Lesson gynecologic examination1.ppt

PROF. DR. GÜL ERTEM
PROF. DR. GÜL ERTEM
GYNECOLOGICAL
GYNECOLOGICAL
EVALUATION
EVALUATION

INTRODUCTION
The gynaecological - history collection &
clinical examination should be thorough and
meticulous.
These include in-depth history taking and
general, abdominal and internal examinations.
A meticulous history taking alone can give
provisional, positive diagnosis in majority of
the cases without any physical examination.

Gynecology is a medical care specific to women
Gynecology is a medical care specific to women
aimed at protecting sexual and reproductive health.
aimed at protecting sexual and reproductive health.
-This care protects against diseases,
-This care protects against diseases,
-Early diagnosis of cancers,
-Early diagnosis of cancers,
-Early diagnosis and treatment of infections affecting
-Early diagnosis and treatment of infections affecting
the reproductive organs
the reproductive organs
-Prevention of complications such as infertility that
-Prevention of complications such as infertility that
may occur later.
may occur later.
GYNECOLOGICAL
EVALUATION

For a complete assessment of the
For a complete assessment of the
patient's health status and a healthy
patient's health status and a healthy
life, gynecological examination should be
life, gynecological examination should be
performed
performed periodically every year
periodically every year.
.

Risk factors such as
Risk factors such as;
;
smoking,
substance abuse,
sexual relationships,
exposure to sexual or family violence,
occupational risks,
exercise and diet status should be
updated regularly.

DIAGNOSIS OF THE FEMALE REPRODUCTIVE
SYSTEM
• The female reproductive organs consist of the
The female reproductive organs consist of the
internal reproductive organs located in the
internal reproductive organs located in the
pelvic cavity and supported by the pelvic floor,
pelvic cavity and supported by the pelvic floor,
and the external reproductive organs located in
and the external reproductive organs located in
the perineum (vulva).
the perineum (vulva).

DIŞ ÜREME ORGANLARI
DIŞ ÜREME ORGANLARI

INTERNAL REPRODUCTIVE
INTERNAL REPRODUCTIVE
ORGANS
ORGANS
Vagina
Vagina
Uterus
Uterus
Tuba uterinae
Tuba uterinae
Ovaries
Ovaries

Lesson gynecologic examination1.ppt

GYNECOLOGICAL EVALUATION
GYNECOLOGICAL EVALUATION
Evaluation of female reproductive organs;
Evaluation of female reproductive organs;
Taking medical history (anamnesis),
Taking medical history (anamnesis),
General physical examination
General physical examination
Gynecological examination and
Gynecological examination and
laboratory tests are performed.
laboratory tests are performed.

TAKING MEDICAL HISTORY (Anamnesis);
should include the following headings:
• A.
A. Application history
Application history
• B. General history
B. General history
• C. Menstruation and fertility
C. Menstruation and fertility
history
history
• D. Family planning (FP) history
D. Family planning (FP) history

A. What to Include in the Application
A. What to Include in the Application
Story:
Story:
• Identity information (age, marital
Identity information (age, marital
status: virgo, married widow, etc.)
status: virgo, married widow, etc.)
• Current disease
Current disease
• Reason for today's visit
Reason for today's visit
The patient or his/her relatives' description of the disease
The patient or his/her relatives' description of the disease
symptoms.
symptoms.

Taking history regarding the reason for
Taking history regarding the reason for
today's visit
today's visit
a)Pain
a)Pain
b)Discharge
b)Discharge
c)Bleeding disorders
c)Bleeding disorders
d)Infertility complaints
d)Infertility complaints

B. General History
B. General History
Information:
Information:
• Current or past cardiovascular diseases
Current or past cardiovascular diseases
• Childhood and later diseases
Childhood and later diseases
• Breast or genital neoplasm
Breast or genital neoplasm
• Information on previous surgical
Information on previous surgical
procedures
procedures

B. Continue
B. Continue
• Drugs (prescribed and unprescribed)
Drugs (prescribed and unprescribed)
and alternative treatment methods
and alternative treatment methods
(acupuncture and mixtures)
(acupuncture and mixtures)
• Medical allergies (penicillin etc.) and
Medical allergies (penicillin etc.) and
non-medical allergies (shrimp)
non-medical allergies (shrimp)
• Familial and genetic anomalies, diseases,
Familial and genetic anomalies, diseases,
cancer cases
cancer cases
• Smoking history
Smoking history

C.
C. Information to be Obtained in
Information to be Obtained in
Menstruation and Fertility History
Menstruation and Fertility History:
:
• Age of menarche or menopause
Age of menarche or menopause
• Menstrual frequency
Menstrual frequency (if the period from the first
(if the period from the first
day of the period to the first day of the next
day of the period to the first day of the next
period is between 21 and 35 days, the frequency of
period is between 21 and 35 days, the frequency of
menstruation is considered normal)
menstruation is considered normal)
• Duration:
Duration: How many days the period lasts (2-7 days
How many days the period lasts (2-7 days
are considered normal)
are considered normal)
• Amount:
Amount: little, normal, a lot and clotted (number of
little, normal, a lot and clotted (number of
pads or tampons used)
pads or tampons used)
• Regularity
Regularity

C.
C. Continue
Continue
• Associated symptoms:
Associated symptoms: Cramps,
headache, nausea, last menstrual
period
• History of abnormal genital bleeding
History of abnormal genital bleeding
(discharge, itching, intermenstrual
(discharge, itching, intermenstrual
or postcoital bleeding, pain during
or postcoital bleeding, pain during
intercourse, fever, etc.)
intercourse, fever, etc.)

C.
C. Continue
Continue
• History of ovarian cancer, family
History of ovarian cancer, family
history
history
• Information on diseases seen in
Information on diseases seen in
family members
family members
• Pregnancies (number of
Pregnancies (number of
pregnancies, number of births,
pregnancies, number of births,
number of living children)
number of living children)

C.
C. Continue
Continue
• Pregnancy outcomes (number of
Pregnancy outcomes (number of
miscarriages, term birth,
miscarriages, term birth,
premature birth, neonatal death,
premature birth, neonatal death,
stillbirth)
stillbirth)
• Date of last birth or miscarriage
Date of last birth or miscarriage
• Duration and frequency of
Duration and frequency of
breastfeeding
breastfeeding

D. Family Planning Story:
D. Family Planning Story:
• Contraceptive method used, if any
Contraceptive method used, if any
• Duration of use, problems if any
Duration of use, problems if any
• Previously used methods and duration of
Previously used methods and duration of
use
use
• Reasons for stopping or changing the
Reasons for stopping or changing the
method
method
• Side effects or complications of any
Side effects or complications of any
method
method

E. PAST SURGICAL HISTORY
• Any previous gynaecological, obstetrical or
general surgery.
• Enquire - The nature of the operation,
anaesthesia related complications and post
operative convalescence.
• Ask about the histo pathological report or
relevant investigations related to previous
surgery.

F. PERSONAL HISTORY
• Educational status
• Appetite, Diet, weight loss, weight gain,
• Exercise or yoga,
• Occupation, Socio-economic status,
• Smoking, drugs, alcohol intake.
• History of taking medicines for a long time,
• Allergy to certain drugs is to be noted.
• Sexual history
• The use of contraception
• Type of contraception

PELVIC EXAMINATION
PELVIC EXAMINATION
• Psychosocial Aspect of Pelvic Examination
Psychosocial Aspect of Pelvic Examination
Many women find pelvic exams
humiliating and embarrassing.
Exams that are harsh, hasty, insensitive,
and performed without verbal
communication with the patient cause
women to feel embarrassed and increase
their fear.

PELVIC EXAMINATION
Pelvic Examination includes :
• Inspection of the external genitalia
• Vaginal examination
-Inspection of the cervix and vaginal walls
-Palpation of the vagina and vaginal cervix
-Bimanual examination of the pelvic organs.
• Digital examination.
• Rectal examination
• Recto vaginal examination

Pre requisites
• The patients bladder must be empty-the
exception being a case of stress
incontinence.
• A female attendant- chaperone (nurse or
relative of the patient) should be present by
the side.
• To examine a minor or unmarried, a
consent from the parent or guardian is
required.

Pre requisites
• Lower bowel (rectum and pelvic colon)
should preferably be empty.
• A light source should be available.
• Sterile gloves, sterile lubricant
(preferably colorless without any
antiseptics), speculum, sponge holding
forceps and swabs are required.

Examination Position :
Examination Position :
• 1. Supine Lithotomy
1. Supine Lithotomy:
: This is the most
This is the most
commonly used position. The patient lies
commonly used position. The patient lies
supine on the examination table, with the
supine on the examination table, with the
hips and knees bent, and the heels placed
hips and knees bent, and the heels placed
on the table stirrups.
on the table stirrups.

2. Semi-Sitting Lithotomy
2. Semi-Sitting Lithotomy
• The patient is semi-sitting on the examination
The patient is semi-sitting on the examination
table and is in the lithotomy position.
table and is in the lithotomy position.
• This position provides the patient with more
This position provides the patient with more
physical comfort, increases verbal
physical comfort, increases verbal
communication and eye contact
communication and eye contact.
.

3. Dorsal Recumbent
3. Dorsal Recumbent (In-Bed
(In-Bed
Examination)
Examination)
• The patient is laid transversely in the
The patient is laid transversely in the
middle of the bed. He is in the supine
middle of the bed. He is in the supine
lithotomy position. The feet are placed
lithotomy position. The feet are placed
on chairs placed at the edge of the bed.
on chairs placed at the edge of the bed.
Dorsal recumbent position

4.Sim's Position :
4.Sim's Position :
• Used in rectal examination.
Used in rectal examination.

5
5. Knee-Chest Position:
. Knee-Chest Position:
• Used for both rectal and vaginal
Used for both rectal and vaginal
examinations.
examinations.

Used Tools in Pelvic Examination
Used Tools in Pelvic Examination
Vaginal speculum
A good light source
Gloves
Liquid lubricant (soapy disinfectants)

• Material for smear and culture for
Material for smear and culture for
cytology; cotton tip applicator, vaginal
cytology; cotton tip applicator, vaginal
spatula, glass slide, fixative, culture
spatula, glass slide, fixative, culture
plate for gonorrhea research.
plate for gonorrhea research.
• A long forceps and sponge
A long forceps and sponge

Pelvic Examination Technique
Pelvic Examination Technique
:
:
Pelvic examination is performed in 4
Pelvic examination is performed in 4
parts:
parts:
Inspection and palpation of
external genitalia
Speculum examination
Bimanual examination
Rectovaginal examination

Examination of
Examination of
external
external
genitalia;labial
genitalia;labial
development,
development,
hair
hair
distribution
distribution
and anomalies
and anomalies
are evaluated.
are evaluated.
1
1.
. Inspection and Palpation of
Inspection and Palpation of
External Genitals
External Genitals

• Vulva;
Vulva; It is evaluated in terms of
discharge, redness, skin rashes, scar
tissue, ulceration, inflammation,
asymmetry, mass, leukoplakia, irritation
and color change.

Inspection of External Reproductive Organs
Inspection of External Reproductive Organs
Gentle traction on the
labia majora facilitates
inspection of the labia
minora and clitoris.
Gentle traction on the
anterior skin brings
the glans into view,
and separation of the
labia minora allows
the urethral meatus to
be seen.

Palpation of Skene's Glands
Palpation of Skene's Glands

Palpation of Bartholin Glands
Palpation of Bartholin Glands
Inflammation, cysts and tumors may be
seen in the area where the Bartholin
glands are located.

Acute or chronic
Acute or chronic
gonorrhea
gonorrhea
infection may
infection may
have occurred.
have occurred.

There may be a
There may be a
cystocele
cystocele in the
in the
anterior wall of
anterior wall of
the vagina.
the vagina.

There may be a
There may be a
rectocele
rectocele on
on
the posterior
the posterior
vaginal wall.
vaginal wall.

It is
It is
checked
checked
whether
whether
there is
there is
relaxation
relaxation
at the exit.
at the exit.

2. Speculum Examination
2. Speculum Examination
• Before the examination, showing the
Before the examination, showing the
speculum and explaining what it does
speculum and explaining what it does
reduces the woman's fears.
reduces the woman's fears.

• To facilitate speculum examination,
To facilitate speculum examination,
the patient is asked to relax and then
the patient is asked to relax and then
strain gently as if defecating.
strain gently as if defecating.

• The speculum is most easily inserted by holding the
The speculum is most easily inserted by holding the
blades slightly obliquely at the entrance of the vagina
blades slightly obliquely at the entrance of the vagina
and pushing them down and inward at a 45º angle.
and pushing them down and inward at a 45º angle.
• The vaginal canal is examined while inserting and
The vaginal canal is examined while inserting and
pushing the speculum.
pushing the speculum.

• The speculum is fixed by turning the
The speculum is fixed by turning the
screw in the open position.
screw in the open position.
• Pap smear, secretion sample for culture,
Pap smear, secretion sample for culture,
or both can be performed at this time.
or both can be performed at this time.

Using a
Using a
speculum, the
speculum, the
cervix is

cervix is

observed for
observed for
color, position,
color, position,
shape, size,
shape, size,
surface
surface
properties,
properties,
lacerations,
lacerations,
ulcerations, and
ulcerations, and
discharge.
discharge.

The cervix is

usually pink.
The cervix is

usually pink.
It appears pale after menopause and
It appears pale after menopause and
cyanotic (purple) during pregnancy.
cyanotic (purple) during pregnancy.
The cervix protrudes 1-3 cm into
The cervix protrudes 1-3 cm into
the vagina.
the vagina.
It is round and symmetrical.
It is round and symmetrical.

The part of the cervix that is seen from the vagina
The part of the cervix that is seen from the vagina
during speculum examination is called the
during speculum examination is called the
“ectocervix”.
“ectocervix”.
The cervix is

covered with a smooth, pink, multi-
The cervix is

covered with a smooth, pink, multi-
layered squamous epithelium that resembles the
layered squamous epithelium that resembles the
vaginal epithelium.
vaginal epithelium.
The epithelium covering the endo-cervical canal is a
The epithelium covering the endo-cervical canal is a
red, irregular, single-layered columnar epithelium.
red, irregular, single-layered columnar epithelium.

The squamocolumnar
The squamocolumnar
junction, the junction of
junction, the junction of
squamous and columnar
squamous and columnar
epithelium, is an
epithelium, is an
important area in
important area in
diagnosing
diagnosing cervical
cancer.

In nulliparous
In nulliparous
women, the cervical
women, the cervical
os is small and round.
os is small and round.

After birth, the cervical os
is a horizontal line.

3. Bimanual Examination:
3. Bimanual Examination:
• The patient is told to relax and a gloved, lubricated
The patient is told to relax and a gloved, lubricated
finger is gently inserted into the vagina and
finger is gently inserted into the vagina and
downward pressure is applied.
downward pressure is applied.
• After a pause to increase relaxation, the middle and
After a pause to increase relaxation, the middle and
index fingers of the examining hand are placed in the
index fingers of the examining hand are placed in the
vagina and the other hand is placed on the
vagina and the other hand is placed on the
abdomen.
abdomen.

The structures within
The structures within
the pelvis are assessed
the pelvis are assessed
by palpation between
by palpation between
the fingers in the
the fingers in the
vagina and abdomen.
vagina and abdomen.
Generally, the fingers
Generally, the fingers
in the vagina are used
in the vagina are used
to lift the structures
to lift the structures
up for palpation.
up for palpation.

In this examination,
In this examination,
the size and
the size and
consistency of the
consistency of the
uterus between the
uterus between the
two hands, any
two hands, any
existing uterine
existing uterine
masses, and the
masses, and the
position of the uterus
position of the uterus
(anterior, inverted)
(anterior, inverted)
are first noted.
are first noted.

• After palpation of the uterus, the
After palpation of the uterus, the
adnexa are palpated.
adnexa are palpated.
• The basic structures to be examined in
The basic structures to be examined in
the adnexa are the fallopian tubes and
the adnexa are the fallopian tubes and
the ovaries.
the ovaries.
• Normally, both are difficult to
Normally, both are difficult to
palpate.The ovaries are felt as oval,
palpate.The ovaries are felt as oval,
smooth or slightly nodular.
smooth or slightly nodular.

• Normally, the adnexa are mobile.
Normally, the adnexa are mobile.
• When their movement is limited or
When their movement is limited or
immobile, in cases of pain or tenderness,
immobile, in cases of pain or tenderness,
an abnormality should be considered
an abnormality should be considered
(pelvic infection (PID), tubal or ovarian
(pelvic infection (PID), tubal or ovarian
abscess, ovarian cyst rupture, adnexitis,
abscess, ovarian cyst rupture, adnexitis,
etc.).
etc.).

4- RECTAL OR RECTO ABDOMINAL
EXAMINATION
• Rectal examination can be done as an adjunct to
vaginal examination.
It is indicated in,
• Children or in adult virgins
• Painful vaginal examination
• Carcinoma cervix
• Atresia vagina
• Patients having rectal symptoms
• To diagnose rectocele

RECTO VAGINAL EXAMINATION
• The procedure consists of introducing the index
finger in the vagina & middle finger in the rectum.
• This examination helps to determine whether the
lesion is in the bowel/between rectum and vagina.

PRINCIPLES TO BE FOLLOWED
• Get a informed consent.
• The surgeon must have skill in the procedure.
• Explain the name of the procedure and in
what way it is helpful.
• Keep up the confidentiality about the
procedure.
• Provide psychological support to the patient.

COMMON INVESTIGTIONS IN GYNAECOLOGY
• Blood values
• Urine examination
• Urethral, vaginal, cervical discharge
• Exfoliative cytology
• Colposcopy
• Imaging techniques
• Endometrial sampling
• Biopsy
• Culdocentesis
• Endoscopy
• Hormonal assays

Nursing Interventions
Nursing Interventions
During Pelvic Examination :
During Pelvic Examination :
• During the examination, the patient's
During the examination, the patient's
hand is held to encourage relaxation.The
hand is held to encourage relaxation.The
light is adjusted, the examination tray,
light is adjusted, the examination tray,
speculum, sponge, and materials required
speculum, sponge, and materials required
for cytology are checked.
for cytology are checked.
• Gloves and a liquid lubricant are provided.
Gloves and a liquid lubricant are provided.
• At the end of the examination, the
At the end of the examination, the
perineum is wiped.
perineum is wiped.

• Before the patient takes her feet
Before the patient takes her feet
off the stirrups, she is allowed to
off the stirrups, she is allowed to
slide backwards on the table and
slide backwards on the table and
after she comes to a sitting position,
after she comes to a sitting position,
she is helped to get off the table.
she is helped to get off the table.

• Elderly patients are given time to sit
Elderly patients are given time to sit
for a while before getting off the table.
for a while before getting off the table.
• If the patient has any questions, they
If the patient has any questions, they
are answered, and what the doctor says
are answered, and what the doctor says
is repeated.
is repeated.
• If the patient needs it, they are helped
If the patient needs it, they are helped
to dress.
to dress.

SPECIAL DIAGNOSTIC
SPECIAL DIAGNOSTIC
METHODS
METHODS
-
- Laboratory examinations (Whole
Laboratory examinations (Whole
blood and urine, VDRL, Parasite)
blood and urine, VDRL, Parasite)
- Skin tests
Skin tests
- - Vaginal culture antibiogram
- Vaginal culture antibiogram
- - Examination of cervical mucus
- Examination of cervical mucus
- - Biopsy (Endometrial biopsy)
- Biopsy (Endometrial biopsy)
- - Cervical conization
- Cervical conization

1. Smear (pap test)
2. Biopsy
3. Hysterosalpingography
4. Pertubation (Intrauterine insufflation)
5. Schiller’s Iodine Test
6. Colposcopy
7. Laparoscopy
8. Hysteroscopy
9. Culdoscopy (Douglascopy)
10.Gynecological ultrasonography
SPECIAL DIAGNOSTIC METHODS-CONTINUED
SPECIAL DIAGNOSTIC METHODS-CONTINUED

EXFOLIATIVE CYTOLOGY - PAPANICOLAOU TEST
• Pap test-This is the screening test for cancer.
• First described by Papanicolaou & Traut in 1943.
• It is a routine gynaecological examination in females,
especially above 35 years.
• Yearly screening up to 30 years, thereafter should be at
the interval of every 2-3 years after three consecutive
yearly negative smears.

Pap smear-screening of cancer
PROCEDURE
•Should be obtained prior to vaginal
examination
•Patient placed in dorsal position with labia
separated
•Cusco’s self retaining speculum inserted
without lubricants
•Cervix exposed,squamocolumnar junction
scraped with concave end of Ayre’s spatula by
rotating all around
•Thin smear is prepared on a glass slide and
fixed by equal amounts of 95% alcohol and
ether
•After 30 min,slide air dried and stained with
papanicolaou or Short stain

Modifications
1. Endoc ervical sampling –endo cervix scraped with a
cytobrush and added to the slide.
2. Fixative spray—cyto spray used in office setup.

Uses of Pap smear
1. Screening for cancer
2. Identification of local viral infections like
herpes and condyloma accuminata.
3. Cytohormonal study

SCREENING PROCEDURE
• Collection of material
• The cervix is exposed with a vaginal
speculum without lubricant and prior to
bimanual examination.
• Lubricants tend to distort cell morphology.

• Cervical scraping
• The material from the cervix is best collected
using Ayre’s spatula made of wood or plastic .
Whole of the squamo columnar junction has
to be scrapped to obtain good material.

Vaginal pool aspiration
• The exfoliated cells accumulated in the vaginal
pool in the posterior fornix is collected either
using a glass pipette about 15 cm long and 0.5
cm in diameter with a strong rubber bulb at one
end or by a swab stick. This is not much reliable.
Fixation and staining
• The material so collected should be immediately
spread over a microscopic slide and at once be
put into the fixative ethyl alcohol before drying.
After fixing for about 30 minutes ,the slide is
taken out, air dried and sent to the laboratory.

INTERPRETATIONS
• Morphological abnormalities of the nucleus
(Dyskaryosis).
• Disproportionate nuclear enlargement.
• Irregularity of the nuclear outline.
• Abnormalities of nucleus in number, size & shape.
• Hyper chromasia.
• Condensation of chromatin material.
• Multi nucleation.

INTERPRETATIONS - Normal cells
1.Basal cells-small,rounded basophilic with large
nuclei
2.Squamous cells from middle layer –
transparent and basophilic with vesicular nuclei
3.Cells from superficial layer-acidophilic with
characterestic pyknotic nuclei
4.Endometrial cells,histiocytes,blood cells and
bacteria

ABNORMAL CELLS
1. Mild dyskaryosis
•Superficial/intermediate squamous cells
•Angular borders,
•Transluscent cytoplasm
•Nucleus < half of area of cytoplasm
•Binucleation is common
•CIN-I

2.Moderate dyskaryosis-CIN II
•Intermediate/parabasal/superficial squamous cell
type
•More disproportionate nuclear enlargement and
hyper chromasia
•Nucleus-1/2-2/3 of total cytoplasm area

3.SEVERE DYSKARYOSIS-CIN III
•Cells- basal type, round/oval/polygonal
/elongated/singly/in clumps
•Nucleus- almost fills the cell, thick, dense, narrow rim
of cytoplasm irregular with coarse chromatin pattern
•Fibre cells- severely dyskaryotic, elongated cell
•Tadpole cell- severely dyskaryotic cell with an elongated
tail of cytoplasm.

4.Carcinoma in situ
•Parabasal cells with
increased nucleo-
cytoplasmic ratio
•Cytoplasm scanty
•Nucleus-irregular,
sometimes multiple
•Chromatin pattern-
granular

5.Invasive
carcinoma
•Cells-single/
clusters
•Tadpole cells
•Irregular nuclei
•Coarse clumping of
chromatin

• Abnormal cells are:
• Mild dyskaryosis – cells are of superficial or
intermediate type squamous cells. Cells have
angular bodies with translucent cytoplasm.The
nucleus occupies less than half of the total area
of the cytoplasm.
• Moderate dyskaryosis – The cells are of
intermediate parabasal or superficial type
squamous cells.Cells have more
disproportionate nuclear enlargement and
hyperchromasia. The nucleus occupies one half
to two –thirds of the total area of the cytoplasm

• Severe dyskaryosis – Cells are of basal type,
looking round, oval, polygonal or elongated
in shape. The nucleus is irregular with coarse
chromatin patterns. The cells may be
different in size and shape.
• Koilocytosis – It is the nuclear abnormalities
associated with human papiloma virus
infection. The nucleus is irregularly enlarged
and shows hyperchromasia with multi
nucleation.

• Carcinoma in situ – Cells are parabasal
type with increased nuclear cyttoplasmic
ratio. The nucleus may be irregular
sometimes multiple and the cytoplasm is
scanty.
• Invasive carcinoma – Cells are single or
grouped in clusters. The cells show
irregular nuclei and clumping of nuclear
chromatin which is also coarse. Large
tadpole cells are seen.

CYTO HORMONAL EVALUATION
• Exfoliative cytology
• Non invasive study of epithelium for
hormonal status
• Principle-The vaginal epithelium highly
sensitive to oestrogen and progesterone.
• Oestrogen—superficial cell maturation
• Progesterone—intermediate cell
maturation
• Procedure—scrapings taken from lateral
wall of upper third of vagina.

INFERENCE
• Normal smear-parabasal, intermediate and
superficial cells
• Oestrogen predominant smear-large
eosinophilic cells with pyknotic nuclei and clear
back ground
• Progesterone predominant smear-
predominantly basophilic cells with vesicular
nuclei and dirty background
• Pregnancy-intermediate and navicular cells
• Post-menopausal smear- parabasal and basal
cells

EXAMINATION OF CERVICAL MUCOUS
Indications
• Bacteriological study
• Hormonal status
• Infertility investigation

Bacteriological study
• Cusco’s bivalve speculum is introduced
without lubricant.
• With the help of a sterile cotton swab ,the
cervical canal is swabbed.
• The material is either sent for a culture or
spread over a microscopic slide for gram
staining.

Hormonal status
• The physical, chemical and cellular
components of the cervical secretions are
dependent on hormones – oestrogen and
progesterone.
• The influence of the hormones on the
cervical mucous is utilized in detection of
ovulation in clinical practice. The pH around
the time of ovulation is about 6.8 – 7.4.

• Spinnbarkeit (stretchability or elasticity)
During the midcycle, the cervical secretion is collected
with a pipette and placed over a glass slide. Another
glass slide is placed over it. Because of increased
elasticity due to high oestrogen level during this
period, the mucus placed between the slides can
withstand stretching upto a distance of over 10 c.m.
• After ovulation ,when corpus luteum forms,
progesterone is secreted. Under its action, the cervical
mucus loses its property of elasticity and the mucus
fractures if the same is attempted. This loss of elasticity
after its presence in the midcycle is the indirect
evidence of ovulation.

• Fern test – During the mid cycle , the cervical
mucus is obtained by a platinum loop or pipette
and spread on a clean glass slide and dried. When
seen under low power microscope it shows
characteristic pattern of fern formation due to
high estrogen in the midmenstrual phase prior to
ovulation.
• After ovulation with increasing progesterone, the
ferning disappears completely after 21st
day. Thus
the presence of ferning even after 21st
day
suggests anovulation and its disappearance is
presumptive evidence of ovulation.

Infertility investigations
• Postcoital test (PCT)
• The patient should report to the clinic preferably
within 8-12 hours following intercourse.
• The cervix is exposed with a cusco’s speculum.
Using a polythelene catheter attached to syringe.
• The endocervical mucus is collected and placed
over a warm glass slide and is examined
microscopically.
• Presence of atleast 10 progressively motile
sperms signifies the test to be normal.

COLPOSCOPY
• The instrument was devised by Hinselmann in
1925. This instrument is designed to magnify
the surface epithelium of the vaginal part of
the cervix including entire transformation
zone.
Procedure
• The client is placed in lithotomy position.
• Cervix can be cleared with help of normal
saline.
• High magnification used.

• Cervix is visualized by using a cusco’s speculum
• Colscopic examination of the cervix and vagina is
done using low power magnification. Cervix is
then cleared of using a swab soaked with normal
saline. Green filter and high magnification are
used.
• Cervix is wiped with 3% acetic acid and
examination is repeated. Acetic acid causes
coagulation of nuclear protein and it prevents
the transmission of light through the epithelium
which is visible as white areas.

INDICATIONS
• Women with abnormal smears.
• Women with clinically suspicious cervices,
specially with history of contact bleeding
despite the presence of negative smear.

IMAGING TECHNIQUES IN GYNAECOLOGY
• X- ray
• Ultrasound
• CT scan
• MRI
• PET

X- ray
• A chest X-ray and intravenous urogram are
essential for investigation in pelvic malignancy.
Plain X-ray of the pelvis is helpful to locate an
IUCD or to look for shadows of teeth or bone in
benign cystic teratoma. Special X-ray using
contrast media are;
• Hysterosalpingogram
• Lymhangiography
• Pelvic neumography

IMAGING TECHNIQUES-Overview
1.X-RAY
•Plain x ray chest and intravenous urogram- pelvic malignancy esp
cervical cancer,prior to staging.
•Plain x ray pelvis- To locate misplaced IUCD
Visualize bone/teeth in benign cystic teratoma
•Hysterosalpingography-to test tube patency,
Intracavity uterine mass and mullerian anomalies of uterus
•Lymphangiography-to locate lymph nodes involved
in pelvic malignancy

ULTRASOUND
• Sonography is used widely in gynaecology
either with the transabdominal or with the
transvaginal probe.
• Transabdominal sonography (TAS), is done
with a linear or curvilinear array transducer
operating at 2.5 – 3.5 MHz. It is best used for
large masses like fibroid or ovarian tumour.

2.ULTRASONOGRAPHY
•Simple,non invasive,painless,safe procedure
•Pelvis and lower abdomen scanned longitudinally and
transversely
•D3 ultrasound-3-D images of pelvic organs
Transabdominal sonography(TAS)-
•Done with transducer operating at 2.5-3.5Mhz
•Bladder full
•Large masses examination –ovarian tumour/fibroid

• Transvaginal sonography (TVS)
• It is done with a probe which is placed close to
the target organ and operates at a high
frequency, thus detailed evaluation of pelvic
organs is possible.
• Transvaginal Colour Doppler Sonography
• This provides additional information of blood
flow to ,from or within an organ.

TRANSVAGINAL SONOGRAPHY (TVS)
•Probe placed close to organ
•High frequency waves used-5-8MHz
•No need of full bladder
•Detailed evaluation of pelvic organs possible
•Better image resolution but poor tissue
penetration
•Difficulty in narrow vagina
Transvaginal colour doppler sonography
•Information regarding blood flow to & from or
within the uterus or adnexa can be obtained.

Computed Tomography
• Supplements information from USG.
• Whole abdomen and pelvis visualized in one sitting
after taking 600-800ml of a dilute contrast medium 1
hour prior to procedure
• Patient is scanned in supine position.
• Accurate in assessing local tumour invasion and
enables accurate localisation in biopsy.
• Diagnose, pelvic vein thrombophlebitis,
intraabdominal abscess and other extra genital
abnormalities.
• Metastatic implants and lymphnodes < 1 cm—not
detected.
• Contraindicated in pregnancy.

Magnetic Resonance Imaging
• Well established cross sectional imaging
modality
• High soft tissue contrast resolution without
air/bone interference
• Limitations-cost, time, availability
• Indicated only when a sonar or CT fails to
detect a lesion or to differntiate post-
treatment fibrosis or tumour

Positron Emission Tomography(PET)
• To differentiate normal tissue from cancerous
one, based on the uptake of 18F-FLURO-
2DEOXYGLUCOSE
Endometrial Sampling
• The endometrial sampling is one of the
diagnostic tests employed in the clinical
workup of women with infertility or abnormal
uterine bleeding. The instrument commonly
used is either a Vabra Aspirator or a Sharman
Curette .

• A thin plastic cannula with aplunger within ,is
negotiated within the uterus. When the
plunger is withdrawn ,adequate endometrium
is obtained due to suction action
• This procedure is used to study hormonal
effect whereas, in endometrial tuberculosis or
post menopausal bleeding endometrial
curettage is done under local anaesthesia.

ENDOMETRIAL BIOPSY
• The most reliable method to study the
endometrium is by obtaining the material by
curettage after dilatation of the cervix usually
under general anaesthesia

INVESTIGATIONS FOR
INFERTILITY

TUBAL PATENCY TEST
• Dilatation and insufflations
• Hystero salpingography
• Laparoscopy
• Sono hystero salpingography
• Fallopscopy
• Salpingoscopy

• Dilatation and insufflations
• It is an operative procedure of dilation of the
cervix and introduction of air (or) co2 in to the
uterine cavity to know the patency of the
fallopian tube

Principle
• The cervical canal is in continuity with the
peritoneal cavity through the tubes. As such,
entry of air or CO2 into the peritoneal cavity
when pushed trans cervically under pressure
give evidence of tubal patency.
WHEN TO BE DONE
• After menstrual phase at least 2 days after
stoppage of menstrual bleeding

INDICATIONS
• To know the tubal patency
• Investigation for infertility
• Following tuboplasty operation
CONTRAINDICATIONS
• Presence of pelvic inflammation

HYSTERO SALPINGOGRAPHY
DEFINITION
• Its an operative procedure used to assess the
interior anatomy of the uterus and tube
including tubal patency,
• It is a radiographic study in which contrast
media is used.

INDICATIONS
• To note the tubal patency
• To detect uterine malformation
• To diagnose cervical incompetency
• To identify trans located IUD
• To confirm the secondary abdominal
pregnancy

PROCEDURE
• It should be done under local anesthesia in radiologic
department
• All preliminaries should be followed before the procedure
• Internal examination done
• Posterior vaginal speculum is introduced the visualize the
cervix
• Hystero salpingo graphic cannula is fitted with a syringe
containing radio-opaque dye injected in the uterine cavity
then fallopian tube.
• The dye is introduced slowly about 5-10ml of solution is
introduced.
• The passage of the dye into the interior may be observed
by using X-ray image transfer and a Videos Display Unit.

LAPARAOSCOPY
DEFINITION
• Laparascopy is a technique of visualization of
peritoneal cavity by means of a fiber optic
endoscope introduced into the abdominal
wall.

INDICATIONS
Diagnostic Laparoscopy:
• 1.Infertility work up- Ovulation study
-Tubal patency
-Endometriosis
- Pelvic adhesions
• 2.Acute pelvic lesion -Acute ectopic
-Acute Appendicitis
-Acute Salpingitis
3.Pelvic mass-Fibroid
-Ovarian Cyst

4.Follow up of pelvic surgery
-Tuboplasty
-Ovarian malignancy
-Evaluation of endometriosis Rx
5.Suspected Mullerian abnormalitis
6.Suspected Uterine perforation
7.To take biopsy

• Therapeutic Laparoscopy
• Adhesiolysis
• -Aspiration of ovarian cyst
• -Ovarian drilling
• -Ovarian cystectomy
• -Ectopic pregnancy
• -Tubal sterilization
• -Endometriosis(Laser or thermal ablation)
• -Myomectomy
• -LAVH

Contraindications
• Severe cardiopulmonary diseases
• Generalized peritonitis
• Intestinal obstruction
• Significant hemo peritoneum
• Extensive peritoneal adhesions
• Large pelvic tumour
• Obesity
• Pregnancy >16 wks

PROCEDURE
• Laparoscopy is usually performed on an outpatient basis
under general anesthesia.
• After the patient is under anesthesia, a needle is inserted
through the navel and the abdomen is filled with carbon
dioxide gas.
• The gas pushes the abdominal wall away from the internal
organs so that the laparoscope can be placed safely into
the abdominal cavity and decrease the risk of injury to
surrounding organs such as the bowel, bladder and blood
vessels.
• The laparoscope is then inserted through an incision in the
navel. Or alternate sites based upon physician experience
or the patient’s prior surgical or medical history.
• While looking through the laparoscope, the physician can
see the reproductive organs including the uterus, fallopian
tubes, and ovaries.

• A small probe is usually inserted through
another incision above the pubic region in
order to move the pelvic organs into clear
view.
• Additionally, a solution containing blue dye is
often injected through the cervix, uterus, and
fallopian tubes to determine if the tubes are
open.
• If no abnormalities are noted at this time, one
or two stitches close the incisions. If
abnormalities are discovered, diagnostic
laparoscopy can become operative
laparoscopy.

SONO HYSTERO SALPINGOGRAPHY
• Advantages
• Its non invasive procedure
• It can detect uterine malformation
• There is no radiation exposure

FALLOSCOPY
• This is to study the entire length of tubal
lumen with the help of a fine and flexible
fibro-optic device.
• It is performed through the uterine cavity
using a hysteroscope.
• It helps direct visualization of tubal ostia,
mucosal pattern, intra tubal polyps or debris.

SALPHINGOSCOPY
• This is used to study the tubal lumen by
introducing a rigid endoscope through the
fimbrial end of the tube.
• It is performed through the operating channel
of a laproscope.

CERVICAL BIOPSY
TYPES
• Surface biopsy
• Punch biopsy
• Wedge biopsy
• Ring biopsy
• Cone biopsy

CERVICAL BIOPSY
• Confirmatory diagnosis of cervical pathology
• Done at OP if pathology detectable
• Wider tissue excision as in cone biopsy – IP
procedure

INDICATIONS
• Diagnostic and therapeutic purpose
• Identification of extent of the lesion
• Unsatisfactory coloposcopic findings
• Cytology and directed biopsy

PROCEDURE
• The procedure is usually performed by
conventional knife.
• The operation can be done under local
anesthesia.
• Blood loss is minimized with prior hemostatic
sutures.
• The cone is cut from the apex of the internal os.
• After that the margin suture is placed at
12”0”clock direction.
• Then send to the laborartory

COMPLICATIONS
• Secondary haemorrhage
• Cervical stenosis
• Infertility
• Diminished cervical smear
• Mid trimester abortion

• CULDOCENTESIS
• It is the trans vaginal aspiration of periotoneal fluid
from the posterior cul-de-sac (or) pouch of Douglas.
Two small pouches called cul-de-sacs (French, literally
‘bottom of a sack)’ are located on either side of the
uterus.
INDICATIONS
• Ectopic pregnancy
• Pelvic abscess

• PROCEDURE
• It should be done under local anesthesia
• Lithotomy position
• Vagina is cleaned with betadine
• Vaginal speculam inserted
• 18G needle is inserted in to the cervico vaginal
route
• After inserting, on withdrawal, if unclotted blood
comes it is from intra peritoneal cavity.
• If it is fluid means we can withdraw with help of
suction catheter.

ENDOSCOPY IN GYNAECOLOGY
• Laparoscopy
• Hysteroscopy
• Salpingoscopy
• Cyctoscopy
• Sigmoidoscopy & proctoscopy

DIAGNOSTIC ENDOSCOPY-Overview
• To visualize body cavity
Lapraroscopy-
• Diagnose uterine,tubal,ovarian,generalised
diseases affecting pelvic organs-
endometriosis,PID,genital TB
• Staging of genital cancers
• Infertility workup
• a/c pelvic lesions-ectopic pregnancy,salphingitis
etc

LAPAROSCOPY
Indications
• Abnormal HSG findings
• Failure to conceive after reasonable period
• Unexplained infertility
• Women who have endometriosis

HYSTEROSCOPY
• Hysteroscopy is an operative procedure whereby the
endometrial cavity can be visualised with the aid of
fibre optic telescope.
• The uterine distension is achieved by co2, normal
saline, or glycerin.
• The instrument is to pass transcervically, usually
without dilatation of the cervix or local anaesthetic.
• However, for operative hysteroscopy, either
paracervical block or GA is required.
• Diagnostic hysteroscopy should be performed in the
postmenstrual period for better view without bleeding.

Hysteroscopy cont.,
INDICATIONS
• Diagnostic
• Abnormal uterine bleeding
• Infertility
• Recurrent miscarriage
• Misplaced IUD
• Chronic pelvic pain

Hysterocsopy indications cont.,
Therapeutic
• Polypectomy
• Endometrial resection
• Metroplasty
• Tubal cannulation
• Sterilization

COMPLICATIONS OF HYSTEROSCOPY
• Uterine perforation
• Peritonitis
• Cervical laceration
• Intrauterine infection

SALPHINGOSCOPY
• In salpingoscopy, a firm telescope is
inserted through the abdominal ostium of
the uterine tube to visualize the tubal
mucosa by distending the lumen with
saline infusion. The telescope is to be
introduced through the laproscope.
• Salphingoscopy allows study of
physiology and anatomy of tubal
epithelium and permits more accurate
selection of patients for IVF rather than the
tubal surgery.

CYSTOSCOPY
• DEFINITION
• Cystoscopy (cysto urethroscopy) is
a diagnostic procedure that uses
a cystoscope, which is an endoscope
especially designed for urological use to
examine the bladder, lower urinary tract,
and prostate gland.
• It can also be used to collect urine
samples, perform biopsies, and remove
small stones

USES OF CYSTOSCOPY
• Cervical cancer prior to staging
• Blood in the urine (hematuria)
• Inability to control urination (incontinence)
• Urinary tract infection
• Signs of congenital abnormalities in the urinary tract
• Suspected tumors in the bladder
• Bladder or kidney stones
• Signs or symptoms of an enlarged prostate
• Pain or difficulty urinating (dysuria)
• Disorders of or injuries to the urinary tract
• Symptoms of interstitial cystitis

FALLOPOSCOPY
• It is to study the entire length of tubal
lumen with the help of a fine and flexible
fiberoptic device.
• It is performed through the uterine cavity,
using a hysteroscope.
• It helps direct visualization of tubal ostia,
mucosal pattern, intratubal polyps, or
debris.

CULDOSCOPY
• It is a medical diagnostic procedure performed
to examine the rectouterine pouch and pelvic
viscera by the introduction of a culdoscope
through the posterior vaginal wall. The word
culdoscopy (and culdoscope) is derived from
the phrase cul-de-sac, which means literally
in French"bottom of a sac".
• More accurately, the name hints to a blind
pouch or cavity in the female body that is
closed at one end and, in a more specific sense,
refers to the rectouterine pouch (or called
the pouch of Douglas).

Culdoscopy cont.,
• Culdoscopy is an important gynecological
diagnostic technique, is gaining wide
acceptance.
• Under local anesthesia, insert a small
illuminated telescope through which one may
inspect the pelvic organs, without having to
resort to a major abdominal operation.
• Conditions diagnosable by culdoscopy
include tubal adhesions (causing
sterility), ectopic pregnancy, salpingitis, and
appendicitis.

Culdoscopy cont.,
• "A major advantage of a culdoscopy is that
there are no abdominal incisions.
• Culdoscopy tends to be reserved for obese
patients or in retroverted uterus.
• This transvaginal procedure involves a
small incision made into vaginal wall &
shows that this method is safer.
• Yet, a culdoscopy may be difficult to
perform because it requires a woman to be
in a knee-to-chest position while under
local anesthesia.

Culdoscopy cont.,
• A culdoscopy takes about 15 to 30
minutes, and women can go home the
same day.
• It may take a few days at home to
recover.
• Sexual intercourse is usually postponed
until the incision is completely healed,
(requires several weeks), and there are no
visible scars.

PROCTOSCOPY AND
SIGMOIDOSCOPY
• For rectal involvement of genital
malignancy, a digital examination or
proctoscopy is usually adequate.
• Proctoscopy is a common medical
procedure in which an instrument called a
proctoscope (also known as a rectoscope,
although the latter may be a bit longer) is
used to examine the anal
cavity, rectum or sigmoid colon.

Proctoscopy cont.,
• A proctoscope is a short, straight, rigid,
hollow metal tube, and usually has a small
light bulb mounted at the end.
• It is approximately 5 inches or 15 cm long,
while a rectoscope is approximately
10 inches or 25 cm long.
• During proctoscopy, the proctoscope is
lubricated and inserted into the rectum, and
then the obturator is removed, allowing an
unobstructed view of the interior of the
rectal cavity.

PROCTOSCOPE CONT.,
• This procedure is normally done to
inspect for hemorrhoids or
rectal polyps and might be mildly
uncomfortable as the proctoscope is
inserted further into the rectum.
• Modern fibre-optic proctoscopes allow
more extensive observation with less
discomfort.

SIGMOIDOSCOPY
• Sigmoidoscopy (from Greek Sigma -
eidos - scopy, to look inside an s-like
object) is the minimally
invasive medical examination of the
largeintestine from the rectum through the
last part of the colon.
• There are two types of
sigmoidoscopy: flexible sigmoidoscopy,
which uses a flexibleendoscope, and rigid
sigmoidoscopy, which uses a rigid
device.

Sigmoidoscopy cont.,
• Flexible sigmoidoscopy is generally the
preferred procedure.
• A sigmoidoscopy is similar to, but not
the same as, a colonoscopy.
• A sigmoidoscopy only examines up to
the sigmoid, the most distal part of the
colon, while colonoscopy examines the
whole large bowel.

 SUMMARY AND CONCLUSION
ASSIGNMENT
THEORY APPL CAT ON
İ İ

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