase menstrual cycle during the 1st week of the menstrual cycle, the echostructure of the endometrium is homogeneous, with low echogenicity. On the 11th-14th day of the cycle
the thickness of the M-echo can increase up to 0.8-1.0 cm; in this case, the zone of increased echogenicity acquires a spongy structure. In the late secretory phase (the last week before menstruation), the thickness of the echogenic zone increases to 1.5 cm.
During menstruation, the M-echo is not clearly defined, a moderate expansion of the uterine cavity with heterogeneous inclusions is detected. In postmenopausal women M-echo is linear (3-4 mm) or pinpoint.
Ultrasound can be an additional method in the examination of patients with pathology of the cervix, it allows to assess the thickness and structure of the mucous membrane of the cervical canal, to identify inclusions that are pathognomonic for a cervical polyp. In addition, echography provides additional information about the size, structure of the cervix, blood supply features (with digital Doppler mapping and pulse Doppler), the state of the parametrium, and sometimes the pelvic lymph nodes.
The ovaries on echograms are defined as formations of an ovoid shape, medium echogenicity, with small hypoechoic inclusions (follicles) with a diameter of 2-3 mm. Up to 10 follicles are determined along the periphery of the ovaries. Only antral follicles are visualized. With dynamic ultrasound, it is possible to trace the development dominant follicle, fix ovulation and the stage of formation of the corpus luteum. Depending on the phase of the menstrual cycle, the volume of the ovaries ranges from 3.2 to 12.3 cm 3. With the onset of postmenopause, the volume of the ovaries decreases to 3 cm 3 in the 1st year of menopause, their structure becomes homogeneous, and echogenicity increases. An increase in volume and a change in structure may indicate a pathological process in the ovaries.
Recently, the study of the blood circulation of the uterus and ovaries using vaginal scanning in combination with color doppler and dopplerography(DG). Intraorganic blood flow reflects the physiological changes that occur in the uterus and ovaries during the menstrual cycle, as well as new vascular formation in the event of a tumor process. To assess the parameters of blood flow in the vessels of the small pelvis, the indicators are calculated from curves with maximum values of systolic and diastolic velocities: resistance index (IR), pulsation index (PI), systole-diastolic ratio (S/D). Deviation of absolute values from normative indicators may indicate a pathological process. In malignant tumors, the most informative indicator of blood flow is IR, which falls below 0.4.
The advantages of three-dimensional (3D) ultrasound are the ability to obtain an image in three planes, which is not available with conventional ultrasound. 3D ultrasound allows a more detailed assessment in three mutually perpendicular projections of the internal structure of the object under study and its vascular bed.
Significantly increase the information content of ultrasound allows hydrosonography (GHA). The HSG technique is based on the introduction of a contrast agent into the uterine cavity, which creates an acoustic window; this allows more precise
determine structural changes in pathological processes of the uterus, malformations of its development, etc.
Indications for the use of the method
I. Infertility.
Tubal infertility factor:
The level of occlusion of the tube (interstitial, ampullar, fimbrial sections);
Degree of occlusion (complete occlusion, stricture);
The condition of the wall of the fallopian tube (thickness, internal relief).
Peritoneal infertility factor:
The nature of adhesions (remote, cobweb, linear, etc.);
Degree of adhesive process.
Uterine factor:
Intrauterine synechia;
Foreign body (intrauterine contraceptive - IUD, calcifications, suture material);
Malformations of the uterus;
Hyperplastic processes of the endometrium (polyps, glandular cystic hyperplasia of the endometrium);
Adenomyosis;
Myoma of the uterus.
II. Intrauterine pathology.
Hyperplastic processes of the endometrium:
endometrial polyps;
Glandular cystic hyperplasia of the endometrium.
Adenomyosis:
Diffuse form;
focal form;
Nodal form.
uterine fibroids:
Assessment of the state of the endometrium when it is impossible to clearly differentiate the uterine cavity;
Differential diagnosis of small sizes of uterine fibroids and endometrial polyps;
Clarification of the type of submucosal uterine fibroids;
Assessment of the patency of the interstitial part of the fallopian tube in interstitial and interstitial-subserous uterine fibroids;
Evaluation of the topography of interstitial-subserous uterine fibroids relative to the cavity before myomectomy.
Intrauterine synechia:
Localization (lower, middle, upper third of the uterine cavity, the region of the mouths of the fallopian tubes);
Character (single or multiple, gross or subtle).
Malformations of the uterus:
Saddle uterus;
Bicornuate uterus;
Complete doubling of the uterus;
Partitions in the uterus (complete, incomplete);
Rudimentary horn in uterus. Contraindications
Possible pregnancy (uterine and ectopic).
Inflammatory diseases of the pelvic organs (including echographic signs of hydrosalpinx).
Indicators of III-IV degree of purity of a smear from the vagina.
HSG is performed on an outpatient basis or in a hospital under aseptic and antiseptic conditions.
In patients with suspected intrauterine pathology, as in the presence of uterine bleeding, HSG is carried out without taking into account the phase of the menstrual cycle. It is advisable to recommend a study in order to clarify the state of patency of the fallopian tubes no later than the 5-8th day of the menstrual cycle.
The study is carried out in the presence of smears of I-II degree of purity from the vagina and cervical canal.
Premedication before HSG is performed for patients with infertility to relieve anxiety, reduce pain, and also exclude reflex spasm of the fallopian tubes.
An intrauterine catheter is installed after the cervix is exposed using vaginal mirrors. To pass the catheter through the internal os of the uterus, fixation of the cervix with bullet forceps is required. The catheter is passed into the uterine cavity to the bottom; when using balloon catheters, the balloon is fixed at the level of the internal os. After the introduction and installation of the intrauterine catheter, bullet forceps and mirrors are removed; transvaginal echography is performed.
As a contrast medium, it is possible to use sterile liquid media (0.9% sodium chloride solution, Ringer's solution *, glucose solution * 5%) at a temperature of 37 °C. The amount of contrast medium injected may vary depending on the type of catheter used (balloon or non-balloon) and the purpose of the study. To assess intrauterine pathology, 20-60 ml of a contrast agent is required. To diagnose tubal-peritoneal factor of infertility in the absence of reverse fluid flow, it is enough to inject 80-110 ml, and when using non-balloon catheters, the volume of injected 0.9% (isotonic) sodium chloride solution increases many times and can be 300-500 ml.
Automatic fluid supply is carried out using an endomat (Storz, Germany), which ensures its continuous supply at a rate of 150-200 ml / min under a constant pressure of 200-300 mm Hg. With small volumes of injected isotonic sodium chloride solution, Janet syringes can be used.
The duration of the study for intrauterine pathology is 3-7 minutes, for the study of patency of the fallopian tubes - 10-25 minutes.
X-ray methods of research
X-ray methods of research are widely used in gynecology.
Hysterosalpingography It is used (currently rarely) to establish the patency of the fallopian tubes, to identify anatomical changes in the uterine cavity, adhesions in the uterus and small pelvis. Water-soluble contrast agents are used (verotrast, urotrast, verografin, etc.). It is advisable to conduct the study on the 5-7th day of the menstrual cycle (this reduces the frequency of false negative results).
X-ray examination of the skull used to diagnose neuroendocrine diseases. X-ray examination of the shape, size and contours of the Turkish saddle - the bone bed of the pituitary gland - allows you to diagnose a pituitary tumor (its signs: osteoporosis or thinning of the walls of the Turkish saddle, a symptom of double contours). Pathological finger impressions on the bones of the cranial vault, a pronounced vascular pattern indicate intracranial hypertension. If a pituitary tumor is suspected, a computed tomography scan of the skull is performed according to x-ray data.
CT scan(CT) - a variant of an X-ray study that allows you to obtain a longitudinal image of the area under study, sections in the sagittal, frontal or any given plane. CT provides a complete spatial representation of the organ under study, the pathological focus, information about the density of a certain layer, thus making it possible to judge the nature of the lesion. In CT images of the studied structures are not superimposed on each other. CT makes it possible to differentiate the image of tissues and organs by the density coefficient. The minimum size of the pathological focus, determined by CT, is 0.5-1 cm.
In gynecology, CT has not received such widespread use as in neurology and neurosurgery. CT of the sella turcica remains the main method for the differential diagnosis of functional hyperprolactinemia and prolactin-secreting pituitary adenoma.
Magnetic resonance imaging(MRI) is based on such a phenomenon as nuclear 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. Computer signal processing makes it possible to obtain an image of an object in any of the spatial planes.
The harmlessness of the method is due to the fact that magnetic resonance signals do not stimulate any processes at the molecular level.
Compared with other radiation methods, MRI has a number of advantages (the absence of ionizing radiation, the ability to simultaneously obtain multiple sections of the organ under study).
Cytogenetic studies
Pathological conditions of the reproductive system may be due to chromosomal abnormalities, gene mutations and hereditary predisposition to the disease.
Cytogenetic studies are carried out by geneticists. Indications for such studies include the absence and delay of sexual development, anomalies in the development of the genital organs, primary amenorrhea, habitual miscarriage of short terms, infertility, violation of the structure of the external genital organs.
markers chromosomal abnormalities are multiple, often erased somatic anomalies of development and dysplasia, as well as a change in sex chromatin, which is determined in the nuclei of cells of the surface epithelium of the mucous membrane of the inner surface of the cheek, taken with a spatula (screening test). The final diagnosis of chromosomal abnormalities can only be established based on the definition of the karyotype.
Indications for the study of the karyotype are deviations in the amount of sex chromatin, short stature, multiple, often erased somatic developmental anomalies and dysplasia, as well as malformations, multiple deformities or spontaneous miscarriages in early dates family history of pregnancy.
Determining the karyotype is an indispensable condition for examining patients with gonadal dysgenesis.
probing the uterus
This is an invasive diagnostic method (Fig. 1.6) used to establish the position and direction of the uterine cavity, its length immediately before performing minor operations. Probing of the uterus is carried out in a small operating room. The study is contraindicated in cases of suspected desired pregnancy.
Puncture of the abdominal cavity through the posterior fornix of the vagina
The indicated puncture (Fig. 1.7) is performed when it is necessary to determine the presence or absence of free fluid (blood, pus) in the pelvic cavity. Manipulation is performed in an operating room on a gynecological chair under local anesthesia 0.25% solution of procaine (novocaine *) or intravenous anesthesia. Having treated the external genitalia and vagina with a disinfectant and exposed the vaginal part of the cervix with mirrors, they grab the posterior lip with bullet forceps and pull it forward. Then, in the posterior fornix strictly under the cervix, strictly along the midline, in the place where "pasto", fluctuation, flattening or protrusion was determined by palpation, a 10-12 cm long needle is inserted tightly put on a 5-10 ml syringe. The needle should penetrate to a depth of 2-3 cm parallel to the posterior surface of the uterus. Slowly pulling out the piston, the contents of the punctured space are sucked into the syringe. Determine the nature, color, transparency of
Rice. 1.6. Invasive diagnostic methods. Probing of the uterus. Artist A.V. Evseev
Rice. 1.7. Puncture of the abdominal cavity through the posterior fornix. Artist A.V. Evseev
punctate. Produce bacterioscopic or cytological examination of smears; sometimes do and biochemical research.
In gynecological practice, puncture of the posterior fornix is used for inflammatory diseases adnexa of the uterus (hydrosalpinx, pyosalpinx, purulent tubo-ovarian formation), retention formations of the ovaries. This manipulation should be carried out under ultrasound guidance.
Aspiration biopsy
Performed to obtain tissue for microscopic examination. The contents of the uterine cavity are sucked off using a tip put on a syringe, or with a special pipel tool.
Examination of children with gynecological diseases
Examination of children with gynecological diseases differs in many ways from examination of adults.
Children, especially when they first visit a gynecologist, experience anxiety, fear, embarrassment and inconvenience in connection with the upcoming examination. First of all, you need to establish contact with the child, reassure, achieve the location and trust of the girl and her relatives. Preliminary conversation with the mother is best done in the absence of the child. You need to give the mother the opportunity to talk about the development of the disease in her daughter, then ask additional questions. After that, you can ask the girl.
A general examination of girls begins with clarification of complaints, anamnesis of life and disease. It is necessary to pay attention to the age, health of the parents, the course of the mother's pregnancy and childbirth related to the examined girl, carefully find out the diseases suffered by the child during the neonatal period, at an early and later age. They note the general reaction of the girl's body to previously transferred diseases (temperature, sleep, appetite, behavior, etc.). They also find out the conditions of life, nutrition, daily routine, behavior in a team, relationships with peers.
Particular attention should be paid to the period of puberty: the formation of menstrual function, vaginal discharge not associated with menstruation.
An objective examination of girls begins with the determination of the main indicators of physical development (height, body weight, chest circumference, pelvic dimensions). Then a general examination of the organs and systems is carried out. Appreciate appearance, body weight, height, sexual development, pay attention to the skin, the nature of hair growth, the development of subcutaneous adipose tissue and mammary glands.
A special examination is carried out according to the following plan: examination and evaluation of the development of secondary sexual characteristics; examination, palpation and percussion of the abdomen, if pregnancy is suspected - auscultation; examination of the external genitalia, hymen and anus; vaginoscopy; rectal-abdominal examination. If a foreign body of the vagina is suspected, a rectal-abdominal examination is first performed, and then a vaginoscopy.
Before the examination, it is necessary to empty the intestines (cleansing enema) and the bladder. Young girls (up to 3 years old) are examined on a changing table, older girls - on a children's gynecological chair, the depth of which can be changed. When examining girls in polyclinic conditions, as well as during the primary
examination in a hospital requires the presence of the mother or one of the next of kin.
When examining the external genital organs, the nature of hair growth is assessed (according to the female type - horizontal line hair growth; according to the male type - in the form of a triangle with a transition to the white line of the abdomen and inner thighs), the structure of the clitoris, large and small labia, the hymen, their color, the color of the mucous membrane of the entrance to the vagina, discharge from the genital tract. A penis-like clitoris combined with male-pattern hair growth in childhood indicates congenital androgenital syndrome (AGS); growth of the clitoris during puberty - an incomplete form of testicular feminization or virilizing tumor of the gonads. "Juicy" hymen, swelling of the vulva, labia minora and their pink color at any age indicate hyperestrogenism. With hypoestrogenism, the external genitalia are underdeveloped, the vulvar mucosa is thin, pale and dry. With hyperandrogenism during puberty, hyperpigmentation of the labia majora and labia minora, male-type hair growth, and a slight increase in the clitoris are noted.
Vaginoscopy - examination of the vagina and cervix optical instrument, combined ureteroscope, and children's vaginal mirrors with illuminators. Vaginoscopy is performed on girls of any age; it allows you to find out the condition of the vaginal mucosa, the size, shape of the cervix and external os, the presence and severity of the "pupil" symptom, pathological processes in the cervix and vagina, the presence foreign body, malformations.
Vaginoscopy for girls in the "neutral" period is performed with a combined ureteroscope using cylindrical tubes of various diameters with an obturator. In the pubertal period, the vagina and cervix are examined with children's vaginal speculums with illuminators. The choice of ureteroscope tube and children's vaginal mirrors depends on the age of the child and the structure of the hymen.
Bimanual recto-abdominal examination produced for all girls with gynecological diseases. Bimanual examination when examining young children should be carried out with the little finger, when examining older girls - with the index or middle finger, which is protected by a fingertip lubricated with petroleum jelly. The finger is inserted while straining the patient.
During rectal examination, the condition of the vagina is ascertained: the presence of a foreign body, tumors, accumulation of blood; in a bimanual study, the condition of the uterus, appendages, fiber and adjacent organs is determined. When palpation of the uterus, its position, mobility, soreness, the ratio of the size of the cervix and the body of the uterus and the severity of the angle between them are examined.
The detection of a unilateral enlargement of the ovary, especially on the eve of menstruation, is an indication for a mandatory re-examination after the end of menstruation.
In young children (up to 3-4 years old) with genital injuries and in older girls with a suspected tumor in the small pelvis, a rectal-abdominal examination is performed under anesthesia.
When examining girls, it is necessary to carefully observe the rules of asepsis and antisepsis due to the high susceptibility of children's genitals to infection. After the end of the external and internal examination, the external genital organs and the vagina are treated with a solution of furacilin (1: 5000). In case of irritation on the skin of the vulva, it is lubricated with streptocidal ointment or sterile petroleum jelly.
In addition, depending on the nature of the disease, the following additional methods research.
Methods of functional diagnostics and hormonal studies(described above) are used in patients with juvenile bleeding, with pathology of puberty and with suspicion of hormonally active ovarian tumors.
Probing of the vagina and uterine cavity indicated for the diagnosis of malformations, a foreign body, with suspicion of hemato- or pyometra.
Separate diagnostic curettage of the mucous membrane of the body of the uterus with hysteroscopy shown both to stop uterine bleeding, and for diagnostic purposes with poor long-term blood secretions in patients with a disease duration of more than 2 years and with the ineffectiveness of symptomatic and hormone therapy. Diagnostic curettage is done under short-term mask or intravenous anesthesia. The cervix is exposed in children's mirrors with a lighting system. Hegar dilators are inserted into the cervical canal up to? 8-9, endometrial scraping is done with a small curette (? 2, 4). With the correct implementation of diagnostic curettage, the integrity of the hymen is not violated.
Endoscopic methods (hysteroscopy, laparoscopy) do not differ from those in adults.
Ultrasound examination of the internal genital organs. Ultrasound of the small pelvis is widely used due to safety, painlessness and the possibility of dynamic observation. Ultrasound can diagnose genital malformations, ovarian tumors and other gynecological diseases.
In normal girls, the uterus is visualized by ultrasound as a dense formation with multiple linear and dot echo structures, which has the shape of an elongated ovoid and is located in the center of the small pelvis behind the bladder. On average, the length of the uterus in children aged 2 to 9 years is 31 mm, from 9 to 11 years - 40 mm, from 11 to 14 years - 51 mm. In girls older than 14 years, the length of the uterus is on average 52 mm.
The ovaries in healthy girls up to 8 years of age are located at the entrance to the small pelvis and only by the end of the 1st phase of puberty do they go deeper into the small pelvis, adjacent to its walls, they are visualized as ellipsoidal formations with a more delicate structure than the uterus. The volume of the ovaries in children aged 2 to 9 years averages 1.69 cm 3, from 9 to 13 years - 3.87 cm 3, in girls over 13 years old - 6.46 cm 3.
Radiographic and radiopaque research methods
In pediatric gynecology, as in adults, X-ray examination of the skull is used, and extremely rarely (according to strict indications) - hysterosalpingography. It is carried out using a special small children's tip for suspected tuberculosis of the genitals or for anomalies in the development of the genital organs in girls over 14-15 years old.
X-ray examination of the hands is of great importance, which is carried out to determine the bone age with its comparison with passport data. There are specially designed tables that indicate the timing and sequence of the appearance of ossification nuclei and the closure of growth zones depending on age.
In children, as in adults, CT and MRI are used for differential diagnosis. In children early age studies are conducted using parenteral drug sleep.
For hysterosalpingography, hysteroscopy, diagnostic curettage and laparoscopy, CT and MRI, the consent of the girl's parents must be obtained, which should be recorded in the medical history.
In addition to the above methods of examination, for the diagnosis of a number of gynecological diseases, cytogenetic study(determination of sex chromatin, according to indications - karyotype). It is indicated for violations of somatic and sexual development (violation of sexual differentiation, delayed sexual development, etc.).
Laboratory research methods
Material for bacterioscopic examination secretions from the genital tract are taken during the examination of the genital organs. A study of vaginal discharge should be carried out in all girls who applied for help, a study of discharge from adjacent organs (urethra, rectum) - according to indications (for example, if gonorrhea, trichomoniasis are suspected). The discharge should be taken with a grooved probe or a rubber catheter. Before inserting the instrument, a cotton ball moistened with a warm isotonic sodium chloride solution is wiped over the entrance to the vagina, the external opening of the urethra and the area of the anus. Tools for taking secretions are inserted into the urethra to a depth of about 0.5 cm, into the rectum - to a depth of about 2-3 cm, and into the vagina - if possible to the posterior fornix. The results of the study are evaluated taking into account the age of the girl.
Gynecology: textbook / B. I. Baisova and others; ed. G. M. Savelyeva, V. G. Breusenko. - 4th ed., revised. and additional - 2011. - 432 p. : ill.
Examination of the external genitalia
Gynecology
3.56. Standard Examination of the external genital organs
3.57. Standard Examination of the cervix using a double-leaf speculum
3.58. Standard Examination of the cervix using a spoon-shaped speculum with a lift
3.59. Standard Bimanual examination
3.60. Standard Vaginal swab for purity
3.61. Standard Pap smear for gonorrhea
3.62. Standard Taking a smear for oncocytology using a cervix-brush
3.63. Standard Ultrasound preparation
3.64. Standard Vaginal douching
3.65. Standard Vaginal bath
3.65. Standard Vaginal tampon
Scheme for collecting an anamnesis in a pregnant woman
1.Passport data.
2. Diseases suffered in childhood, adulthood, their course, treatment.
3.Heredity.
4. Working and living conditions.
5. Epidemiological history.
6. Allergological history.
7. Obstetric and gynecological history:
menstrual function(menarche and features of the establishment of the menstrual cycle, duration, soreness and regularity of menstruation, the amount of blood lost during menstruation, the date of the last menstruation);
sex life(at what age, is he married);
gynecological diseases (what, when, the duration and nature of their course, the therapy performed, the results of treatment);
generative function - the number of previous pregnancies with a detailed clarification of their course and outcome (artificial and spontaneous abortions, childbirth);
current pregnancy (first and second half of pregnancy, previous diseases and for how long, outpatient, inpatient treatment).
Target: assessment of the condition of the external genital organs.
Resources: gynecological chair, disposable gloves, individual diaper.
1. Explain to the woman the need for this study.
2. Lay the pregnant woman on a gynecological chair (position on the back with legs bent at the knees and hip joints, legs apart), on an individual diaper.
3. Put on disposable gloves.
4. Examine the external genital organs: the pubis, the type of hair growth on the pubis, whether the large and small lips cover the genital gap.
5. With the first and second fingers of the left hand, spread the labia majora and inspect in sequence: the clitoris, urethra, vaginal vestibule, ducts of the Bartholin and paraurethral glands, posterior commissure and perineum.
6. The first and second fingers of the right hand in lower third labia majora, first on one side, and then on the other, palpate the Bartholin glands.
7. Ask the woman to stand.
8. Remove disposable gloves, discard according to infection prevention regulations.
9. Wash your hands with soap.
2. 1. Algorithm for examining the external genital organs.
Indications:
· Assessment of physical development.
Equipment:
· Gynecological chair.
· Individual diaper.
Sterile gloves.
1. Explain to the woman about the need for this study.
2. Ask the woman to undress.
3. Treat the gynecological chair with a cloth moistened with 0.5% calcium hypochlorite solution and lay out a clean diaper.
4. Lay the woman on the gynecological chair.
5. Perform hand hygiene:
6. Apply 3-5 ml of antiseptic to your hands (70% alcohol or lather your hands thoroughly with soap).
Wash your hands using the following technique:
Vigorous friction of the palms - 10 seconds, mechanical, repeat 5 times;
The right palm washes (disinfects) the back of the left hand with rubbing movements, then the left palm also washes the right, repeat 5 times;
The left palm is located on the right hand; fingers interlaced, repeat 5 times;
Alternating friction of the thumbs of one hand with the palms of the other (palms clenched), repeat 5 times;
Variable friction of the palm of one hand with the closed fingers of the other hand, repeat 5 times;
7. Rinse hands under running water, holding and so that the wrists and hands are below the level of the elbows.
8. Turn off the faucet (using a paper towel).
9. Dry your hands with a paper towel.
If it is not possible to wash hands hygienically with water, you can treat them with 3-5 ml of antiseptic (based on 70% alcohol), it should be applied to hands and rubbed until dry (do not wipe hands). It is important to observe the exposure time - hands must be wet from the antiseptic for at least 15 seconds.
10. Put on clean sterile gloves:
Remove rings, jewelry;
Wash hands as necessary (normal or hygienic
hand treatment);
· Open the upper packaging on disposable gloves and remove the gloves in the inner packaging with tweezers;
Unscrew the top edges of the standard package with sterile tweezers, in which the gloves lie with the palm surface up, and the edges of the gloves are turned outward in the form of cuffs;
With the thumb and forefinger of the right hand, grab the inverted edge of the left glove from the inside and carefully put it on left hand;
Bring the fingers of the left hand (wearing a glove) under the lapel of the back surface of the right glove and put it on the right hand;
· Without changing the position of the fingers, unscrew the curved edge of the glove;
· Also unscrew the edge of the left glove;
Keep hands in sterile gloves bent in elbow joints raised forward at a level above the waist; Examine the external genital organs: pubis, type of hairline growth, whether the large and small labia cover the genital gap.
11. With the first and second fingers of the left hand, spread the labia majora and inspect in sequence: the clitoris, urethra, vaginal vestibule, ducts of the Bartholin and paraurethral glands, posterior commissure and perineum.
12. With the first and second fingers of the right hand in the lower third of the labia majora, first on the right, then on the left, palpate the Bartholin glands.
13. Inspection is over. Ask the woman to get up and get dressed.
14. Removing gloves:
With the fingers of the left hand in a glove, grab the surface of the edge of the right glove and remove it with an energetic movement, turning it inside out;
Insert the thumb of the right hand (without a glove) inside the left glove and, grabbing the inner surface, with an energetic movement remove the glove from the left hand, turning it inside out;
Drop used gloves into the KBU (Safe Disposal Box)
15. Wash your hands with soap and water
16. Record the results of the inspection in the primary documentation.
Target: assessment of the condition of the external genital organs.
Resources: gynecological chair, disposable gloves, individual diaper.
Action algorithm.
2. Lay the pregnant woman on a gynecological chair (position on the back with legs bent at the knee and hip joints, legs apart), on an individual diaper.
3. Put on disposable gloves.
4. Examine the external genital organs: the pubis, the type of hair growth on the pubis, whether the large and small lips cover the genital gap.
5. With the first and second fingers of the left hand, spread the labia majora and inspect in sequence: the clitoris, urethra, vaginal vestibule, ducts of the Bartholin and paraurethral glands, posterior commissure and perineum.
6. With the first and second fingers of the right hand in the lower third of the labia majora, first on one side, and then on the other, palpate the Bartholin glands.
7. Ask the woman to stand.
8. Remove disposable gloves, discard according to infection prevention regulations.
9. Wash your hands with soap.
Looking at the mirrors
Purpose of the study: visual assessment of the condition of the vagina and the vaginal part of the cervix.
Resources: gynecological chair, gynecological mirrors, disposable gloves, individual diaper.
Action algorithm.
1. Explain to the woman the need for this study.
2. Lay the woman on a gynecological chair (position on her back with legs bent at the knee and hip joints, legs apart), on an individual diaper.
3. Provide lighting for good review vagina and cervix.
4. Put on disposable gloves.
5. Take a speculum from the sterile table.
spoon-shaped take the mirror in your right hand, spread the labia majora with your left hand (1-2 fingers) and insert the mirror in the direct size of the small pelvis along the back wall of the vagina to the posterior fornix, expand it into a transverse size. Press the speculum against the back wall of the vagina (making room for the lift) and shift the speculum handle to your left hand. With your right hand, insert the lift into the vagina in the direct size of the pelvis along the front wall, then turn it into a transverse size and expose the cervix and vagina.
double leaf enter the mirror sideways in a closed state in a straight size of the pelvis, first spreading the labia minora with your left hand. Gradually move the mirror deep into the vagina, unfold it, setting it in the transverse size of the pelvis, open the mirror and expose the cervix and vagina.
6. On examination, pay attention to: the color of the vaginal mucosa, the nature of the discharge, the presence of pathological processes, the color of the cervical mucosa, the presence of pathological processes on the cervix, the shape of the cervix, the shape of the external os.
7. Remove the speculum from the vagina and immerse it in a disinfectant solution.
8. Ask the woman to stand.
9. Remove disposable gloves, discard according to infection prevention regulations.
10. Wash your hands with soap.
Bimanual study
Purpose of the study: assessment of the state of the internal genital organs.
Resources: gynecological chair, individual diaper, disposable gloves.
Action algorithm.
1. Explain to the woman the purpose of this study.
2. Inform about the need to empty the bladder.
3. Lay the woman on a gynecological chair (position on the back with legs bent at the knee and hip joints, legs apart), on an individual diaper.
4. Explain that breathing should be free during the examination.
5. Put on disposable gloves.
6. 1 and 2 fingers of the left hand spread the large and small labia.
7. With your right hand, middle, and then with your index finger, enter the vagina ( thumb should face the pubic symphysis).
8. With the fingers of the right hand inserted into the vagina, examine the condition of the vagina, the vaginal vaults.
9. Then, bringing the fingers of the inner hand under the cervix, explore the uterus by pressing the fingers of the outer hand on the bottom of the uterus, plunging them into the anterior abdominal wall above the womb (the fingers of the left and right hands should be facing each other).
10. Thus, by palpating the uterus, determine its location, size, consistency, mobility, pain.
11. Move the fingers of the outer and inner hands from the corners of the uterus to the sides of the pelvis. Examine the ovaries and fallopian tubes, determine their size, shape, pain, mobility.
12. Use the right (inner) hand to palpate the inner surface of the pelvis (sciatic spines, sacral cavity, cape), determine the presence of exostoses.
13. When removing the right hand from the vagina, carefully inspect it for the presence of discharge and their nature.
14. Remove gloves, discard according to infection prevention regulations.
15. Wash your hands with soap.
Pelvimetry
Purpose of the study: determination of the external dimensions of the pelvis.
Resources: couch, pelvis.
Action algorithm.
1. Explain to the woman the need for the procedure.
2. Lay the woman on the couch, on her back with straightened legs.
3. Stand to the right of the woman, facing her.
4. Take the tazomer so that the scale is turned upwards, and the thumb and forefinger lie on the buttons of the tazomer.
5. With your index fingers, feel the points between which the distance is measured, pressing the buttons of the tazomer to them and mark the value of the resulting size on the scale.
6. To measure the distance between the awns ilium(Distancia spinarum) press the buttons of the tazomer to the outer edges of the anterior-upper spines (normal size is 25-26 cm).
7. To measure the distance between the iliac crests (Distancia cristarum), move the buttons of the pelvis to the most protruding points of the iliac crests and measure the distance between them (normal size is 28-29 cm).
8. To measure the distance between the skewers thigh bones(Distancia trochanterica) find the most protruding points of the skewers of the femur and press the buttons of the tazomer to them (the normal size is 30-31 cm).
9. To measure the direct size - external conjugates (Conjugata externa), lay the woman on her side. The lower leg should be bent at the hip and knee joints, and the overlying one is straightened. Place the buttons of the tazomer in front on the upper outer edge of the symphysis and behind on the supra-sacral fossa (located under the spinous process of the fifth lumbar vertebra, which corresponds to the upper corner of the Michaelis rhombus). The normal size is 20-21 cm.
10. To obtain a true conjugate (Conjugata vera), subtract 8-10 cm from the result, depending on the value of the Solovyov index (see the standard “Definition of the Solovyov index).
11. Wash your hands.
12. Record the received data in the medical records.
13. Treat the tazomer with a disinfectant solution.
Measurement of the Solovyov index.
Purpose of the study: indirect determination of the thickness of the pelvic bones.
Resources: tape measure.
Action algorithm.
2. Seat the pregnant woman in a chair.
3. Measure the circumference of the wrist joint on the pregnant woman's hand with a sterile measuring tape.
4. Mark the result.
5. Wash your hands.
6. Record the result of the measurement in the medical documentation.
Note.
Determination of the true conjugate by the Solovyov index:
If the Solovyov index is less than 14 cm (thin bones), subtract 8 cm from the value of the external conjugate, subtract 1.5 cm from the value of the diagonal conjugate;
If the Solovyov index is 14-15 cm (bones of medium thickness), subtract 9 cm from the value of the outer conjugate, subtract 1.5 cm from the value of the diagonal conjugate;
If the Solovyov index is more than 15 cm (thick bones), subtract 10 cm from the value of the external conjugate, subtract 2 cm from the value of the diagonal conjugate.
Measuring the Michaelis diamond
Purpose of the study: determination of the shape of the narrowing of the pelvis.
Resources: tape measure.
Action algorithm.
1. Warn the pregnant woman about the upcoming study.
2. Ask the pregnant woman to undress.
3. Sit on a chair on the side of the pregnant woman's back.
4. Take measurements of the vertical and horizontal diagonals with a sterile centimeter tape:
vertical diagonal - the distance from the upper corner of the Michaelis rhombus (supra-sacral fossa) to the lower corner (apex of the sacrum), normally 11 cm.
horizontal diagonal - the distance between the lateral angles of the Michaelis rhombus (upper posterior iliac spines), normally 10-11 cm.
5. Note the results.
6. Wash your hands.
7. Record the measurement results in the medical records.
A special gynecological examination begins with an examination of the external genitalia. At the same time, attention is paid to hair growth in the pubis and labia majora, possible pathological changes (swelling, tumors, atrophy, pigmentation, etc.), the height and shape of the perineum (high, low, trough-shaped), its ruptures and their degree, the state of the sexual cracks (closed or gaping), prolapse of the walls of the vagina (independent and when straining). When pushing the genital slit, it is necessary to pay attention to the color of the mucous membrane of the vulva, examine the condition of the external opening of the urethra, paraurethral passages, excretory ducts of the large glands of the vestibule of the vagina, pay attention to the nature of the vaginal discharge. After examining the external genital organs, the anal area should be examined (the presence of cracks, hemorrhoids, etc.).
The appearance and condition of the external genital organs, as a rule, correspond to age. In women giving birth, pay attention to the condition of the perineum and genital gap. With normal anatomical ratios of the tissues of the perineum, the genital slit is closed and slightly opens only with a sharp straining. In case of violation of the integrity of the muscles of the pelvic floor, the genital gap gapes even with slight tension, the walls of the vagina fall.
The mucous membrane of the entrance to the vagina healthy woman has a pink color. In inflammatory diseases, it can be hyperemic, sometimes with the presence of purulent raids. During pregnancy, due to congestive plethora, the mucosa acquires a bluish color, the intensity of which increases with increasing gestational age.
Hypoplasia of the labia minora and labia majora, pallor and dryness of the mucous membrane, vagina are signs of hypoestrogenism. Juiciness, cyanosis of the vulva, abundant secretion of cervical mucus - signs advanced level estrogen. Intrauterine hyperandrogenism is indicated by hypoplasia of the labia minora, an increase in the head of the clitoris, an increased distance between the base of the clitoris and the external opening of the urethra (more than 2 cm) in combination with hypertrichosis. Then they begin to study with the help of mirrors, which has a special great importance in gynecology to detect pathological changes vagina and cervix. An examination with a vaginal speculum is a mandatory part of every gynecological examination, as many pathological conditions on the cervix and in the vagina are not accompanied by certain symptoms. It allows you to assess the condition of the vaginal mucosa (color, folding, tumor formations), its depth. On the cervix, the shape of the external uterine os, the presence of inflammatory changes, tumor formations (polyps, exophytic form of cancer, etc.), the nature of the discharge from the cervical canal are determined.
