Textbook Of Gynecology. Dc Dutta’s

Chapter 9. Examination of a Gynecological Patient

The clinical examination should be thorough and meticulous. These include in-depth history taking and examinations—general, abdominal and internal. It should be emphasized that a meticulous history taking alone can give a positive diagnosis in majority of cases without any physical examination. The examination should, in fact, proceed with the provisional diagnosis in mind. On occasion, ancillary aids are required to confirm the diagnosis. For a careful history taking, the following outlines are of help:

A patient hearing should be given about the complaints made by the patient in her own words. In order to substantiate the guess made out of her complaints, some pertinent questions (open-ended or specific) may be asked tactfully and judiciously. Looking at the patient (direct observation) before speaking may give many clues (nonverbal) to the diagnosis, e.g. fear, sadness, apathy or anger.

HISTORY

This should be taken in details. If multiple symptoms are present, their chronologic appearances are to be noted. Integration of the symptomatology to one pathology is to be tried first before embarking on the diagnosis of multiple pathology. Enquiry should be made about the bowel habits and urinary trouble, if any.

Menstrual History: Enquiry should be made about:

♦ Age of onset of the first period (menarche).

♦ Regularity of the cycle

♦ Duration of period

♦ Length of the cycle

♦ Amount of bleeding—Excess is indicated by the passage of clots or number of pads used

♦ First day of the last menstrual period (LMP).

The menstrual history can be reproduced as 13/4/28, representing that the onset of period was at the age of 13, bleeding lasts for 4 days and occurs every 28 days.

Obstetric History: If the patient had been previously pregnant, details are to be enquired as per tabulation below. Many a times, the complaints may be related to the pregnancy complications or lactation.

No. date

Year and events

Pregnancy events

Labor delivery

Method of delivery

Puer- perium

Baby weight and sex. Birth asphyxia. Duration of breastfeeding, contraception

1.

           

2.

           

The obstetric history is to be summed up as—

Past Medical History

Relevant medical disorders—systemic, metabolic or endocrinal (diabetes, hypertension, hepatitis) should be enquired. Their presence requires care during operative procedure. Next pertinent point is the interrogation about sexually transmitted diseases.

Past Surgical History

This includes general, obstetrical or gynecological surgery. The nature of the operation, anesthetic procedures, bleeding or clotting complication if any, postoperative convalescence are to be enquired. Any histopathological report or relevant investigation related to the previous surgery is most often helpful.

Family History

It is of occasional value. Malignancy of the breast, colon, ovary or endometrium is often related. Tubercular affection of any family member can give a clue in diagnosis of pelvic tuberculosis.

Personal History

Occupation, marital status—married, widow, divorced or separated should be enquired. If married—details of sexual history should be taken, especially in case of infertility. Sexual history includes any sexual dysfunction, or dyspareunia. Contraceptive practice, if any should be enquired—especially relevant in pill users or cases having IUCD, as these methods often produce some adverse symptoms. History of taking drugs for a long time or allergy to certain drugs is to be noted.

EXAMINATION

The examination includes:

■ General and systemic examination

■ Gynecological examination

♦ Breast examination

♦ Abdominal examination

♦ Pelvic examination.

GENERAL AND SYSTEMIC EXAMINATION

The general and systemic examination should be thorough and meticulous.

Built—Too obese or too thin—May be the result of endocrinopathy and related to menstrual abnormalities

Nutrition—Average/Poor

Stature—Including development of secondary sex characters

Pallor

Jaundice

Edema of legs

Teeth, gums and tonsils—For any septic foci

Neck—Palpation of thyroid gland and lymph nodes, especially the left supraclavicular glands

Cardiovascular and respiratory systems—Any abnormality may modify the surgical procedure, if it deems necessary

Pulse Blood pressure.

GYNECOLOGICAL EXAMINATION

Breast Examination (Fig. 9.1)

This should be a routine especially in women above the age of 30 to detect any breast pathology, the important being carcinoma. In India, breast carcinoma is the second most common malignancy in female, next to carcinoma cervix.

Abdominal examination

Prerequisites

■ Bladder should be empty. The only exception to the procedure is the presence of history suggestive of stress incontinence. If history is suggestive of chronic retention of urine, catheterization should be done taking aseptic precautions, using sterile simple rubber catheter

■ The patient is to lie flat on the table with the thighs slightly flexed and abducted to make the abdominal muscles relaxed (see Fig. 9.3B)

■ The physician usually prefers to stand on the right side

■ Presence of a chaperone (a female) for the support of the patient and the physician.

Actual steps:

Inspection Palpation

Percussion Auscultation

Fig. 9.1. Examination of the breasts : 1. Inspection with the arms at her sides; 2. Inspection with the arms raised above the head; 3. Inspection with hands at the waist (with contracted pectoral muscle); 4. Palpation of the axillary nodes; 5. Palpation of the supraclavicular nodes; 6. Palpation of the outer half of the breast (a pillow is placed under the patient's shoulder)

Inspection: The skin condition of the abdomen— presence of old scar, striae, prominent veins or eversion of the umbilicus is to be noted. By asking the patient to strain, one can elicit either incisional hernia or divarication of the rectus abdominis muscles. In intestinal obstruction, the abdomen is uniformly distended and the respiration is of thoracic type. In pelvic peritonitis, the lower abdomen is only distended with diminished inspiratory movements. In ascites, one can find fullness only in the flanks with the center remaining flat. A huge pelvic tumor is more prominent in the hypogastrium situated either centrally or to one side. Female escutcheon over the mons pubis is noted. Palpation: The palpation should be done with the flat of the hand gently rather than the tips of the fingers. If rigidity of the abdominal muscles is encountered, it may be due to high tension or due to muscle guard. If a mass is felt in the lower abdomen, its location, size above the symphysis pubis, consistency, feel, surface, mobility from side to side and from above to down, and margins are to be noted. Whether the lower border of the mass can be reached or not should be elicited. In general, lower border cannot be reached in pelvic tumor, but in ovarian tumor with a long pedicle one can go below the lower pole. If the tumor is cystic and huge, one can exhibit a fluid thrill felt with a flat hand placed on one side of the tumor when the cyst is tapped on the other side of the tumor with the other hand. Whether a mass is felt or not, routine palpation of the viscera (for any organomegaly) includes—liver, spleen, cecum and appendix, pelvic colon, gallbladder and kidneys.

Percussion: A pelvic tumor is usually dull on percussion with resonance on the flanks. However, if there are intestinal adhesions or the tumor is retroperitoneal, it will be resonant. In presence of ascites, the flanks will be dull on percussion and the shifting dullness, if elicited, confirms the diagnosis of free fluid in the peritoneal cavity. It is, however, mandatory to elicit presence of free fluid in the peritoneal cavity in every cases of pelvic tumor (Fig. 9.2).

Fig. 9.2 : Relation of the dull and resonant areas in lower abdominal tumor and ascites. Upper figure in recumbent posture. Lower figure with patient in decubitus posture

Figs 9.3 : Positions of the patient for gynecological examination: (A). Sims' position — The patient lies on her left side with right knee and thigh drawn up towards the chest, the left arm along the back; (B). Dorsal position; (C). Lithotomy position

Auscultation: Ordinarily, auscultation reveals only the intestinal sounds. Hypoactive bowel sounds are found in paralytic ileus, hyperactive bowel sounds may be due to intestinal obstruction. The uterine souffle may be heard over a pregnant uterus or vascular fibroid, which is synchronous with the patient’s pulse. If the tumor is of pregnant uterine origin, fetal heart sound can be heard beyond 24 weeks.

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 by digital examination

- Bimanual examination of the pelvic organs

♦ Rectal examination

♦ Rectovaginal examination.

PREREQUISITES

► The patient’s bladder must be empty—the exception being a case of stress incontinence

► A female attendant (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

► 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.

POSITION OF THE PATIENT (FIG. 9.3)

The patient is commonly examined in dorsal position with the knees flexed and thighs abducted. The physician usually stands on the right side. This position gives better view of the external genitalia and the bimanual pelvic examination can be effectively performed.

However, the patient can be examined, in any position of the physician’s choice. Lateral or Sims’ position seems ideal for inspecting any lesion in anterior vaginal wall as the vagina balloons with air as soon as the introitus is opened by a speculum.

Lithotomy position (patient lying supine with her legs on stirrups) is ideal for examination under anesthesia.

Fig. 9.4: Inspection of vulva in dorsal position

INSPECTION OF THE VULVA (FIG. 9.4)

♦ To note any anatomical abnormality starting from the pubic hair, clitoris, labia and perineum

♦ To note any palpable pathology over the areas

♦ To note the character of the visible vaginal discharge, if any

♦ To separate the labia using fingers of the left hand to note external urethral meatus, visible openings of the Bartholin’s ducts (normally not visible unless inflamed) and character of the hymen.

♦ To ask the patient to strain to elicit:

- Stress incontinence—urine comes out through urethral meatus (see p. 399).

- Genital prolapse and the structures involved— anterior vaginal wall, uterus alone or posterior vaginal wall or all the three (see p. 204).

♦ Lastly, to look for hemorrhoids, anal fissure, anal fistula or perineal tear.

VAGINAL EXAMINATION

Inspection of the vagina and cervix

Which one is to be done first—inspection or palpation?

Speculum examination should preferably be done prior to bimanual examination. The advantages are:

- Cervical scrape cytology and endocervical sampling can be taken as ‘screening’ in the same sitting

- Cervical or vaginal discharge can be taken for bacteriological examination

- The cervical lesion may bleed during bimanual examination, which makes the lesion difficult to visualize.

Two types of speculum are commonly used—Sims’ or Cusco’s bivalve. While in dorsal position, Cusco is widely used but in lateral position, Sims’ variety has got advantages (Figs 9.5A and B).

The cervix is best visualized with the Cusco’s variety. But while the vaginal fornices are only visualized by Cusco, the anterior vaginal wall is to be visualized by Sims’ variety. Sims’ speculum is advantageous in cases of genital prolapse.

Apart from inspection, collection of the discharge from the cervix or from the vaginal fornices or from the external urethral meatus is taken for bacteriological examination.

It is a routine practice to take cervical scrape cytology and endocervical sampling for cytological examination in all patients as a screening procedure, if not done recently.

Digital examination

Digital examination is done using a gloved index finger lubricated with sterile lubricant. In virgins with intact hymen, this examination is withheld but can be employed under anesthesia.

Palpation of any labial swelling (commonly Bartholin’s cyst or abscess) is made with the finger placed internally and thumb placed externally (Fig. 9.6). The urethra is now pressed from above down for any discharge escaping out through the meatus.

Figs 9.5A and B: Introduction of Cusco's speculum: (A) The transverse diameter of the closed blades are placed in the anteroposterior position and inserted slightly obliquely to minimize pressure on the urethra; (B) Blades are inserted in a downward motion and then rotated. Rotate to 90° and then to open up the blades. Inspection is then made using a good light

Palpation of the vaginal walls is to be done from below upwards to detect any abnormality either in the wall or in the adjacent structures.

The vaginal portion of cervix is next palpated to note:

♦ Direction—In anteverted uterus, the anterior lip is felt first and in retroverted position either the external os or the posterior lip is felt first

♦ Station—Normally the external os is at the level of ischial spines

♦ Texture—In nonpregnant state, it feels firm like tip of the nose

♦ Shape—It is conical with smooth surface in nulliparae but cylindrical in parous women

♦ External os—It is smooth and round in nulliparae but may be dilated with evidence of tear in parous women

♦ Movement—Painful or not

♦ Whether it bleeds to touch.

Integrity and tone of the perineal body are to be elicited by flexing the internal finger posteriorly and palpating the perineal body between the internal finger and the thumb placed externally. The finger is now turned laterally above the level of levator ani muscles. The muscles can be palpated between the vaginal finger and the thumb placed externally over the labium majus.

Fig. 9.6. Palpation of a labial swelling (Bartholin's gland)

Fig. 9.7. Position of the fingers during bimanual examination

Bimanual examination

The techniques are difficult to describe in words but perfectness will be achieved only through experience.

The gloved right index and middle fingers smeared with lubricants are inserted into the vagina. If the introitus is narrow or tender, one finger may be used. The relative position of the fingers during introduction is shown in Figure 9.7. The left hand is placed on the hypogastrium well above the symphysis pubis so that the pelvic organs can be palpated between them. The examination should be methodical, gentle but purposeful. To be more informative, abdominal hand is to be used more than the vaginal fingers and the patient is asked to breathe through the mouth for better relaxation of the abdominal muscles.

The information obtained by bimanual examination includes:

♦ Palpation of the uterus

♦ Palpation of the uterine appendages

♦ Pouch of Douglas.

■ Palpation of the uterus

The two internal fingers, which are placed in the anterior fornix exert a pushing force at the uterocervical junction in an upward direction towards the lumbar vertebrae and not towards the symphysis pubis. The pressure exerted by the left hand should be not only downwards but from behind forwards (Fig. 9.8). The uterine outline between the two hands can thus be palpated clearly as anteverted. If the uterus is retroverted, it will not be so felt but can be felt if the internal fingers push up the uterus through the posterior fornix. After the uterine outline is defined, one should note its position, size, shape, consistency and mobility. Normally, the uterus is anteverted, pearshaped, firm and freely mobile in all directions.

■ Palpation of the uterine appendages

For palpation of the adnexa, the vaginal fingers are placed in the lateral fornix and are pushed backwards and upwards. The counter pressure is applied by the abdominal hand placed to one side of the uterus in a backward direction. The normal uterine tube cannot be palpated. A normal ovary may not be felt. If it is palpable, it is mobile and sensitive to manual pressure.

Fig. 9.8. Bimanual examination of the uterus

The pouch of Douglas

The pouch of Douglas can be examined effectively through the posterior fornix. Normally, the fecal mass in the rectosigmoid or else the body of a retroverted uterus is only felt. Some pathology detected in the pouch of Douglas should be supplemented by rectal examination.

RECTAL OR RECTOABDOMINAL EXAMINATION

Rectal examination can be done in isolation or as an adjunct to vaginal examination.

Indications of Rectal Examination

♦ Children or in adult virgins

♦ Painful vaginal examination

♦ Carcinoma cervix—to note the parametrial involvement (base of the broad ligament and the uterosacral ligament can only be felt rectally) or involvement of the rectum

♦ To corroborate the findings felt in the pouch of Douglas by bimanual vaginal examination

♦ Atresia (agenesis) of vagina

♦ Patients having rectal symptoms

♦ To diagnose rectocele and differentiate it from enterocele.

The lower bowel should preferably be empty. The rectoabdominal procedure is almost the same as that of vaginal examination except that only the gloved index finger smeared with vaseline is to be introduced into the rectum (Fig. 9.9A).

Figs 9.9A and B: (A) Rectoabdominal; (B) Rectovaginal examination

RECTOVAGINAL EXAMINATION: The procedure consists of introducing the index finger in the vagina and the middle finger in the rectum. This examination may help to determine whether the lesion is in the bowel or between the rectum and vagina. Any thickening of beadiness of uterosacral ligaments or presence of endometriotic nodules are noted. This is of special help to differentiate a growth arising from the ovary or rectum (Fig. 9.9B).

Identification of a mass felt on bimanual examination

Uterine tumor (Fig. 9.10)

► Uterus is not separated from the mass.

► Movements of the mass felt per abdomen are transmitted to the cervix and vice versa, the exception being one of subserous pedunculated fibroid.

Fig. 9.10: Identification of an uterine tumor in bimanual examination

Adnexal mass

► The uterus is separated from the mass (Figs 9.11 and 9.12)

► Movements of the mass (tumor) are not transmitted to the cervix, the exception being one if the mass is fixed with uterus.

Fig. 9.11: Identification of ovarian tumor in bimanual examination

Fig. 9.12. Identification of an adnexal mass in bimanual examination

DIAGNOSTIC PROCEDURES

For confirmation of diagnosis or rarely in cases with diagnostic difficulty, ancillary aids are required.

■ Blood Values: Hemoglobin estimation should be done in all cases of excessive bleeding. Total and differential count of white blood cells and ESR are helpful in diagnosis of pelvic inflammation. Serological investigation includes blood for VDRL to be done in selected cases of HIV. Platelet count and bleeding and coagulation time are helpful in pubertal menorrhagia.

■ Urine: Routine and Microscopic Examination for the presence of protein, sugar, pus cells and casts are done. In the presence of excessive vaginal discharge, it is preferable to collect the midstream urine (vide infra).

Culture and drug sensitivity is done in suspected cases of urinary tract infection. Any of the following methods are used to collect the urine for the purpose.

(i) Midstream collection: The patient herself should separate the labia with the fingers of left hand. A sterile cotton swab moistened with sterile water is passed over the external urethral meatus from above down and is then discarded. With the vulva still separated the patient is to pass urine. During the middle of the act of micturition, a part of urine is collected in a sterile wide mouth container.

Fig. 9.13A: Methods of catheterization by rubber catheter. Cleansing of the vestibule from above down by a moist swab

(ii) Catheter collection: This should be collected by a doctor or a nurse. This is especially indicated when the patient is not ambulant or having chronic retention. Meticulous washing of the hands with soap and wearing sterile gloves are mandatory. The patient is in dorsal position with the thighs apart. The labia are separated using the fingers of left hand. A sterile cotton swab moistened with sterile water is passed from above down over the external urethral meatus. The sterile autoclaved rubber catheter or a disposable plastic catheter is to be introduced with the proximal 4 cm remaining untouched by the fingers. With meticulous asepsis, the technique does not increase urinary tract infection (Figs 9.13A and B).

(iii) Suprapubic bladder puncture: The result is more reliable and bladder infection is minimum. The patient is asked not to void urine to make the bladder full. A fine needle fitted with a syringe is passed through the abdominal wall just above the symphysis pubis into the bladder. About 5-10 mL of urine is collected. The patient is asked to void the urine immediately.

Whatever method employed in the collection of urine, the sample should be sent immediately to the laboratory. There may be multiplication of the organisms with time.

Fig. 9.13B: Note the use of left fingers for disposition of the external urethral meatus and holding the catheter well away from the tip by the right hand

■ Urethral discharge: With a sterile gloved finger, the urethra is squeezed against the symphysis pubis from behind forwards. The discharge through the external urethral meatus is collected with sterile swabs. One swab may be sent for culture and the other to be spread on to a slide, stained and examined under microscope.

■ Vaginal or cervical discharge: The patient is advised not to have vaginal douche at least in previous 24 hours. Cusco’s bivalve speculum is introduced without lubricant and prior to internal examination. The material collected in the posterior blade or from the cervical canal as the case may be, is taken either by a platinum loop or swab stick.

For Culture: The cotton swab stick is put in a sterile container with a stopper and to be sent immediately to the laboratory. The culture is usually unnecessary in vaginal infection. For trichomoniasis, Kupferberg’s media or Feinberg Whittington media; for Candida albicans—Nickerson’s or Sabouraud’s media is used.

Identification of Organism in Slide

a. Trichomonas vaginalis: The material is dropped over a slide and then mixed with one drop of normal saline. It is then covered with a coverslip. Actively motile trichomonads can be seen under microscope easily (see Fig. 12.2). It can be effectively visualized after staining with 1 percent brilliant cresyl violet; leukocytes and other bacteria will not take up the dye.

 

b. Monilia: One drop of the discharge is mixed with one drop of 10% potassium hydroxide and is covered with a coverslip. The mycelia of the fungus can be seen under microscope. Alternatively, the discharge is spread over a slide, dried and stained with methylene blue to demonstrate the mycelia (see Fig. 12.4).

CERVICAL AND VAGINAL SMEAR FOR EXFOLIATIVE CYTOLOGY

The indications are:

♦ As a screening procedure

♦ For cytohormonal study ♦ Others

SCREENING PROCEDURE

Collection of material: The cervix is exposed with a Cusco’s 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 squamocolumnar junction has to be scrapped to obtain good material (Fig. 9.15).

Fig. 9.15: Collection of smear: (A) Using Ayre's spatula from the squamocolumnar junction for screening; (B) By cytobrush taking endocervical sampling for screening; and (C) By wooden spatula from the lateral vaginal fornix for cytohormonal study

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.

Collection by any one of the methods should be combined with endocervical sampling either by cytobrush or with moist cotton tip applicator (Figs 9.14 and 9.15).

Fixation and Staining

The principle of the staining is to achieve clear nuclear definition and to define cytoplasmic coloration.

The material so collected should be immediately spread over a microscopic slide and at once put into the fixative ethyl alcohol (95%) before drying. After fixing for about 30 minutes, the slide is taken out, air dried and sent to the laboratory with proper identification. The slide so sent is stained either with Papanicolaou’s or Sorr’s method and examined by a trained cytologist. Indeed, trained cytopathologist and cytotechnologist are vital for the success of any screening program (Table 9.1).

BENEFITS: The objective of screening is to reduce the incidence and mortality from cervical cancer. Even a single smear in a life time, if appropriately timed, will produce some benefits. If extended only to high-risk group, the mortality from the cancer deaths will still be reduced to 60 percent.

Pap smear test has been effective reducing the incidence of cervical cancer by 80% and the mortality by 70%. As a result of Pap test, more and more preinvasive carcinoma is detected. Opportunistic screening done by a trained staff is effective when follow-up (call and recall) is maintained. Pap testing after total hysterectomy, done for benign lesion is not recommended.

INTERVALS: All sexually active women should be screened starting from the age of 21 years or after 3 years of vaginal sex with no upper age limits. Screening should be yearly till the age of 30. Thereafter, it should be done at an interval of every 2-3 years after three consecutive yearly negative smears (ACOG 2009). The high risk group should be screened with HPV DNA testing combined with cytology (p. 324)The negative predictive value of one negative HPV DNA test and two negative cytology tests are almost 100%. When both the tests are negative, the screening interval may be increased to 6 years.

MORPHOLOGICAL ABNORMALITIES OF THE NUCLEUS (DYSKARYOSIS)

► Disproportionate nuclear enlargement

► Irregularity of the nuclear outline

► Abnormalities of the nucleus—in number, size and shape

► Hyperchromasia

► Condensation of chromatin material

► Multinucleation.

Abnormal cells are:

Mild dyskaryosis—Cells are of superficial or intermediate type squamous cells. Cells have angular borders with translucent cytoplasm. The nucleus occupies less than half of the total area of cytoplasm. Binucleation is common. Mild dyskaryosis correlates with cells from surface of CIN I (see p. 320).

Moderate dyskaryosis—The cells are of intermediate, parabasal or superficial type squamous cells. Cells have more disproportionate nuclear enlargement and hyperchromasia compared to mildly dyskaryotic cells. The nucleus occupies one half to two-thirds of the total area of the cytoplasm.

Severe dyskaryosis (Fig. 9.17)—Cells are of basal type, looking round, oval, polygonal or elongated in shape. The abnormal cells may occur in clumps or singly. The abnormal nucleus either practically fills the cell or there may be a thick, dense and narrow rim of cytoplasm around it. The nucleus is irregular with coarse chromatin pattern. The cells may be different in size and shape. Severely dyskaryotic cells when elongated, are sometimes called fiber cells. A severely dyskaryotic cell with an elongated tail of cytoplasm is described as a tadpole cell. Severely dyskaryotic cells correlate with CIN 3.

Koilocytosis is the nuclear abnormalities associated with human papilloma virus infection. Cells show typical central clearing (perinuclear halo) with peripheral condensation of cytoplasm. The nucleus is irregulary enlarged and shows hyperchromasia with multinucleation. Patients with koilocytosis on repeated smear, need colposcopic evaluation (see p. 115).

Fig. 9.16: Liquid-based cytology—normal squamous cells and endocervical cells

Fig. 9.17: Severe dyskaryosis

Carcinoma in situ (Fig. 9.18)—Cells are parabasal type with increased nuclear cytoplasmic ratio. The nucleus may be irregular sometimes multiple. The chromatin pattern is granular. 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.

Reporting system: Reporting system on the grading basis (Papanicolaou’s) is replaced by some with two remarks only—normal or abnormal (Table 9.2). An abnormal smear indicates the presence of lesion either CIN and/or papilloma virus infection or invasive malignancy. A doubtful or inconclusive smear dictates repeat smear.

TABLE 9.2

PAPANICOLAOU'S GRADING

Group - I

Normal

Group - II

Presence of borderline atypical cells— probably due to infection. No evidence of malignancy

Group - III

Cells suspicious of malignancy

Group - IV

Presence of few malignant cells

Group -V

Presence of large number of malignant cells

Accuracy: A single Pap smear has a diagnostic sensitivity of about 60 percent. False negative results may be up to 25%.

Fig. 9.18: Carcinoma in situ

False negative rate of Pap smear after three consecutive negative tests is less than 1 percent. There are several reasons for false-negative smear. This may be due to technical error where smear is too scanty, too thick, too bloody, poorly stained or due to misinterpretation by the cytologist. Error in cytology could be reduced further by liquid-based thin layer slide preparation and automated (computer) screening methods. Abnormal cytology is an indication of colposcopic evaluation and directed biopsy. If colposcopy is not available, biopsy is to be taken from the unstained areas following application of Schiller’s or Lugol’s iodine (see Ch. 22). In the presence of infection, repeat cytology has to be done after the infection is controlled (Table 9.3).

LIQUID-BASED CYTOLOGY (LBC): Cervical smear is taken using a plastic spatula. The spatula is rinsed in a liquid media. Cells are separated by centrifugation. Thin layer smears are made. National Institute of Clinical Excellence (NICE) has recommended to replace the conventional smear with LBC. LBC avoids the risk of false-positive, false-negative or unsatisfactory smears (Fig. 9.16).

CYTOHORMONAL STUDY: The vaginal epithelium is highly sensitive to the hormones estrogen and progesterone. The non-invasive study of the epithelium for hormonal status is steadily increasing owing to the speed, cheapness and accuracy.

Instructions to the patient

► To avoid intercourse for about 48 hours

► Not to use vaginal douche for 24 hours

► To withhold use of hormonal drugs.

Procedures: The lateral wall of the upper-third of the vagina (most sensitive to hormonal influence) is lightly scraped with a wooden spatula after taking due precautions mentioned earlier. The material so collected is to be fixed and stained as mentioned earlier. The physician should mention the following information, such as age, first day of the last period, menstrual pattern and any hormone therapy.

Inferences: The exfoliated vaginal epithelial cells normally include parabasal, intermediate and superficial cells. The parabasal cells are small, round and basophilic; the intermediate cells are transparent and basophilic while the superficial cells are large, thin acidophilic with pyknotic nuclei. The estrogen produces superficial cell maturation; progesterone, androgen, corticosteroids, ‘pill’ and pregnancy produce intermediate cell maturation, whereas lack of any hormonal activity produces parabasal cell dominance (Table 9.4).

TABLE 9.4  

MATURATION INDEX FROM BIRTH TO MENOPAUSE

 

M I

Smear features

Inference

At birth

0/95/5

Combined effect of circulating maternal hormones—estrogen, progesterone and corticoids

Childhood

80/20/0

MI shifting to left because of diminished steroid hormones

Reproductive period:

- Preovulatory

0/40/60

Smear clear, cells are discrete

Estrogen ++

- Mild secretory

0/70/30

Smear dirty, cells in clusters

Estrogen +; Progesterone ++

- During pregnancy

0/95/5

Marked folding of the intermediate cells—'navicular cells’

Estrogen ++; Progesterone ++;

Corticosteroids +

- Postpartum

100/0/0

Parabasal maturation

Postmenopausal

0/100/0 or 100/0/0

Lack of estrogen

The estrogenic smear is suggested by preponderance of large eosinophilic cells with pyknotic nuclei (cornified cells). The background remains clear (see Fig. 8.11).

The progesterone smear is of predominantly basophilic cells with vesicular nuclei. The background looks dirty (see Fig. 8.11).

Interpretations: The number of cornified cells per 100 cells counted is expressed as cornification or karyopyknotic index. It is mostly replaced by a more appropriate expressive method—called maturation index (MI). The maturation index relates to the relative percentage of parabasal, intermediate and superficial cells per 100 cells counted. It is expressed in three numbers, the left one parabasal percentage, the intermediate in the centre and on the right, the percentage of the superficial cells (Table 9.4).

Other Indications of Cytology Study are

♦ The exfoliative cell cytology is used in follow-up cases of carcinoma cervix treated either by surgery or radiotherapy

♦ Sex chromatin study—The materials are from scraping of buccal mucosa and to be stained with Papanicolaou stain. The presence of Barr body in more than 25% cells is diagnostic of female sex

♦ Aspirated ascitic, cystic or pleural fluid is subjected to Papanicolaou stain for evidences of malignant cells.

EXAMINATION OF CERVICAL MUCUS

■ 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 culture or spread over a microscopic slide for Gram staining.

HORMONAL STATUS: The physical, chemical and cellular components of the cervical secretion are dependent on hormones—Estrogen and progesterone. Estrogen increases the water and electrolyte content with decrease in protein. As such, the mucus becomes copious, clear and thin. Progesterone, on the other hand, decreases the water and electrolytes but increases the protein. As a result, the mucus becomes scanty, thick and tenacious. The influence of the hormones on the cervical mucus is utilized in detection of ovulation in clinical practice.

■ 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 estrogen level during this period, the mucus placed between the slides can withstand stretching up to a distance of over 10 cm. After ovulation when corpus luteum forms, progesterone is secreted. Under its action, the cervical mucus looses its property of elasticity and while attempting the above procedure, the mucus fractures when put under tension much earlier. This loss of elasticity after its presence in the midcycle is the indirect evidence of ovulation.

■ Fern test—During the midcycle, 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. It is due to high sodium chloride and low protein content in the mucus 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 (Fig. 9.19).

Fig. 9.19: Typical fern pattern appearance of cervical mucus

The cervical scoring system of Insler (1979) takes into the account the amount, spinnbarkeit, ferning of the mucus along with state of the external os of the cervix. A score of 10-12 indicates complete follicular maturation.

INFERTILITY INVESTIGATIONS

Postcoital test (PCT)—Marion Sims (1866) and Max Huhner (1913)

Cervical mucus is a glycoprotein gel with interstitial channel between mucin strands. These strands expand and contract in response to steroid hormones. This helps sperm transport upwards (see Fig. 16.4).

Principle: It is the examination of the cervical mucus to evaluate the presence of progressively motile sperm in it. This test is done several hours after (within 8-12 hours) sexual intercouse. Presence of at least 10 progressively motile sperm per high power field signifies the test is normal. PCT has got poor predictive value. Moreover, the test procedure is inconvenient and embrassing. Routine postcoital test is not recommended.

COLPOSCOPY

The instrument was devised by Hinselmann in 1925. Colposcope and colpomicroscope are the low-power binocular microscope, mounted on a stand. It is designed to magnify the surface epithelium of the vaginal part of the cervix including entire transformation zone. The magnification is to the extent of 15-40 times in colposcopy and about 100-300 times in colpomicroscopy (Fig. 9.20).

Procedure: The patient is placed in lithotomy position. The cervix is visualized using a Cusco’s speculum (Fig. 9.5). Colposcopic examination of the cervix and vagina is done using low power magnification (6-16 fold). Cervix is then cleared of any mucus discharge using a swab soaked with normal saline. Green filter and high magnification can be used now. Next, the cervix is wiped gently with 3 percent acetic acid and examination repeated. Acetic acid causes coagulation of nuclear protein which is high in CIN. This prevents transmission of light through the epithelium, which is visible as white (acetowhite) areas (see Fig 22.6A).

Fig. 9.20: Colposcope

Technique of colposcopy needs ease of maneuver (frontal distance of 225 to 250 mm), magnification (6-16 times), adequate light source (30,000 lux), the stand to permit mobility and the examination table for patient's comfort

IMAGING TECHNIQUES IN GYNECOLOGY

X-RAY

A chest X-ray and intravenous urogram are essential for investigation in pelvic malignancy, cervical cancer in particular, prior to staging. Plain X-ray of the pelvis is helpful to locate an IUCD (see Fig. 29.7) or to look for shadows of teeth or bone in benign cystic teratoma (see Fig. 20.10). Special X-ray using contrast media are:

♦ HSG (details in p. 588).

♦ Lymphangiography—to locate the lymph nodes involved in pelvic malignancy.

ULTRASOUND

Ultrasound is a noninvasive imaging procedure that utilizes high frequency sound waves. It was first introduced by Ian Donald (Glasgow - 1950) in the field of medicine. Sonography is used widely in Gynecology either with the transabdominal (TAS) or with the transvaginal (TVS) probe. Because of safety, high patient acceptance and relatively low cost, ultrasonography has become a common diagnostic modality in gynecology, these days.

Transabdominal Sonography (TAS) is done with a linear or curvilinear array transducer operating at 2.5-3.5 MHz. TAS requires full bladder to displace the bowel out of pelvis. Full bladder serves as an acoustic window for the high-frequency sound waves. Ultrasound is very accurate (>90%) in recognizing a pelvic mass but cannot stabilize a tissue diagnosis. Tissue resolution of <0.2 mm can be obtained with sonography. TAS is best used for large masses like fibroid or ovarian tumor. Higher is the frequency of ultrasound wave, better is the image resolution but lesser is the depth of tissue penetration.

Transvaginal Sonography (TVS) is done with a probe, which is placed close to the target organ. There is no need of a full bladder. It also avoids the difficulties due to obesity, faced in TAS. TVS operates at a high frequency (5-8 MHz). Therefore, detailed evaluation of the pelvic organs (within 10 cm of the field) is possible with TVS. But the drawbacks of TVS are mainly due to narrow vagina as in virgins, postmenopausal women or post-radiation vaginal stenosis.

Transvaginal Color Doppler Sonography (TV- CDS)—Provides additional information of blood flow to, from or within an organ (uterus or adnexae). This flow can be measured by analysis of the waveform using the pulsatility index.

Use of Ultrasound in Gynecology

■ Infertility workup

♦ Serial measurement of ovarian follicular diameter (folliculometry) and endometrial thickness are done using TVS. Mature follicle should measure between 18 and 20 mm in diameter. The favorable periovulatory endometrium should be between 7 and 11 mm thick (see Chapter 16)

♦ Ultrasound can provide presumptive evidence of ovulation. Following ovulation, internal echoes appear within ruptured follicle and free fluid is observed in pouch of Douglas

♦ To detect correct timing of ovulation by folliculometry in conjunction with plasma estradiol. This helps in induction of ovulation, artificial insemination and ovum retrieval in IVF

♦ Sonographic guided oocyte retrieval in IVF and GIFT programs, is now accepted as the best method

■ Ectopic pregnancy can be detected on TVS as a “tubal ring”, separate from the ovary in a patient with empty uterine cavity. TV-CDS is of more help to detect the vascularity of “tubal ring” when it is unruptured

■ Pelvic mass can be evaluated as regard to its location and consistency. Uterine fibroid, ovarian mass, endometrioma, tubo-ovarian mass, etc. can be delineated when there is confusion in clinical diagnosis. However, major limitation is due to its lack of specificity

■ Oncology: TV-CDS can assess the vascularity of the mass. Low flow impedance with high flow velocity raises the suspicion of a malignant tumor.

Presence of papillary excrescences, mural nodules, septations, cystic lesion with solid components, snow storm appearance (hydatidiform mole) and ascites are the other sonographic features of malignancy.

■ Endometrial disease: Women with unexplained uterine bleeding, or postmenopausal bleeding are better studied with TVS. An endometrial thickness of less than 5 mm is considered atrophic. Endometrial biopsy is needed for postmenopausal women with thicker endometrium (see p. 356).

■ Sonohysterography involves instillation of saline in the uterine cavity and study with TVS. Submucous fibroid or polyp is better diagnosed with this method.

■ To locate missing IUD (see p. 483).

■ Sonohysterosalpingography (see p. 239).

■ Sonographically guided procedures.

A needle guide is attached to the shaft of the vaginal probe. With the use of real time, TVS can guide the needle course in a safe path. This technique can be utilized for many diagnostic and therapeutic purposes:

♦ Aspiration of cystic masses, e.g. chocolate cyst (see p. 312)

♦ Follicular aspiration, e.g. ovum retrieval in IVF (see p. 253)

♦ Aspiration of tubo-ovarian abscess.

♦ Biopsies

■ Transrectal sonography can be used where TVS cannot be used due to vaginal narrowing

■ Saline infusion sonography (SIS):

Infusion of normal saline into the uterine cavity and doing transvaginal (high resolution) sonography is helpful for the diagnosis of many uterine patho-logy. SIS catheter is inserted through the cervical os. Normal saline is infused slowly (5-10 mL) when the uterus is imaged with vaginal ultrasound.

Common indications of SIS are:

► Postmenopausal bleeding.

► Abnormal uterine bleeding.

► Recurrent miscarriage.

► Infertility.

COMPUTED TOMOGRAPHY (CT SCAN)

The CT scan provides high resolution two-dimensional images. Cross-sectional images of the body are taken at very close intervals (few millimeters thick) in the form of multiple slices. CT can differentiate tissue densities and this gray-scale pictures can be read on an X-ray film or a television monitor.

Fig. 9.21: CT scan of the pelvis showing an ovarian mass

Pelvic organs could be differentiated from gastrointestinal and urinary systems using contrast media. Contrast media can be given orally, IV or rectally. CT is most useful in the diagnosis of lymph node metastases, depth of myometrial invasion in endometrial cancer, ovarian mass and myomas. CT can detect enlarged lymph nodes but cannot differentiate between benign hyperplasia or metastatic carcinoma. However, lymph nodes must be enlarged at least by 2 cm to be detected by CT. Cerebral metastases of choriocarcinoma or microadenoma of the pituitary can best be detected by CT procedure. CT scan also facilitates the percutaneous needle biopsy of suspicious lymph nodes. In obese or in cases of distended stomach or gut, it is an ideal alternative to sonar (see Fig. 37.81). CT is useful in assessing tumor extent and detecting metastases (Fig. 9.21). CT has its role in staging of ovarian cancer as it can detect pertoneal, omental and serosal deposits in addition to liver and nodal (retroperitoneal and intraperito-neal) metastasis (see p. 662). It is superior to ultrasound. Lower limit of detectable intraperitoneal implants is between 1 and 5 mm. CT scans are useful in evaluating pituitary tumors. The best images from CT are obtained when there are significant differences in tissue densities. Helical CT is a current modification and has many advantages. Helical CT has replaced pulmonary angiography and ventilation-perfusion scans for the diagnosis of pulmonary embolism.

However, it is more costly and there is chance of surface radiation. Surface radiation dose of CT scan of the abdomen and pelvis is between 2 and 10 cGY. However, value of CT in the assessment of pelvic organs is limited. MRI is preferred where available.

MAGNETIC RESONANCE IMAGING (MRI)

The phenomenon of nuclear magnetic resonance was first described by Felix Bloch and Edward Purcell in 1946. MR as a basis for an imaging technique was employed in practice about 30 years later by Lauterbur.

The MRI creates cross-sectional images of the body using a combination of radiowaves (nonionizing radiation) and magnetic fields. Biologic tissue nuclei with protons or neutrons have got magnetic properties. When a pulse of radiowaves is imposed on the nuclei a strong resonance will occur and the energy is absorbed by the nuclei. A signal is detected in a receiver coil, situated close to the tissue, when the energy is emitted by the nuclei. The strength of the emitted signal varies directly with the proton density. In gynecology, resolution is 0.5 to 1 mm. The radiowaves penetrate bone and air without attenuation. Respiratory movements have got little effect on the pelvic organs. Sagittal and coronal views can be obtained without moving the patient. Patients with implants (pacemakers) cannot undergo MRI. Gadolium is used as IV contrast for better visualization of organs and their abnormalities.

Uses of MRI

♦ MRI can differentiate the different zones (endometrium, inner and outer myometrium) of the uterus clearly (see Fig. 37.84). It can measure the depth of myometrial penetration of endometrial cancer preoperatively

♦ MRI can detect accurately the parametrial invasion of cervical cancer but cannot identify lymphatic metastases reliably. It is more reliable in distinguishing post-treatment fibrosis and recurrence

♦ MRI is superior to CT or ultrasound in diagnosing adenomyosis, myomas and endometrial cancer (including myometrial invasion)

♦ Endovaginal or endorectal coils produce high resolution images of the cervix and parametrium. Tumor volume can be measured with 3D imaging system. Coronal and axial planes are used to determine the invasion of the bladder, rectum, parametrium and uterine body

♦ MRI does not require the use of radio-opaque contrast agents. MRI uses gadolinium, a magneti-cally opaque contrast agent and it is not nephrotoxic

♦ MRI is found to be safe in pregnancy and is not mutagenic

♦ Leiomyomas are better diagnosed with MRI.

♦ MRI is a noninvasive tool in the diagnosis of endometriosis. It can measure the depth of penetration, which is responsible for pelvic pain.

♦ MRI is superior to CT in the evaluation of metastatic lymph nodes or recurrent pelvic tumor. However, neither CT nor MRI can detect microscopic malignant disease (see p. 664).

MRI is twice more expensive than CT.

Hazards

Main hazards are electroconvulsions and atrial fibrillation. This is due to rapidly changing magnetic field. Hence, caution should be exercised with epileptic patients and who had recent myocardial infarction. Other limitation of MRI is patient acceptance. Many patient feel ‘trapped’ in the machine (psychological distress).

POSITRON EMISSION TOMOGRAPHY (PET)

The PET is based on the tissue uptake of 18F-fluoro-2 deoxyglucose (FDG). FDG-PET can measure the difference between the normal tissue and cancerous tissue. Cancer tissues process this glucose analogue differently compared to that of normal tissues. This glucose analogue is given IV. FDG-PET scan is then done and the images are interpreted.

FDG-PET scan is more sensitive for detection of metastatic disease and recurrence of ovarian or cervical malignancy. It is also useful to assess the response following tumor therapy. FDG-PET scan is found to be more sensitive and specific compared to CT or MRI.

Sensitivity of PET in detecting pelvic node metastasis is 80% compared to MRI (70%) and CT (48%).

CONCLUSIONS

All the imaging systems have got their role in gynecological practice.

X-ray, either plain or using contrast media, has got its place. It is cheaper and quite informative with minimal risks of irradiation.

Ultrasound establishes a definite place in diagnostic evaluation. Ultrasound guided procedures are used for both the diagnostic and therapeutic purposes.

CT is useful in the diagnosis of lymph node metastasis and depth of myometrial invasion in endometrial cancer. It may be employed in selected cases to detect microadenoma of pituitary or metastatic lesions in the brain or liver.

MRI: Superior to CT or ultrasound. It is especially helpful to differentiate post-treatment fibrosis and tumor. It is safe in pregnancy.

♦ PET is helpful to differentiate normal tissues from cancerous one.

ENDOMETRIAL SAMPLING

Endometrial sampling is one of the diagnostic tests, most frequently performed as an outdoor procedure. This rapid, safe and inexpensive test is employed in the clinical work up of women with infertility or abnormal uterine bleeding or for periodic screening during HRT. The instrument commonly used is either a Vabra aspirator or a Sharman curette. Currently endometrial sampler (Pipelle) is used as an outpatient procedure (Fig. 9.22). A thin plastic cannula (2-4 mm diameter), with a plunger within, is negotiated within the uterus. It is done as an outpatient procedure. When the plunger is withdrawn, adequate endometrium is obtained due to suction action. This procedure is reliable and is accepted by the patient. Indications of endometrial sampling are: (a) Dysfunctional uterine bleeding;

(b) Abnormal bleeding following the use of hormone replacement therapy; (c) Abnormal perimenopausal or menopausal bleeding. Pipelle is the instrument of first choice for endometrial sampling. The failure rate of the procedure is < 8%. To study the hormonal effect, material from the fundus and upper part of the body is to be taken. However, additional diagnostic procedures, such as hysteroscopy should be done when needed. When a large tissue mass is needed for histological studies, a thorough endometrial curettage is to be done under anesthesia as in endometrial tuberculosis or postmenopausal bleeding.

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 anesthesia. Its clinical application is described in appropriate chapters (see p. 194, 558).

TESTS FOR TUBAL PATENCY: These are descri-bed in the Chapter 16 (see p. 238).

CERVICAL BIOPSY: To confirm the clinical diagnosis of the cervical pathology, biopsy is mandatory. It can be done in the outpatient department or in indoor. Biopsy can be taken safely at the outpatient department, if the pathology is detectable, but for wider tissue excision as in cone biopsy, it should be done as an inpatient procedure. The details are described in page 589.

CULDOCENTESIS

Definition

Culdocentesis is the transvaginal aspiration of peritoneal fluid from the cul-de-sac or pouch of Douglas.

Indications

► In suspected disturbed ectopic pregnancy or other causes producing hemoperitoneum

► In suspected cases of pelvic abscess.

Steps

► The procedure is done under sedation

► The patient is put in lithotomy position

► Vagina is cleaned with Betadine

► A posterior vaginal speculum is inserted

► An 18 gauge spinal needle fitted with a syringe is inserted at a point 1 cm below the cervicovaginal junction in the posterior fornix (Fig. 9.23)

► After inserting the needle to a depth of about 2 cm, suction is applied as the needle is withdrawn.

 If unclotted blood is obtained, the diagnosis of intraperitoneal bleeding is established. If no blood or fluid is obtained, the needle is withdrawn slowly while intermittent suction should be maintained. If the tap is found dry, another attempt is to be made.

Fig. 9.23: Culdocentesis

ENDOSCOPY IN GYNECOLOGY

(See Chapter 35)

Endoscopy has become an essential armamentarium in the diagnostic evaluation of gynecologic lesions as well as for operative procedures. Gynecological endoscopy includes the procedures as mentioned in Table 9.7.

LAPAROSCOPY

Laparoscopy is a technique of visualization of peritoneal cavity by means of a fiberoptic endoscope introduced through the abdominal wall. Prior pneumoperitoneum is achieved by introduction of carbon dioxide or air. For diagnostic purposes, either local or general anesthesia may be used. Its use is gradually widening both in diagnostic and therapeutic field in gynecology. The details are in Chapter 35 (Fig. 9.24).

Indications

♦ Diagnostic

♦ Operative (see Chaper 35)

Diagnostic

♦ Infertility work up (see Chapter 16)

- Peritubal adhesions.

- Chromopertubation (see p. 238).

- Minimal endometriosis (see p. 308).

- Ovulation stigma of the ovary.

- Before reversal of sterilization operation (see p. 247).

♦ Chronic pelvic pain (see p. 555)

♦ Nature of a pelvic mass: Fibroid, ovarian cyst

♦ To diagnose an acute pelvic lesion

- Ectopic pregnancy (see p. 555).

- Acute appendicitis.

- Acute salpingitis—diagnosis and collection of pus for culture.

♦ Follow-up of pelvic surgery (second look)

- Tuboplasty

- Ovarian malignancy

- Evaluation of therapy in endometriosis.

Fig. 9.24: Chlamydial infection causing perihepatic adhesions (Fitz-Hugh-Curtis syndrome) diagnosed by laparoscopy

♦ To visualize transformation zone with colpomi-crohysteroscopy when colposcopic finding is unsatisfactory.

Operative—(see p. 622).

Complications—(see p. 623).

Conclusion: The instruments for endoscopic procedures are costly and require a great deal of expertise for diagnostic and especially for operative procedures.

♦ Investigation protocol of amenorrhea

♦ Diagnosis of suspected Mullerian abnormalities (see p. 45)

♦ Uterine perforation.

Timing of laparoscopy: In infertility work up, it may be done in the periovulatory period to facilitate chromopertubation and also diagnosis of ovulation. However, in endometriosis, it is preferably done in the premenstrual period when the ectopic endometrial implants increase in size.

Operative—(see Chapter 35).

Complications—(see p. 619).

HYSTEROSCOPY (See P. 587)

Hysteroscopy is an operative procedure whereby the endometrial cavity can be visualized with the aid of fiberoptic telescope. The uterine distension is achieved by carbon dioxide, normal saline or glycine. The instrument is to pass transcervically, usually without dilatation of the cervix or local anesthesia. However, for operative hysteroscopy, either paracervical block or general anesthesia is required. Diagnostic hysteroscopy should be performed in the postmenstrual period for better view without bleeding. The chance of conception disturbance is absent (Fig. 9.25).

Recently, contact hysteroscopy has become more popular since a distending medium is not needed. The interpretation of endometrial pathology is similar to colposcopy in that it depends on color, contour and vascular pattern.

Indications: ■ Diagnostic ■ Operative

The technical details and operative hysteroscopy are dealt in Chapter 35.

Diagnostic

♦ Unresponsive irregular uterine bleeding to exclude uterine polyp, submucous fibroid or products of conception

♦ Congenital uterine septum in recurrent abortion

♦ Missing threads of IUD

♦ Intrauterine adhesions (uterine synechiae)

SALPINGOSCOPY: In salpingoscopy, a firm telescope is inserted through the abdominal ostium of the uterine tube so that the tubal mucosa can be visualized by distending the lumen with saline infusion. The telescope is to be introduced through laparoscope.

Salpingoscopy allows study of the physiology and anatomy of the tubal epithelium and permits more accurate selection of patients for IVF rather than the tubal surgery.

FALLOPOSCOPY—see p. 239.

CYSTOSCOPY: The main use of cystoscopy in gynecology is to evaluate cervical cancer prior to staging and, to investigate the urinary symptoms including hematuria, incontinence and fistulae.

CULDOSCOPY: Culdoscopy is an optical instrument designed to visualize the pelvic structures through an incision in the pouch of Douglas. Its use has almost been replaced by laparoscopy.

PROCTOSCOPY AND SIGMOIDOSCOPY: For rectal involvement of genital malignancy, a digital examination or at best proctoscopy is usually adequate.

EXAMINATION UNDER ANESTHESIA (EUA): EUA is indicated where bimanual examination cannot be conducted properly either because of extreme tenderness or inadequate relaxation of abdominopelvic muscles or non-cooperative patient. It should be done routinely in all cases of uterine malignancy for clinical staging. It is extended freely to examine virgins or in cases with pediatric gynecological problems.

LASER IN GYNECOLOGY

The word ‘Laser’ is an acronym for light amplification by Stimulated Emission of Radiation:

Physics of Laser

The important physical properties of laser are:

(i) Monochromacity—Light beams of a particular laser have got the same wavelength.

(ii) Coherent—The light waves are all perfectly aligned and unidirectional.

(iii) Collimated—The light beams run parallel and do not diverge.

(iv) The laser beam can be converged by a convex lens to a sharp focus, called spot size.

(v) Power density is the measure of laser effects upon tissue. It is expressed as watts/cm2.

(vi) Smaller the spot size, greater is the power density.

(vii) Laser-tissue interaction—The water in the cells (80% by volume) boils instantly at the temperature of 100°C. The cell explodes and vaporizes. The cell protein and minerals are incinerated and look charred.

(viii) The depth of tissue destruction is very precise and there is very little lateral effect.

(ix) Laser effect depends on power (watts), spot size, power density, and laser-tissue contact time.

(x) Beams of CO2 and Nd: YAG laser are invisible. There is preferential absorption of laser by one tissue from another.

Common laser systems used in gynecology are carbon dioxide, Nd : YAG, KTP and Argon (Table 9.8).

Fiberoptic laser laparoscopy (KTP 532 and Argon) has the following advantages: Accurate targetting, better hemostasis, contact modes of cutting, vaporization, coagulation and less laser plume production.

USES OF LASER IN GYNECOLOGY

Principal use of laser in gynecology is for the purpose of tissue cutting, coagulation or vaporization. It is used widely in genital tract surgery and with endoscopic surgery. It is commonly used in the management of:

(i) Cervical intraepithelial neoplasia (CIN) (see p. 320).

(ii) Conization of the cervix (see p. 589).

(iii) Vulvar intraepithelial neoplasia (VIN) (see p. 318).

(iv) Vaginal intraepithelial neoplasia (VAIN) (see p. 319).

(v) Vaporization of pelvic endometriosis (see p. 312).

(vi) Laser laparoscopy for ovarian cystectomy, adhesiolysis, removal of ectopic pregnancy and presacral neurectomy.

(vii) Laser laparoscopy assisted hysteroscopy, for dividing large pedicles that have been coagulated or suture ligated.

(viii) Hysteroscopic surgery—Laser ablation of endometrium (see p. 193), resection of uterine septum (metroplasty) and submucous fibroids (see p. 283).

Limitations of Laser

♦ The equipment is expensive

♦ Technical complexity—requires sufficient training.

HAZARDS OF LASER SYSTEMS

Laser must be used by a trained person. Laser protection guidelines must be strictly followed to protect the operator, assistant, the theatre staff and the patient from the accidental hazards. A laser controlled area (LCA) must have warning signs when laser is in use. Special spectacles are used to protect the eyes.

Common hazards are :

[ A —(i) Eyes—visual loss due to corneal or retinal damage, (ii) Skin damage, and (iii) Damage from laser smoke.

B —General: (i) Burn injury (use of spirit and paper drapes must be avoided in theatre), (ii) Inflammable anesthetic gases are to be used with great care,

(iii) Reflections of laser beam is dangerous. Shining instruments are not to be used, (iv) Fire extinguisher should always be available (v) Plume of smoke should be extracted.

KEY POINTS

The clinical examination should be thorough and meticulous. The examination should in fact proceed with the provisional diagnosis in mind. A patient hearing should be given about the complaints made by the patient in her own words.

Menstrual history includes age of menarche, cycle length, regularity, duration of period, amount of flow and the first day of the last menstrual period.

Integration of the symptomatology to a single pathology is to be tried first before embarking on the diagnosis of multiple pathology.

The general and systemic examination should be thorough and meticulous.

Clinical breast examination (CBE) should be a routine part of the gynecologic examination (Fig. 9.1). Annual CBE of women with age > 40 years is recommended (ACOG).

CBE begins with inspection and then a thorough palpation (see p. 565). The examiner should check for nipple discharge (see p. 566) as well as the axillary lymph nodes (see p. 565).

Bladder should be empty prior to examination.

Abdominal palpation should be done with the flat of the hand rather than the tips of the fingers. Whether a mass is felt or not, routine palpation of the viscera includes liver, spleen, cecum, pelvic colon, gallbladder and kidneys.

It is mandatory to elicit presence of free fluid in the peritoneal cavity in all cases of pelvic tumors.

Pelvic examination includes inspection of external genitalia, vaginal examination (inspection with a speculum, palpation and bimanual examination), rectal examination and rectovaginal examination.

Rectovaginal examination is of special help to differentiate a growth arising from the ovary or rectum.

Dyskaryosis is the morphological abnormality of the nucleus. It may be mild, moderate or severe. Koilocytosis is associated with human papilloma virus infection.

As a screening procedure, the material from the cervix is best collected using Ayre's spatula. About 5 cases of cervical intraepithelial neoplasia are diagnosed per 1000 patients and invasive carcinoma of the cervix in order of 1 in 1000. The Pap smear screening should best be done at interval of 3 years after 2 yearly negative smears from 18 years to 60 years. However, screening interval depends on patient's risk level (Table 9.1).

Diagnostic accuracy of Pap smear after three consecutive negative tests is about 99 percent.

For cytohormonal study, the smear is taken from the lateral wall of the upper-third of the vagina. The estrogenic smear is suggested by preponderance of large eosinophilic cells with pyknotic nuclei. The progesterone smear is predominantly basophilic with vesicular nuclei. The background is dirty.

Power density is the most important determinant of the laser effects. Greater the power density, the less the thermal effect and less is the hemostatic property.

Maturation index (MI), is expressed by three numbers as the percentage of parabasal, intermediate and superficial cells written from left to the right. There is significant shift in maturation index from birth to menopause.

Examination of cervical mucus is done for bacteriological study, to know the hormonal status and in infertility investigation.

Estrogenic mucus is clear, abundant and has got the power of elasticity and shows pattern of fern tree formation. Progesterone smear is thick and viscid, loses its property of elasticity and ferning disappears.

Postcoital test (PCT) is done on day 12 or 13. The reporting time is within 8-12 hours following intercourse. Presence of at least 10 progressively motile sperm per high power field signifies the test to be normal. Routine postcoital test is not recommended.

Menstrual cycles after puberty and before menopause are frequently anovulatory and irregular.

Pap smears should be performed every 1-3 years depending upon patients' risk factors.

Ultrasonography (TAS, TVS or TV-CDS) has become a common diagnostic modality in gynecology. It is widely used in infertility work up (sonohysterosalpingography, folliculometry, detection of ovulation and oocyte retrieval in IVF programme), evaluation of pelvic mass, ectopic pregnancy and endometrial disease. Sonographically guided procedures provide added information.

CT is useful in detection of enlarged pelvic lymph nodes and microadenoma of pituitary. Helical CT is a modification that uses movement of the patient combined with rotation of several radiographic registers in a spiralling fashion. Vascular images are so high quality that it has replaced pulmonary angiography and ventilation-perfusion scans. Surface radiation dose from CT is between 2 and 10 rads.

MRI uses radiowaves (nonionising) and magnetic fields. It accurately shows parametrial invasion of cervical cancer but cannot reliably identify the lymph node metastases. It can measure the depth of myometrial penetration in endometrial carcinoma preoperatively. High resolution images in multiple planes are obtained. Tumour volume can be measured with 3D imaging system.

MRI should not be used in pateints with cochlear implants or pacemakers. It is safe in women with pregnancy or IUDs.

Endometrial sampling is useful in the clinical work-up of women with infertility or abnormal perimenopausal bleeding. It can be performed in the OPD using a narrow plastic cannula (pipette).

Culdocentesis is indicated in suspected cases of haemoperitoneum or pelvic abscess.

Pap test (cervical smear test) is the most effective cancer screening procedure. It reduces the incidence of cancer cervix by 80% when used regularly.

Cervical cancer is caused by HPV (see p. 323) infection. Virtually most HPV infections regress spontaneously. An HPV-DNA test can be used to triage women with ASC-US cytology reports.

Colposcope is a lower power binocular microscope. It is employed in cases with abnormal cervical smear and with clinically suspicious cervices, especially with history of contact bleeding even if the smear is negative. Colposcopy directed biopsy is the best one when the lesion is not clinically detected. Colposcope is used to evaluate women with abnormal cytology (p. 115, 324).

The use of laparoscopy is gradually widening. The major diagnostic uses are infertility, chronic pelvic pain and to exclude pelvic lesion (see Ch. 35).

Hysteroscopy is gaining popularity as a diagnostic aid in unresponsive uterine bleeding, uterine synechiae, congenital uterine septum or missing threads of IUD (see Ch. 35).

Salpingoscopy is the evaluation of tubal mucosa with a telescope, introduced through the abdominal ostium of the tube.

Principal use of laser in gynecology is for tissue cutting, coagulation or vaporisation. Laser effects depend on power (watts), spot size, power density and laser-tissue contact time. Commonly used laser systems in gynecology are CO2, Nd:YAG, KTP 532 and Argon (Table 9.8).



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