Modern gynecology: diagnostic methods. Clinical methods and instrumental diagnostics in gynecology Additional methods for studying gynecological diseases

Methods for examining gynecological patients:

1. History– provides for the collection of information about medical and social factors, past diseases, hereditary factors, menstrual, sexual, generative function, gynecological diseases and operations with details of their course, treatment methods and outcome, complaints and history of the development of the present disease, bad habits, allergic reactions and drug tolerance, health status and diseases of the husband, functions of related organs.

2. Inspection.

During an external examination, the following is assessed:

A) type of constitution: infantile, hypersthenic, asthenic, intersex, normosthenic

B) the nature of hair growth and the condition of the skin: excess hair growth, increased greasiness, porosity, folliculitis, stretch marks, their color, quantity and location

C) condition of the mammary glands: size, hypoplasia, hypertrophy, symmetry, changes in the skin

D) determination of body length and weight: body mass index is determined

D) condition of internal organs: examined systematically

E) examination of the abdomen: palpation, percussion and auscultation

3. Gynecological examination(see question 22).

4. Instrumental research methods(probing of the uterus, separate diagnostic curettage, biopsy, aspiration curettage, abdominal puncture, blowing of the fallopian tubes, bladder catheterization).

5. Cytological and functional studies(see question 24).

6. Hormonal studies(see question 25)

7. Endoscopic methods

8. Ultrasound diagnostics(see question 30)

9. X-ray methods(see question 29).

Main symptoms of gynecological diseases:

1) menstrual dysfunction:

a) amenorrhea – absence of menstruation for more than 6 months, can be physiological and pathological, primary and secondary

b) hypomenstrual syndrome – expressed in weakening, shortening and slowing of menstruation (hypo, oligo, opsomenorea)

c) hypermenstrual syndrome – manifests itself in the form of frequent, prolonged and heavy menstruation (poly, hyper, promenorrhea)

d) menorrhagia – bleeding associated with the menstrual cycle

e) metrorrhagia - acyclic uterine bleeding not associated with the menstrual cycle

e) algodismenorrhea - painful menstruation

g) ovulatory disorders – diseases with persistence of ovulation

h) anovulatory disorders - diseases in the absence of ovulation

2) sexual dysfunction: lack of sexual feeling (libido), lack of satisfaction (orgasm), painful sexual intercourse, presence of bloody discharge after intercourse (contact bleeding)

3) impaired fertility

4) infertility– as a result of inflammatory diseases, injuries to the soft tissues of the birth canal, abnormalities in the position of organs, menstrual dysfunction

5) pathological secretion (leucorrhoea)– there are:

a) vestibular - caused by inflammatory processes of the external genitalia or large glands of the vestibule of the vagina

b) vaginal – for extragenital diseases (pulmonary tuberculosis, hypothyroidism), local infection, helminthic infestation, foreign body in the vagina

c) cervical – for inflammation of the cervix, erosions, ruptures, polyps, cancer, tuberculosis of the cervix

d) uterine – for endometritis, submucosal fibroids, polyps, malignant tumors

e) tubal – for inflammatory diseases of the fallopian tubes, malignant diseases

6) pain– the occurrence and nature of pain is determined by the characteristics of the innervation of the genital organs, the state of the central nervous system and the nature of the disease

7) urinary tract dysfunction: increased frequency or difficulty urinating, urinary incontinence, pain when urinating

8) bowel function disorders: constipation, diarrhea, pain during bowel movements, incontinence of feces and gases

Additional research methods include, in particular, probing of the uterus. It is carried out using a uterine probe with a centimeter scale to clarify the position of the length and the presence of pathological formations in the uterine cavity.

To do this, after treating the external genitalia and vagina, a probe is inserted into the uterine cavity and the uterine cavity is examined.

Biopsy

A biopsy is a histological examination of an excised pathological area (cervix, vagina) performed using a scalpel or conchotome. The excised area is placed in a 40% formalin solution or 96% alcohol.

Bacterioscopic examination of the vagina, cervix and urethra

A bacterioscopic examination of the vagina, cervix and urethra is carried out by taking a smear applied to a glass slide indicating the place from which the smear was taken (v—vagina, c—cervical canal, u—urethra, r—rectum). A smear is taken using a Volkmann spoon or tweezers.

Abdominal puncture

Puncture of the abdominal cavity through the posterior fornix is ​​carried out after exposing it in the speculum by retracting the cervix upward. This study is carried out for the purpose of differential diagnosis between the inflammatory process and ectopic pregnancy.

Diagnostic curettage of the uterine cavity

Diagnostic curettage of the uterine cavity is performed using the usual method, followed by histological examination of the scraping. In this case, scrapings of the cervical canal and the uterine cavity are studied separately.

Endoscopic methods

Endoscopic methods are used both for diagnostic purposes and for treatment in a number of cases:

• Colposcopy allows you to examine the cervix with a 10-30-fold magnification, which allows you to detect the atypical structure of cells. During colposcopy, you can use the Schiller test (when the cervix is ​​lubricated with 3% Lugol's solution, pathological cells are not stained);
• hysteroscopy is an examination of the inner surface of the uterus using optical equipment with magnification up to 50 times;
• laparoscopy is performed after filling the abdominal cavity with gases (CO2, N02, oxygen, air). After the gas is administered, the abdominal organs are examined using a special device (laparoscope). If necessary, using special instruments, this method can perform a number of surgical interventions: removal of the uterus, ovary, dissection of adhesions, removal of myomatous nodes, etc., up to volumetric operations (supravaginal amputation of the uterus).

Ultrasound

Ultrasound examination (ultrasound) is a temporary and fairly common diagnostic method in gynecology. This method makes it possible to produce the structural features of the organ under study and determine its size. The method has no contraindications.

Currently, ultrasound is supplemented by Dopplerometry, which makes it possible to determine the nature of the blood supply to internal organs. It is advisable to conduct a control study on the 5th-8th day of the menstrual cycle. At the same time, the normal thickness of the endometrium is 10-15 mm, and immediately after menstruation - 5 mm.

Hysterosalpingography

It is performed to check the patency of the fallopian tubes. It is advisable to conduct the study on the 5th-7th day of the menstrual cycle (the uterus and tubes are in a relaxed state).

A contrast agent (urotrast, verotrast, verografin) is injected into the uterine cavity using a special syringe with a nozzle. And after closing the cervix using bullet forceps or Musot forceps, an x-ray is taken, which must be repeated after 24 hours. With passable fallopian tubes, the contrast agent enters the free abdominal cavity and is smeared in it, and with obstruction, the level at which the fallopian tube is not passable is clearly visible.

X-ray of the sella turcica (skull) area

It is carried out to clarify the pathology of the pituitary gland, which affects the neurohumoral regulation of menstrual function.

Hormonal studies

Hormonal studies are used to identify the causes of menstrual dysfunction in order to determine the level of damage (hypothalamus - pituitary gland - adrenal glands - ovaries - uterus).

For differential diagnosis of the level of disorders, a number of functional tests are also used: a test with a releasing factor, with choriogonin, with estrogens, with clomiphene, with ACTT.

To clarify the diagnosis, additional research methods are used. Of these methods, it is necessary to highlight those that are currently used by all gynecological patients, as well as healthy women seeking preventive examination. Such additional methods include cytological, bacterioscopic examination and colposcopy.

Cytological examination. It is produced for the purpose of early detection of cancer of the uterus and fallopian tubes. From the surface of the cervix, material is obtained using fingerprint smears (a glass taken with tweezers is applied to the surface of the cervix, or an Eyre spatula is passed along the cervix with a rotational motion). The material is taken from the cervical canal with a special spoon or grooved probe.

The material is applied to a glass slide and air dried. After special staining, the smears are examined. Mass cytological examination during preventive examinations makes it possible to identify a contingent of women (if atypical cells are identified) 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 magnifies the object in question by 10-30 times or more. Colposcopy allows you to identify early forms of precancerous conditions, select the site most suitable for biopsy, and also monitor healing during treatment.

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

Bacterioscopic examination. It is used to diagnose inflammatory processes and allows you to determine the type of microbial factor. Bacterioscopy of vaginal discharge helps determine the degree of vaginal cleanliness, which is necessary before gynecological operations and diagnostic procedures.

In some cases, bacterioscopic examination allows one to identify a sexually transmitted disease in its asymptomatic 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 involving 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 with the index finger moving from top to bottom and applied to a glass slide in a thin layer. each smear is taken with a separate instrument).

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

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

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

IV degree of purity - no vaginal bacilli, many pathogenic microbes, including 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), a forceps and a uterine probe. All instruments are used sterile. To treat the vagina, you need alcohol, tincture of iodine and gauze balls. Probing of the uterus is performed in a hospital setting, observing the rules of asepsis and antiseptics. The doctor performs manipulation only when the vagina is clean I-II after the patient has emptied her bladder.

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

Research using bullet forceps. This study helps clarify the connection of the tumor with the genital organs. It is used when it is unclear whether the tumor comes from the uterus, appendages or intestines.

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

After exposing the cervix using speculum, it is treated with alcohol and grabbed by the front lip with bullet forceps.

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

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

A set of necessary instruments: spoon-shaped vaginal speculum, forceps (2), bullet forceps (2), uterine probe, sets of dilators and curettes. You also need alcohol, tincture of iodine, sterile dressings (balls, napkins, etc.), bottles with formaldehyde solution to preserve the resulting material for histological examination. The bottles must be marked with the patient's name, date of manipulation, place from which the material was taken (cervix, uterine cavity), and clinical diagnosis.

Contraindications: III-IV degree of vaginal cleanliness, presence of signs of acute and subacute inflammatory process in the uterus and appendages, infectious diseases, elevated body temperature. This applies to planned surgery 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 antiseptics is mandatory. To prepare the patient, be sure 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 uterine body is often performed separately, which provides a more accurate diagnosis (in this case, the resulting material is collected in two different bottles). Biopsy. A biopsy and histological examination of the obtained tissue make it possible 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 antiseptics is mandatory.

A set of necessary tools: spoon-shaped mirrors, forceps, tweezers, bullet forceps (2), scalpel, scissors, needle with needle holder, catgut. Sterile material, alcohol, and tincture of iodine are also needed.

The resulting piece of tissue is placed in a formalin solution and sent for histological examination with the appropriate direction.

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

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 required, onto which the aspirate is applied, air dried, and transported to the laboratory.

Abdominal puncture. Puncture of the abdominal cavity is performed through the posterior vaginal fornix and the anterior abdominal wall. A puncture is performed through the posterior fornix if a tubal pregnancy is suspected, sometimes in case of 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 ascitic fluid may indicate a connection between ascites and some kind of heart disease, cirrhosis of the liver.

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

Preparing the patient as for diagnostic curettage. Asepsis is mandatory. During tubal pregnancy, dark blood with small clots is obtained. When receiving a serous or purulent effusion, it is necessary to carry out a bacteriological examination (the punctate for culture is collected in a sterile tube with a stopper).

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

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, synechiae in the uterine cavity, infertility.

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

Contraindications: III-IV degree of vaginal cleanliness, acute and subacute forms of inflammatory processes, pregnancy.

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

Compliance with the rules of asepsis and antiseptics is mandatory. After the contrast agent is introduced into the uterine cavity, the patient is taken to the X-ray room in a horizontal position (on a gurney). In the picture, the uterine cavity normally has a triangular shape with clear contours. When the tubes are patent, the contrast agent flows into the abdominal cavity.

Gas X-ray pelvigraphy (pneumopelvigraphy) involves injecting carbon dioxide into the abdominal cavity (creating pneumoperitoneum), and then taking X-rays (the outline of the uterus, ligaments, and appendages are clearly visible in the image).

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

The patient's preparation is as follows: on the eve and on the day of the examination, a cleansing enema is given, and immediately before the procedure, the bladder should be emptied. After the examination, the patient may be bothered by bloating and a feeling of fullness; in this case, it is necessary to create an inclined position with her head down and her pelvis raised.

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

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

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

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

Culdoscopy is performed through the posterior vaginal fornix. During laparoscopy, abdominal wall access is used.

Indications: necessity or difficulties 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 in case of obesity of the abdominal wall, if it is necessary to examine the ovaries. Laparoscopy is performed in nulliparous women, as well as when it is necessary to examine the appendix or tumors located in front of the uterus.

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

Preparing 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 external genital area 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 anterior abdominal wall).

Study of the functions of the fallopian tubes. To check the patency and functional capacity 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. To carry out pertubation and hydrotubation, there is special equipment consisting of a tip connected by a system of tubes to a cylinder for injecting air (or a device for introducing liquid) and to a pressure gauge indicating the pressure of air or liquid. During pertubation, kymographic recording of contractile movements of the tubes is possible at the same time. When performing pertubation and hydrotubation, it is necessary to comply with the rules of asepsis and antiseptics.

Contraindications: III-IV degree of vaginal cleanliness, colpitis, cervicitis, acute and subacute inflammatory processes 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 carried out with the patient in the usual position on the gynecological chair. The patient must first empty her bladder.

A set of necessary tools: vaginal speculum, 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 a 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 a vaginal smear, the discharge from the posterior vaginal fornix is ​​applied to a glass slide in 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 estrogens, a keratinization process occurs in the stratified squamous epithelium of the vagina, which is 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 estrogen content, the so-called intermediate cells are exfoliated from the vaginal wall. With a low estrogen content (hypoestrogenism due to ovarian hypofunction or postmenopause), basal cells from the deeper layers are exfoliated and predominate in the smear. Depending on the ratio of epithelial cell types, 4 types (or reactions) of a vaginal smear are distinguished:

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

Type II - basal and intermediate cells in the smear with a predominance of basal cells and leukocytes. 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 keratinizing cells. Observed with sufficient estrogen saturation.

With a normal menstrual cycle, types III and IV are observed (depending on the phase of the cycle). A quantitative assessment of the cytological picture is also possible, in which the percentage of superficial cells with pyknotic nuclei to the total number of superficial cells is determined - the karyopyknotic index (K.PI).

The symptom, or phenomenon, of the pupil is as follows. In the follicular phase of the cycle, the cervical glands produce mucous secretion, the largest amount of which accumulates towards the middle of the cycle. The external opening of the cervical canal expands with this secretion and resembles a pupil, which is visible when examined 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 weak or absent, and with excess estrogen production, this symptom can be expressed for a longer time.

The phenomenon of arborization of cervical mucus (fern sign) is that cervical mucus, applied to a glass slide and air-dried, forms crystals in the form of a fern leaf. The fern symptom is observed parallel to 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 entire cycle: in the follicular phase Rt = 36.2--36.7 ° C, in the luteal phase it increases by 0.4--0.5 ° C, and with the onset of menstruation it decreases again . Fluctuations in Rt depend on the ratio of estrogen and progesterone. Typically, 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 is confirmed by histological examination of the endometrium, namely its secretory transformation. Scraping should be done in the second half of the menstrual cycle (on the 22nd-24th day of the cycle). The absence or insufficiency of secretory transformation of the endometrium indicates a dysfunction of the corpus luteum.

Ovarian function is also assessed by the content of hormones in blood plasma and urine. To clarify the level of disturbance (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, hCG, ACTH, synthetic progestins, progesterone, cyclic, with glucocorticoids, etc.). Ultrasonography. 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 property of tissues of different densities to absorb ultrasonic energy differently.

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

Catheterization of the bladder 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 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 using a cystoscope of the ureteral orifices, from which, with normal kidney function, indigo carmine flows out in an intense stream 4-5 minutes after its administration. The absence of indigo carmine secretion indicates ureteral obstruction (presence of stone, compression by 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 between renal prolapse and ovarian tumors, etc.

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

Irrigoscopy is an examination of the large intestine. A comprehensive examination of the patient makes it possible to diagnose a gynecological disease (as well as concomitant diseases) and outline a treatment plan.

3. General and special methods for studying gynecological patients.

Common research methods include:

1. External gynecological examination- when examining the external genitalia, the degree and nature of the hairline (female or male type), the development of the labia minora and majora, the condition of the perineum, the presence of pathological processes (inflammation, tumors, ulcerations, condylomas, pathological discharge) are taken into account. Pay attention to the gaping of the genital fissure, whether there is prolapse or prolapse of the vagina and uterus (with straining), a pathological condition in the area of ​​the anus (varicose nodes, cracks, condylomas, discharge of blood and pus from the rectum). The vulva and the entrance to the vagina are examined, taking into account their color, the nature of the secretion, the presence of pathological processes (inflammation, cysts, ulcerations), the condition of the external opening of the urethra and the excretory ducts of the Bartholin glands, the hymen.

2. Examination using gynecological speculum- performed after examination of the external genitalia. By inserting a speculum into the vagina, the mucous membrane of the vagina and cervix is ​​examined. At the same time, attention is paid to the color of the mucous membrane, the nature of the secretion, the size and shape of the cervix, the condition of the external pharynx, the presence of pathological processes in the area of ​​the cervix and vagina (inflammation, trauma, ulceration, fistulas).

Technique for examining the cervix with vaginal speculum: with the left hand, the labia majora and minora are separated, the entrance to the vagina is widely exposed, then the posterior speculum (spoon-shaped) is inserted according to the direction of the vagina (front from above - posteriorly down), the posterior mirror is located on the posterior wall of the vagina I slightly pushes the perineum backward; then, parallel to it, an anterior speculum is inserted (a flat lift is used), with which the anterior wall of the vagina is lifted upward. If it is necessary to increase access to the cervix, flat plate speculums are inserted into the lateral vaults of the vagina. For inspection, in addition to spoon-shaped mirrors (Simpson) and flat lifts, leaf mirrors (cylindrical, Cusco) are used, which are inserted to the vaginal vault in a closed form, then the valves are opened and the cervix becomes accessible for inspection; The vaginal walls are examined gradually, removing the speculum from the vagina.

3. Vaginal examination- determine the condition of the pelvic floor, palpate the area where the Bartholin glands are located, and palpate the urethra from the anterior wall of the vagina. The condition of the vagina is determined: volume, folding of the mucosa, distensibility, presence of pathological processes (infiltrates, scars, stenoses, tumors, malformations). The features of the vaginal vault (depth, mobility, pain) are identified. Next, the vaginal part of the cervix is ​​examined: size (hypertrophy, hyperplasia), shape (conical, cylindrical, deformed by scars, tumors, condylomas), surface (smooth, bumpy), consistency (normal, softened, dense), position relative to the pelvic axis (directed anterior, posterior, left, right), the state of the external pharynx (closed or open, round shape, transverse slit, gape), neck mobility (excessively mobile, immobile, limited mobility), the presence of ruptures is noted.

4. Two-manual (vaginal-abdominal, bimanual) examination- the main method for recognizing diseases of the uterus, appendages, pelvic peritoneum and fiber. Carry out after removing the mirrors. The index and middle fingers of one gloved hand are inserted into the vagina, the other hand is placed on the anterior abdominal wall. First, the uterus is examined, and its position, size, shape, consistency, mobility, and pain are determined by palpation. Having completed the examination of the uterus, the appendages are examined. The fingers of the outer and inner hands are gradually moved from the corners of the uterus to the side walls. Normal tubes are usually not palpable; healthy ovaries can be found with sufficient experience of the examiner; they are determined on the side of the uterus in the form of small oblong formations. Unchanged uterine ligaments are usually not identified; with inflammation and tumors, the round, main and uterosacral ligaments can be palpated. Then pathological processes in the area of ​​the pelvic peritoneum and tissue (infiltrates, scars, adhesions) are identified.

Technique of vaginal and bimanual (vaginal-abdominal-wall, two-handed) examination: the middle finger of the right hand is inserted into the vagina, with which the perineum is slightly pulled back, then the index finger of the right hand is inserted and both fingers are moved along the axis of the vagina until it stops (from the front from top to bottom and back), with the thumb directed to the symphysis, and the little finger and The ring fingers are pressed against the palm, the back of their main phalanges rests against the perineum. The pelvic floor area, the area where the Bartholin glands are located, are palpated, the urethra is palpated, the condition of the vagina is determined, and the vaginal part of the cervix is ​​examined. Then they move on to two-handed examination, for which the left hand is placed above the pubis. The right hand is moved to the anterior fornix, slightly pushing the cervix posteriorly. The body of the uterus is palpated with the fingers of both hands. Having completed the examination of the uterus, they begin to examine the appendages. The fingers are gradually moved from the corners of the uterus to the side walls of the pelvis: the fingers of the right hand are moved to the corresponding posterolateral arch, and the left hand to the iliac region. Moving the hands towards each other until they touch at the sacroiliac joint, mix them forward and repeat such movements two or three times until the area from the angle of the uterus to the side wall of the pelvis is examined.

5. Rectal (rectal) and rectal-abdominal wall examinations - used in girls and young women, with atresia, aplasia, vaginal stenosis; in addition to bimanual examination for tumors of the genital organs, for inflammatory diseases, in the presence of discharge from the rectum, fistulas, cracks, abrasions, etc. The examination is carried out with the 2nd finger of the right hand, which must be lubricated with Vaseline. During the examination, the cervix, uterosacral ligaments, and pelvic tissue are easily reached and palpated. The body of the uterus and appendages are examined with the external hand (rectal-abdominal examination).

6. Recto-vaginal examination - used in the presence of pathological processes in the wall of the vagina, rectum, and surrounding tissue. The index finger is inserted into the vagina, the middle finger into the rectum. In this case, infiltrates, tumors and other changes are easily determined.

Special methods

Functional diagnostic tests are used to determine the activity of the ovaries and characterize the estrogen saturation of the body:

I. Examination of cervical mucus- the method is based on the fact that during the normal menstrual cycle the physicochemical properties of mucus are subject to changes: by the time of ovulation, its quantity increases and viscosity decreases under the influence of certain mucus enzymes, the activity of which increases by this period.

1. Symptom of the "pupil"- expansion of the external pharynx with mucus from the cervical canal. The symptom is associated with a change in the amount of mucus depending on the hormonal saturation of the body. The symptom becomes positive from 5-7 days of the cycle. Evaluated using a three-point system: 1 point (+): the presence of a small dark spot (early follicular phase); 2 points (++): 0.2-0.25 cm (mid follicular phase); 3 points (+++): 0.3-0.35 cm (ovulation). After ovulation, the “pupil” symptom gradually weakens and disappears by days 20-23 of the menstrual cycle.

2. Fern symptom- crystallization of cervical mucus under the influence of estrogens. Evaluated using a three-point system: 1 point (+) - the appearance of small crystals (early follicular phase, with slight secretion of estrogen); 2 points (++) - clear crystal pattern (medium follicular phase with moderate estrogen secretion); 3 points (+++) - strongly expressed crystallization in the form of a leaf (maximum production of estrogen during ovulation). The symptom is negative in the luteal phase of the cycle.

3. Symptom of “cervical mucus” tension- stretching of the mucus more than 6 cm with a forceps inserted into the cervical canal. The mucus is stretched into a thread, the length of which is measured in centimeters. The test is assessed using a three-point system: 1 point (+) - thread length up to 6 cm (low estrogen stimulation); 2 points (++) - 8-10 cm (moderate estrogenic stimulation); 3 points (+++) - 15-20cm (maximum estrogen production). During the luteal phase of the cycle, mucus tension decreases.

II. Colpocytological study of cellular composition vaginal smears - based on cyclic changes in the vaginal epithelium.

1. Vaginal smear reaction:

a - basal, parabasal cells, leukocytes are determined in the smear - severe estrogen deficiency;

b - parabasal cells and single intermediate cells in the smear - severe ovarian hypofunction;

c - intermediate cells and single superficial cells in the smear - moderate ovarian hypofunction (present in the normal menstrual cycle in the follicular and luteal phases, with the exception of the periovulatory period);

d - in the smear there are superficial cells, single intermediate ones, among the superficial ones there are cells with wrinkled nuclei - good estrogen saturation, determined in the periovulatory period.

2. Maturation index- percentage of superficial, intermediate and parabasal cells. It is written in the form of three numbers, of which the first is the percentage of parabasal cells, the second is intermediate and the third is superficial cells. 0/20/80 - periovulatory period, maximum level of estrogen and surface cells; 0/70/30 - early follicular phase.

3. Karyopyknotic index (KPI)- percentage of superficial cells with pyknotic nuclei to cells with vesicular (non-pyknotic) nuclei. The CPI at the beginning of the follicular phase is 25-30% by the time of ovulation - 60-70%, in the luteal phase it decreases to 25%.

III. Basal temperature measurement- the test is based on the hyperthermic effect of progesterone. The latter has a direct effect on the thermoregulation center located in the hypothalamus. Therefore, with an increase in progesterone secretion in the second half of the normal menstrual cycle, there is an increase in basal temperature by 0.4-0.8 0 C. In the follicular phase, the basal temperature is below 37 0 C, the ovulation period drops to 36.2 0 - 36.3 0 C , after ovulation it rises to 37.1 0 - 37.3 0 C, rarely to 37.6 0 C and remains at low-grade levels in the luteal phase (at least 10-12 days), immediately before menstruation it drops to the original figures. Basal temperature can be used to judge the duration of the cycle phases, their usefulness, and the presence or absence of ovulation.

IV. Histological examination of endometrial scraping. The method is based on the appearance of characteristic changes in the endometrium under the influence of ovarian steroid hormones. Estrogens cause proliferation, and progesterone causes secretory transformations.

Normally, during the secretion phase, the glands are dilated, have a polypoid shape, and a compact and spongy layer is visible. The cytoplasm in the cells of the glandular epithelium is light, the nucleus is pale. A secretion is visible in the lumen of the glands. With hypofunction of the corpus luteum, the glands are weakly tortuous, with narrow lumens. During an anovulatory menstrual cycle, the endometrial glands are narrow or slightly dilated, straight or convoluted. The glandular epithelium is cylindrical, tall, the nuclei are large, located basally or at various levels. Atrophic endometrium is characterized by a predominance of stroma, sometimes single glands are visible. Scraping is extremely scanty

V. Blood test. It is based on the fact that the composition of the formed elements changes in accordance with the phases of the menstrual cycle. During the late follicular phase, the number of leukocytes, platelets and red blood cells increases. By the beginning of menstruation, the amount of these elements is minimal. The method is less reliable due to large individual fluctuations.

VI. Skin allergy test. It is based on the appearance of an allergic reaction in response to the administration of hormonal drugs (estrogens, progesterone). At the site of administration of hormonal drugs, a papule is formed, the size of which increases with an increase in the level of estrogen or progesterone. In this case, simultaneously with the increase in the size of the papule, a local allergic reaction occurs: redness of the papule, itching. If the cycle is anovulatory, there is no change in the papule due to the introduction of estrogen. A change in the papule upon administration of progesterone during the period of expected maximum function of the corpus luteum (late luteal phase) indicates that ovulation has occurred and satisfactory function of the corpus luteum. The test is carried out over several menstrual cycles.

Hormonal functional tests are used for topical and differential diagnosis of endocrine diseases both horizontally (ovaries-adrenal glands-thyroid gland) and vertically (uterus - ovaries - pituitary gland - hypotholamus - neurotransmitter mechanisms).

a) test with progesterone- used for amenorrhea of ​​any etiology to exclude the uterine form; It is considered positive if 2-4 days after 6-8 days of intramuscular administration of progesterone or 8-10 days after a single administration of oxyprogesterone capronate, the patient develops a menstrual-like reaction. A positive test excludes the uterine form of amenorrhea and indicates progesterone deficiency. A negative test can be due to uterine amenorrhea or estrogen deficiency.

b) test with estrogens and progesterone- carried out to exclude (confirm) uterine or ovarian forms of amenorrhea. The patient is administered one of the estrogen drugs intramuscularly (estradiol benzoate, folliculin) or orally (ethinyl estradiol) for 10-14 days, then progesterone as in the test with progesterone. The onset of a menstrual-like reaction indicates a pronounced deficiency of endogenous estrogens; a negative result indicates a uterine form of amenorrhea.

c) test with dexamethasone- used to determine the nature of hyperandrogenism in women with signs of virilization, based on inhibition of ACTH secretion. Before and after the sample, the content of 17-KS is determined. A decrease in the level of 17-KS after the test by 50-75% indicates an adrenal source of androgens (test positive), by 25-30% - an ovarian origin of androgens (test negative).

d) test with clomiphene- indicated for diseases accompanied by anovulation, often against the background of oligo- or amenorrhea. The test is carried out after menstruation or a menstrual-like reaction. Clomiphene citrate is prescribed from 5 to 9 days from the onset of a menstrual-like reaction, its effect is felt through the hypothalamus. A negative test with clomiphene (no increase in the concentration of estradiol, gonadotropins in the blood plasma, monophasic basal temperature, absence of a menstrual-like reaction) indicates a hypothalamic-pituitary disorder.

e) test with luliberin- carried out with a negative test with clomiphene. 100 mg of a synthetic analogue of luliberin is administered intravenously. Before the start of drug administration and 15, 30, 60 and 120 minutes after administration, blood is taken from the ulnar vein through a permanent catheter to determine the LH content. With a positive test, by the 60th minute the LH content increases to levels corresponding to ovulation, which indicates preserved function of the anterior lobe of the pituitary gland and dysfunction of the hypothalamic structures.

Collection of passport data.

Complaints:

Detail localization and character:

1. bleeding
2. dysfunction of adjacent organs
3. sexual dysfunction
4. itching, etc.

General life history

— diseases suffered in the past: acute and chronic infectious diseases, extragenital pathology and gynecological diseases, surgical interventions;

- heredity;

— allergy and blood transfusion history;

— labor and epidemiological history;

— working and living conditions;

- husband's health.

Special life history

Menstrual function– at what age did menstruation begin, when did it begin, cycle (after how many days and for how many days), character (heavy, moderate, scanty), pain, date of last menstruation

Sexual function- at what age did sexual activity begin, what kind of marriage, pain during sexual intercourse (dyspareunia), contraceptive methods used.

Fertility— in chronological order, the number of all pregnancies, their course, outcome, complications during childbirth and the postpartum period.

Secretory function– leucorrhoea, character, volume, color, smell, what it associates with, treatment.

Function of neighboring organs– disturbances in the act of urination and defecation.

Medical history

– when and how the disease began, the dynamics of the disease, treatment, effect.

Objective examination:

— inspection;

— general condition, temperature;

— body features, indicators of body weight growth, features of the distribution of subcutaneous fat, the condition of the skin,

degree of hair growth according to the FERRIMAN and GOLLWEY scale, shape, degree of development and structure of the mammary glands;

To assess physical development, they are used morphograms, which are based on anthropometric data. The parameters of standing height, chest circumference above and below the mammary glands, transverse size of the pelvis (d. trochanterica) and the sum of its 4 main dimensions (c. externa, d. spinarum, d. cristarum, d. trochanterica) are plotted on the morphogram grid. In healthy girls, the morphogram is represented by a straight line. If the morphogram deviates from the normal one, one can indirectly judge disorders of somato-sexual development.

Inspection and palpation of the breast is carried out for all women (on days 7-10 of the menstrual cycle). The examination is carried out while standing, then with your arms raised up (assessing skin retraction and nipple asymmetry), then moving your hands to your hips (to relax the pectoral muscles), squeezing your thighs with your hands (to contract the pectoralis major muscles and assess the connection of the mass formation with the muscles).

Rate:

- degree of gland formation;

- dimensions;

- asymmetry of the mammary glands or visible formations;

- change in skin color;

— condition of the nipples: retraction or ulceration, discharge from the nipples;

- retraction (umbilication) of the skin;

- tuberosity (graininess) of the mammary glands;

- “lemon peel” symptom;

- expanded venous network;

- presence of papillomas.

Palpation of the mammary glands.

Palpation is carried out superficial and deep while standing and lying on your back.

- Palpation with one hand, palmar surface of the fingers, passing the mammary gland between the fingers and the chest wall.

- Bimanual palpation - with two hands, one supports the gland from below, the other palpates. Palpation in the “lying” position: the mammary gland “spreads” over the surface of the chest wall and intramammary formations become accessible to palpation.

— Palpation of the areola and nipple with determination of discharge: serous, purulent, bloody.

— Palpation of the axillary lymph nodes: one hand fixes the patient’s hand on the side of palpation, the second penetrates the axillary region.

When a tumor in the mammary gland is described:

- size;

— localization (taking into account the four quadrants of the breast);

— consistency;

- soreness;

— shape (smooth, uneven, clarity of contours);

— mobility of nodes;

- connection with surrounding tissues;

- condition of the skin over the formation.

— objective data of organs and systems (respiratory, cardiovascular, digestive, urinary, neuro-endocrine systems).

Special gynecological examination

It is carried out after emptying the bladder and bowels on a gynecological chair. Examination of gynecological patients includes:

1) examination of the external genitalia and vestibule of the vagina:

- type of hair growth, condition of the genital slit;

- anatomical structure of the clitoris;

- the condition and color of the integument of the labia majora and minora, the vulva and the vestibule of the vagina, the condition of the urethra, paraurethral passages, Bartholin glands, the nature of the discharge; examination of the anal area (presence of fissures, hemorrhoids);

2) examination using mirrors to assess the condition of the vaginal mucosa, color, shape, size of the cervix and external pharynx, the presence of pathological processes of developmental defects;

3) vaginal examination

• Manual - One-handed vaginal examination is performed with the index and middle fingers of one hand, which are inserted into the vagina. First, the thumb and index fingers of the left hand spread the labia majora, and then the fingers of the right hand (index and middle) are inserted into the vagina. The thumb is directed towards the symphysis, and the little and ring fingers are pressed to the palm.
  Assess: the condition of the entrance, the length of the vagina, the depth of the vaginal vaults, the length and condition of the vaginal part of the cervix, the external os;
• Bimanual examination:
  During a bimanual examination, two fingers of one hand are inserted into the anterior vaginal fornix, pushing the cervix posteriorly, and with the palm of the other hand, the doctor palpates the body of the uterus through the abdominal wall.
  Assess: the condition of the body of the uterus and appendages (position, size, consistency, mobility, soreness); condition of the parametrium, pelvic floor muscles;

4) rectal examination: condition of the pelvic floor muscles, lower rectum, intestinal mucosa, presence of space-occupying formations;

5) recto-abdominal examination: in girls, girls who are not sexually active, in the presence of tumor-like formations in the pelvic cavity and abdominal cavity. A recto-vaginal examination is mandatory in postmenopausal women.